1
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Brown MC, Tickle K, Woods K, Sidonio RF. Adequate menstrual suppression in adolescents with inherited bleeding disorders often requires multiple treatment changes: Retrospective cohort study of a multidisciplinary clinic. Pediatr Blood Cancer 2024; 71:e30944. [PMID: 38462776 DOI: 10.1002/pbc.30944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/25/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
Heavy menstrual bleeding (HMB) is often the presenting symptom for females with inherited bleeding disorders (IBD). Multidisciplinary clinics leverage the expertise of hematologists and women's health specialists. This study characterizes the complexity of HMB management for adolescents with IBDs from a large multidisciplinary clinic. Adolescents often required multiple different menstrual suppression treatments, with only about 20% achieving acceptable suppression with their first treatment. Adolescents switched therapy most often for uncontrolled bleeding, followed by adverse effects, and patient preference. Given the difficulty in achieving adequate menstrual suppression, multidisciplinary clinics offer necessary expertise in accomplishing bleeding control with minimal adverse effects.
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Affiliation(s)
- Megan C Brown
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kelly Tickle
- Aflac Cancer and Blood Disorders at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kalinda Woods
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert F Sidonio
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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2
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Hall EM, Ravelo AE, Aronoff SC, Del Vecchio MT. Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females. BMC Womens Health 2024; 24:136. [PMID: 38378571 PMCID: PMC10880246 DOI: 10.1186/s12905-024-02921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding. METHODS A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. RESULTS Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin. CONCLUSIONS The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.
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Affiliation(s)
- Erin M Hall
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ana E Ravelo
- Department of Pediatrics, Brown University, Providence, RI, USA
| | - Stephen C Aronoff
- Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Michael T Del Vecchio
- Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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3
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2023; 288:90-107. [PMID: 37499278 DOI: 10.1016/j.ejogrb.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.
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Affiliation(s)
- J L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1 avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165 chemin du Grand Revoyet, 69495 Pierre-Benite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital europeen Georges-Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hotel Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40 avenue Serge Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371 avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
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4
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Munro MG, Mast AE, Powers JM, Kouides PA, O'Brien SH, Richards T, Lavin M, Levy BS. The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia. Am J Obstet Gynecol 2023; 229:1-9. [PMID: 36706856 DOI: 10.1016/j.ajog.2023.01.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/09/2023] [Accepted: 01/14/2023] [Indexed: 01/26/2023]
Abstract
For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation, iron deficiency anemia. It is recognized that these 2 clinical entities are not only highly prevalent, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both heavy menstrual bleeding and iron deficiency, with or without anemia, adversely impact quality of life-heavy menstrual bleeding during the episodes of bleeding and iron deficiency on a daily basis. These combined issues adversely affect the lives of reproductive-aged girls and women of all ages, from menarche to menopause, and their often-insidious nature frequently leads to normalization. The effects on cognitive function and the related work and school absenteeism and presenteeism can undermine the efforts and function of women in all walks of life, be they students, educators, employers, or employees. There is also an increasing body of evidence that suggests that iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders, critically important evidence that begs the normalization of iron stores in reproductive-aged women. The authors seek to raise individual, societal, and professional awareness of this underappreciated situation in a fashion that leads to meaningful and evidence-based changes in clinical guidance and healthcare policy directed at preventing, screening, diagnosing, and appropriately managing both disorders. This manuscript provides evidence supporting the need for action and describes the elements necessary to address this pervasive set of conditions that not only affect reproductive-aged girls and women but also the lives of children everywhere.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Alan E Mast
- Versiti Blood Research Institute, Milwaukee, WI
| | - Jacquelyn M Powers
- Department of Pediatrics, Baylor College of Medicine, Houston TX; Cancer and Hematology Center, Texas Children's Hospital, Houston, TX
| | - Peter A Kouides
- Mary M. Gooley Hemophilia Center, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sarah H O'Brien
- Center for Health Equity and Outcomes Research and the Hemostasis and Thrombosis Center, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Pediatric Hematology, Oncology & Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH
| | - Toby Richards
- Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Michelle Lavin
- National Coagulation Centre, St James' Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Barbara S Levy
- Department of Obstetrics and Gynecology, University of California, San Diego, San Diego, CA; Department of Obstetrics and Gynecology, The George Washington University, Washington, DC
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5
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Tàssies Penella M. Papel de los trastornos de la hemostasia en el sangrado uterino anormal. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2022.100820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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6
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Amos LE, Sherman AK, Carpenter SL. Diagnosis of Bleeding Disorders in Adolescents Hospitalized for Heavy Menstrual Bleeding. TH OPEN 2022; 6:e267-e275. [PMID: 36299809 PMCID: PMC9512591 DOI: 10.1055/a-1892-1987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Background
There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer.
Objectives
This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events.
Patients/Methods
Consecutive patients with cancer-related PE (March 1, 2006–October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE.
Results
Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%;
p
= 0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%;
p
= 0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%;
p
< 0.001) and interventricular septum displacement (53 vs. 20%;
p
< 0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE.
Conclusion
Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.
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Affiliation(s)
- Lauren E. Amos
- Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospital, Kansas City, Missouri, United States
- Department of Pediatrics, The University of Missouri-Kansas City, Kansas City, Missouri, United States
| | - Ashley K. Sherman
- Department of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shannon L. Carpenter
- Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospital, Kansas City, Missouri, United States
- Department of Pediatrics, The University of Missouri-Kansas City, Kansas City, Missouri, United States
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7
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. [Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:345-373. [PMID: 35248756 DOI: 10.1016/j.gofs.2022.02.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.
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Affiliation(s)
- J-L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4, rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hôtel-Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40, avenue Serge-Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
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8
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O'Flynn O'Brien KL, Wheeler AP, Borzutzky C, Haley KM, Kouides P, Adeyemi-Fowode O. Provider Attitudes and Practices Regarding Intrauterine System (IUS) Insertion in Adolescents With and Without Bleeding Disorders for Management of Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2021; 34:514-521. [PMID: 33497749 DOI: 10.1016/j.jpag.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/21/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE Heavy menstrual bleeding (HMB) may be the sentinel event for identifying a patient with a bleeding disorder (BD). The levonorgestrel intrauterine system (LNG IUS) has been proposed as a treatment for HMB in adolescents with and without BDs; however, no standard protocols for LNG IUS insertion in these populations exist. Providers were surveyed regarding the use of the LNG IUS in adolescents with HMB, with and without BD. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: An institutional review board-approved survey assessing provider attitudes, LNG IUS insertion practices, and patient outcomes in adolescents with HMB, with and without BD, was electronically distributed to 3523 providers in the fields of hematology, adolescent medicine, and obstetrics and gynecology. Descriptive analysis was performed. RESULTS A total of 312 respondents across all 3 specialties completed the survey. Nearly 100% of respondents considered the LNG IUS safe and effective treatment for adolescents with HMB, both with and without BD. Additionally, 66% of providers chose LNG IUS as the ideal treatment for HMB in patients with BD. Differences were noted in clinical setting for LNG IUS insertion, peri-procedural medication use, and post-procedure follow-up among specialties. Providers across all specialties reported low complication rates related to IUS insertion and use in both patient groups. CONCLUSION Providers considered the LNG IUS safe and effective treatment for HMB in adolescents with and without a diagnosed BD. Practice patterns regarding LNG IUS insertion in this population vary. Further research is necessary to explore IUS outcomes in adolescent patients with HMB, with and without BD, and to inform evidence-based protocols for LNG IUS insertion.
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Affiliation(s)
- Katherine L O'Flynn O'Brien
- Department of Pediatric and Adolescent Gynecology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.
| | - Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Borzutzky
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles/Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Kristina M Haley
- Division of Hematology and Oncology, Oregon Health and Science University, Portland, Oregon
| | - Peter Kouides
- Mary M. Gooley Hemophilia Treatment Center, Rochester Regional Health, Rochester, New York
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9
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Screening hemostatic defects in Saudi University students with unexplained menorrhagia: a diagnosis, which could be missed. Blood Coagul Fibrinolysis 2021; 32:278-284. [PMID: 33741756 DOI: 10.1097/mbc.0000000000001033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bleeding disorders are a common cause of unexplained menorrhagia in adolescents. However, there is lack of information provided on Arab girls. To estimate the prevalence of coagulation factor deficiencies and platelet dysfunction among Saudi university students with unexplained menorrhagia. In this cross sectional study, 463 adolescent girls surveyed for having heavy menses for further evaluation of underlying bleeding tendencies using screening standardized questionnaire. Only 109 girls out of the total 463 girls reported menorrhagia and were included in the evaluation. All girls with menorrhagia were evaluated by Pictorial blood assessment chart (PBAC) for precise evaluation of menstrual blood loss (PBAC score >100), had underwent pelvic ultrasonography and screening of hemostatic abnormalities (complete blood count, PFA-100, PT, aPTT, vWF:RCo, vWF:Ag, coagulation factors assay). On the basis of the score of PBAC more than 100, 25.6% (28/109) of adolescent women (age ranged: 17-25 years old) had confirmed menorrhagia. In 30.8% of them, an ultimate diagnosis of bleeding tendency or hemostatic abnormality was detected [five cases of probable von Willebrand disease (vWD) or low level of vWF:Ag and/or vWF:RCo, two cases of probable platelet dysfunction, and one case of factorV (FV) deficiency]. Anemia was found in 39.28% (11/28) of them; however, only 4 (36%) had received iron supplements. Our study demonstrated that hemostatic defects are not uncommon in Saudi adolescent women presenting with menorrhagia but mostly unrecognized and untreated. It is probably advisable to screen women with menorrhagia for these defects.
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10
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Brown MC, White MH, Friedberg R, Woods K, Childress K, Kulkarni M, Sidonio RF. Elevated von Willebrand factor levels during heavy menstrual bleeding episodes limit the diagnostic utility for von Willebrand disease. Res Pract Thromb Haemost 2021; 5:e12513. [PMID: 33977212 PMCID: PMC8105159 DOI: 10.1002/rth2.12513] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/11/2021] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is often the first bleeding symptom for female individuals with inherited bleeding disorders. Guidelines recommend performing the hemostatic evaluation at HMB presentation. Von Willebrand factor (VWF) levels increase with stress, making it unclear if VWF studies during acute bleeding are beneficial in diagnosing von Willebrand disease (VWD). OBJECTIVES To determine the utility of testing for VWD during acute HMB. PATIENTS/METHODS This retrospective cohort study evaluated VWF levels of individuals presenting to the emergency department (ED) with HMB from January 1, 2017, to December 31, 2018, after prospective implementation of a clinical practice guideline recommending hemostatic evaluation in the ED. We compared VWF and factor VIII (FVIII) levels between acute presentation and follow-up visit after bleeding resolution. We compared the diagnostic accuracy of initial and follow-up labs. RESULTS During the study period, 221 individuals were seen in the ED for acute HMB, and 39 had VWD testing at both time points. Median FVIII and VWF levels were higher during acute bleeding than at follow-up. The difference in VWF levels between visits was negligible when initial FVIII value was normal. Overall incidence of VWD was 7.5%; 69% of those with VWD had low VWF levels during acute HMB. CONCLUSION VWD testing during acute HMB detects the majority of individuals with VWD but also leads to elevated levels of VWF, potentially limiting at the accuracy of diagnostic labs during acute bleeding episodes. Delayed testing until resolution of anemia and active bleeding may provide more accurate diagnostic evaluation for VWD.
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Affiliation(s)
- Megan C. Brown
- Aflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| | - Michael H. White
- Aflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| | | | - Kalinda Woods
- Department of Gynecology and ObstetricsEmory UniversityAtlantaGAUSA
| | - Krista Childress
- Division of Pediatric SurgeryChildren's Healthcare of AtlantaAtlantaGAUSA
- Division of Gynecologic SpecialtiesDepartment of Gynecology and ObstetricsEmory UniversityAtlantaGAUSA
| | | | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
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11
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Jain S, Zhang S, Acosta M, Malone K, Kouides P, Zia A. Prospective evaluation of ISTH-BAT as a predictor of bleeding disorder in adolescents presenting with heavy menstrual bleeding in a multidisciplinary hematology clinic. J Thromb Haemost 2020; 18:2542-2550. [PMID: 32654321 DOI: 10.1111/jth.14997] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/30/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) can be the first manifestation of an undiagnosed bleeding disorder (BD). Identifying a BD can be challenging in the adolescent age group. The utility of bleeding assessment tools (BAT) remains elusive in this population. AIM We evaluated the ability of the International Society on Thrombosis and Haemostasis-BAT (ISTH-BAT) in predicting a BD in adolescents referred for HMB to a multidisciplinary hematology clinic. METHODS Two hundred adolescents with HMB underwent a standardized evaluation for BD. The clinical characteristics, laboratory data, and bleeding scores (BS) assessed using ISTH-BAT were prospectively collected. Comparisons were made between patients based on the diagnosis of BD receiver operating characteristic (ROC) curve analyses of ISTH-BAT were performed to assess its value for predicting BD. RESULTS Overall, 33% (n = 67) of adolescents were diagnosed with a BD. The mean ISTH-BAT BS was higher in BD as compared to those without (4.1 versus 3.1, P < .0001), but the mean menorrhagia-specific scores did not differ (2.9 in both groups). The ISTH-BAT demonstrated a modest discriminative ability as a screening tool to identify BD in girls with HMB with an area under the curve (AUC) of 0.71. The ROC analysis demonstrated that with increasing BS, the sensitivity decreased, but the specificity increased. At BS = 3, sensitivity was 88%, specificity 31%, and accuracy 50%; at BS = 5, sensitivity was 37%, specificity 94%, and accuracy was 75%. There was no change thereafter. CONCLUSION In adolescents with HMB, an ISTH-BAT BS of >4 instead of the established cut-off of >2 in children is highly specific in predicting a BD.
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Affiliation(s)
- Shilpa Jain
- Division of Pediatric Hematology-Oncology, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
- Western New York BloodCare, Buffalo, NY, USA
| | - Song Zhang
- Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kendra Malone
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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12
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Guelcher CJ, Chase J, Pollard D. Women and girls with heavy menstrual bleeding and inherited bleeding disorders: A call to action for the Haemophilia Treatment Centre Nurse. Haemophilia 2020; 27 Suppl 3:82-86. [PMID: 32469119 DOI: 10.1111/hae.14019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/09/2020] [Indexed: 12/27/2022]
Abstract
Over the last several decades, the increasing focus on women with inherited bleeding disorders (WBD) has brought more patients into Haemophilia Treatment Centres (HTC) around the world. These women present with unique challenges including a significant risk of heavy menstrual bleeding (HMB). The influx of a new patient group has necessitated expansion of the services provided by the multi-disciplinary team in HTCs. Nurses already play a central role in patient and family education within the HTC. As such, they are well positioned to participate in the development of adaptations within the HTC infrastructure to provide clinical care and education specifically for WBD. The nursing experts in HTCs should play an active role in outreach as well as providing education to WBD. Despite this supposition, review of the growing body of literature surrounding the topic of WBD is notable for a paucity of literature highlighting the role of the HTC nurse and potential impact on this, relatively new, but steadily increasing, patient population.
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Affiliation(s)
| | - Jaime Chase
- John Hunter Children's Hospital, New Lambton Heights, NSW, Australia
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13
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Gresele P, Falcinelli E, Bury L. Inherited platelet disorders in women. Thromb Res 2020; 181 Suppl 1:S54-S59. [PMID: 31477229 DOI: 10.1016/s0049-3848(19)30368-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 01/22/2023]
Abstract
Inherited platelet disorders (IPD) are a heterogeneous group of hemorrhagic diseases affecting both men and women, but usually associated with more evident bleeding symptoms in women due to the exposure to sexspecific hemostatic challenges, like menstruation and delivery. Indeed, up to 50% of women presenting with menorrhagia are diagnosed an IPD, moreover women with IPD can have ovulation-associated bleeding events and are at higher risk of endometriosis. Large retrospective studies have shown that women with IPD have a significantly increased risk of post-partum hemorrhage, predicted by a high bleeding score at previous history and by a platelet count below 50X109/L. In addition, in patients with IPD, female sex was associated with a higher frequency of excessive bleeding after surgery, even when excluding gynecological procedures. In conclusion, IPD may represent a serious problem for women's health, and their diagnosis and appropriate management is crucial to ensure female patients a good quality of life.
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Affiliation(s)
- Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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14
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Wilkie GL, Taggart AA, Prensner JR, Billett AL, Laufer MR. Burkitt Lymphoma Presenting as Menorrhagia and a Vaginal Mass in an Adolescent. J Pediatr Adolesc Gynecol 2019; 32:90-92. [PMID: 30278229 DOI: 10.1016/j.jpag.2018.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/02/2018] [Accepted: 09/24/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Menorrhagia is a common gynecologic complaint among adolescents, which rarely is secondary to malignancy. Burkitt lymphoma can mimic gynecologic malignancy, however it is rarely seen in adolescents. Burkitt lymphoma of the gynecologic tract requires early diagnosis and intervention for optimal outcomes. CASE We report a case of a 15-year-old adolescent who had multiple admissions for menorrhagia that was thought to be secondary to anovulatory bleeding until pelvic ultrasound revealed a large 8-cm vaginal/cervical mass. Histologic examination of the biopsy specimen revealed Burkitt lymphoma, which was treated with chemotherapy leading to resolution of her menorrhagia. SUMMARY AND CONCLUSION Burkitt lymphoma presenting as a vaginal/cervical mass is exceedingly rare, especially in the adolescent patient. Burkitt lymphoma is generally highly responsive to chemotherapy, and symptoms rapidly improve after initiation of treatment.
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Affiliation(s)
- Gianna L Wilkie
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Ashley A Taggart
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - John R Prensner
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Amy L Billett
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Marc R Laufer
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
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15
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Karol D, Tsang P, Rhee G, Weiss D, Khamisa K, Saidenberg E. Development of competencies related to diagnosis and management of bleeding disorders in women and girls for use in residency training. Haemophilia 2019; 25:e103-e105. [PMID: 30604911 DOI: 10.1111/hae.13674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Dalia Karol
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip Tsang
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gaeun Rhee
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Weiss
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karima Khamisa
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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16
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Alaqzam TS, Stanley AC, Simpson PM, Flood VH, Menon S. Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2018. [PMID: 29524595 DOI: 10.1016/j.jpag.2018.02.130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We performed a retrospective chart review of adolescents younger than 21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information including demographic characteristics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into 2 categories on the basis of the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared. RESULTS Seventy-three subjects were tested for a bleeding disorder. Of the subjects who completed testing, 34 (46%) were diagnosed with a bleeding disorder. Thirty-nine subjects (54%) had heavy menstrual bleeding because of other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without a bleeding disorder. In a comparison of hormone therapy success, the levonorgestrel intrauterine device (89%, 8 out of 9 subjects) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10 mg/d (83%, 5 out of 6 subjects), and the transdermal patch (80%, 4 out of 5 subjects). All subjects using tranexamic acid as well as hormonal therapy had 100% achievement of menstrual suppression. CONCLUSION A high frequency of bleeding disorders was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. Although combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option.
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Affiliation(s)
- Tasneem S Alaqzam
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Angela C Stanley
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa M Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Veronica H Flood
- Division of Hematology and Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seema Menon
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
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17
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Zia A, Stanek J, Christian-Rancy M, Ahuja SP, Savelli S, O'Brien SH. Utility of a screening tool for haemostatic defects in a multicentre cohort of adolescents with heavy menstrual bleeding. Haemophilia 2018; 24:957-963. [PMID: 30207633 DOI: 10.1111/hae.13609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/11/2018] [Accepted: 08/06/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Heavy menstrual bleeding (HMB) may be expected for many adolescents after menarche. Accurate assessment of HMB, a key component in the diagnosis of a haemostatic defect (HD), is a well-recognized challenge. AIM Our objective was to determine the diagnostic accuracy of an HMB-specific screening tool for HDs in adolescents with HMB, presenting to a secondary care setting. METHODS Adolescents with HMB were evaluated for a HD at 4 US centres. A screening tool, the Philipp Tool, developed and validated in adult women with HMB, was administered. We modified the tool by assigning a score based on the number of affirmative responses. Sensitivity, specificity and likelihood ratios (LRs) of a positive tool, modified tool, with a pictorial blood assessment chart (PBAC) score >185, and with serum ferritin ≤20 ng/mL were calculated for HDs. RESULTS Among 248 adolescents with HMB, 29% were diagnosed with HDs. Sensitivity, specificity and LR of a positive screening tool for HDs were 95% (range 88-99), 14% (9-21) and 1.1 (1-1.2), respectively. A score of ≥2, addition of a PBAC score >185 and ferritin ≤20 ng/mL changed the sensitivity, specificity and LR of the tool to 72% (61-81), 94% (83-99), 76% (65-85); 60% (53-68), 24% (16-34) and 39% (31-47) and 1.8 (1.4-2.2), 1.2 (1.1-1.4) and 1.2 (1-1.4), respectively. CONCLUSION Although sensitive, the discriminative ability of the tool to identify adolescents with HDs from those without, who presented with HMB, was low. Further research is needed to optimize or develop an adolescent-specific HMB tool for secondary care settings.
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Affiliation(s)
- Ayesha Zia
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,Nationwide Children's Hospital, Columbus, Ohio
| | - Myra Christian-Rancy
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,Nationwide Children's Hospital, Columbus, Ohio
| | - Sanjay P Ahuja
- Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | | | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,Nationwide Children's Hospital, Columbus, Ohio.,The Ohio State University, Columbus, Ohio
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18
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Abstract
Abnormal uterine bleeding is common in adolescents and is thought to affect 9% to 14% of women in their reproductive years. Certain unique aspects of underlying inherited or acquired blood disorders exacerbate the "expected" hormonal imbalance at this age, thereby increasing the morbidity of the underlying problem. A multifactorial etiology demands a collaborative approach between hematologists and gynecologists or adolescent medicine physicians to effectively manage abnormal uterine bleeding in young women with blood disorders.
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Affiliation(s)
- Kathryn E Dickerson
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Neethu M Menon
- Pediatric Hematology Oncology, Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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19
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Mullins ES, Miller RJ, Mullins TLK. Abnormal Uterine Bleeding in Adolescent Women. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0164-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Abnormal Uterine Bleeding including coagulopathies and other menstrual disorders. Best Pract Res Clin Obstet Gynaecol 2018; 48:51-61. [DOI: 10.1016/j.bpobgyn.2017.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/06/2017] [Accepted: 08/07/2017] [Indexed: 12/20/2022]
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21
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Heavy Menstrual Bleeding in Adolescents. J Pediatr Adolesc Gynecol 2017; 30:335-340. [PMID: 28108214 DOI: 10.1016/j.jpag.2017.01.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/14/2016] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
Heavy menstrual bleeding (HMB) is a very common gynecological condition in female adolescents and a frequent presenting complaint of those with bleeding disorders. Recommendations have been established to screen for bleeding disorders in this age group where appropriate. The purpose of this document is to impart clinical recommendations regarding HMB in adolescents. Specifically, in this article we provide a description of the epidemiology, clinical presentation, diagnostic approach, and treatment of HMB in adolescents.
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22
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Singh S, Best C, Dunn S, Leyland N, Wolfman WL. Saignements utérins anormaux chez les femmes préménopausées. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S231-S263. [PMID: 28063539 DOI: 10.1016/j.jogc.2016.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding. Thromb Res 2016; 143:91-100. [PMID: 27208978 DOI: 10.1016/j.thromres.2016.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/26/2016] [Accepted: 05/01/2016] [Indexed: 11/20/2022]
Abstract
Unpredictable, prolonged or heavy menstrual bleeding (HMB) may be expected for many adolescents soon after menarche. A decade of clinical experience and research has now established firmly that bleeding disorders (BD) are common in adolescents with HMB. Despite these advances, many questions remain, and several aspects of the diagnosis and management of BDs in adolescents are not supported by rigorous clinical trials. In this overview, four major areas will be discussed. First, we will discuss the frequency of BDs in young women with HMB. Up to 20% of older females with HMB are thought to have an underlying BD. Estimates from retrospective studies in adolescents suggest a prevalence that varies anywhere from 10 to 62%. Prospective studies with uniform hemostatic evaluation are needed to answer this question definitively. Second, we will review existing tools that help screen and diagnose adolescents with HMB with an underlying BD. Although identification of an underlying BD in older women with HMB is relatively straight forward, uncertainties remain for adolescents. Heavy menstrual bleeding in this age group may have different pathophysiological underpinnings than those in older women and may often be disregarded as anovulatory. There is an urgent need to develop novel tools, and evaluate existing diagnostic strategies in adolescents. Third, we will discuss the optimal medical management of HMB in young adolescents. As direct evidence is largely lacking, these areas are also subject to extrapolation from older women. Lastly, an important area- prediction, and management of future bleeding in those adolescents who are diagnosed with a mild BD-will be discussed. Throughout, areas of controversy and opportunities for further research are highlighted.
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24
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Dowlut-McElroy T, Williams KB, Carpenter SL, Strickland JL. Menstrual Patterns and Treatment of Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders. J Pediatr Adolesc Gynecol 2015; 28:499-501. [PMID: 26231609 DOI: 10.1016/j.jpag.2015.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 03/03/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To characterize menstrual bleeding patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective review of female patients aged nine to 21 years with known bleeding disorders who attended a pediatric gynecology, hematology, and comprehensive hematology/gynecology clinic at a children's hospital in a metropolitan area. MAIN OUTCOME MEASURES Prevalence of heavy menstrual bleeding at menarche, prolonged menses, and irregular menses among girls with bleeding disorders and patterns of initial and subsequent treatment for heavy menstrual bleeding in girls with bleeding disorders. RESULTS Of 115 participants aged nine to 21 years with known bleeding disorders, 102 were included in the final analysis. Of the 69 postmenarcheal girls, almost half (32/69, 46.4%) noted heavy menstrual bleeding at menarche. Girls with von Willebrand disease were more likely to have menses lasting longer than seven days. Only 28% of girls had discussed a treatment plan for heavy menstrual bleeding before menarche. Hormonal therapy was most commonly used as initial treatment of heavy menstrual bleeding. Half (53%) of the girls failed initial treatment. Combination (hormonal and non-hormonal therapy) was more frequently used for subsequent treatment. CONCLUSIONS Adolescents with bleeding disorders are at risk of heavy bleeding at and after menarche. Consultation with a pediatric gynecologist and/or hematologist prior to menarche may be helpful to outline abnormal patterns of menstrual bleeding and to discuss options of treatment in the event of heavy menstrual bleeding.
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Affiliation(s)
- Tazim Dowlut-McElroy
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Karen B Williams
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Section of Hematology, Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospitals, Kansas City, Missouri
| | - Julie L Strickland
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; Section of Gynecological Surgery, Department of Surgery, Children's Mercy Hospitals, Kansas City, Missouri
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Díaz R, Dietrich JE, Mahoney D, Yee DL, Srivaths LV. Hemostatic abnormalities in young females with heavy menstrual bleeding. J Pediatr Adolesc Gynecol 2014; 27:324-9. [PMID: 25256871 DOI: 10.1016/j.jpag.2013.12.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the prevalence of hemostatic abnormalities, including bleeding disorders and risk factors, in young females referred to a multidisciplinary clinic for evaluation of heavy menstrual bleeding (HMB). METHODS Retrospective chart review was undertaken for 131 post-menarchal girls with HMB, 7 to 17 years of age, enrolled in the institutional 'Menorrhagia Data Registry' protocol. The diagnostic approach included: (1) complete blood count, prothrombin time, partial thromboplastin time, fibrinogen, von Willebrand panel (2) platelet aggregometry, specific clotting factor assay, fibrinolytic pathway analysis, and factor XIII level as needed. The prevalence of hemostatic abnormalities and the prognostic significance of clinical variables associated with hemostatic abnormalities in young girls with HMB were evaluated. RESULTS A hemostatic abnormality was identified in 69 (53%) young girls with HMB. Of these, 27 (21%) had an underlying bleeding disorder and 42 (32%) had a risk factor for bleeding, namely low von Willebrand factor activity. A larger number of girls with underlying bleeding disorder had personal history of other bleeding symptoms (48% vs 31%) and bleeding after surgical or dental procedure (25% vs 8%) when compared to females without hemostatic abnormality. Furthermore, girls with risk factor for bleeding (low vWF activity) were more likely to have bleeding after surgical or dental procedure (15% vs 8%) and family history of bleeding (79% vs 60%) than patients without hemostatic abnormality. CONCLUSIONS There is high prevalence of hemostatic abnormalities, including bleeding disorders and risk factors, in young girls with HMB. These findings support comprehensive and systematic hemostatic evaluation in this group of patients.
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Affiliation(s)
- Rosa Díaz
- Texas Children's Hospital, Houston, TX.
| | - Jennifer E Dietrich
- Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Houston, TX
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Gursel T, Biri A, Kaya Z, Sivaslıoglu S, Albayrak M. The frequency of menorrhagia and bleeding disorders in university students. Pediatr Hematol Oncol 2014; 31:467-74. [PMID: 24684279 DOI: 10.3109/08880018.2014.886316] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE Menorrhagia is an important health problem in women of reproductive age. The aims of this study were to assess the prevalence of menorrhagia and hemostatic abnormalities associated with menorrhagia in university students. METHODS The pictorial blood assessment chart (PBAC) was used to identify students with menorrhagia. Those with a PBAC score > 100 were examined by pelvic ultrasound and laboratory tests including complete blood count, levels of clotting factors, von Willebrand factor antigen, and ristocetin cofactor activity and Platelet Function Analyser-100 (PFA-100). Platelet aggregation was studied in students with prolonged PFA-100 closure time. RESULTS Menorrhagia was identified in 82 (21.8%) of 376 students. Six of 82 students who had pelvic pathologies were excluded. Eleven (14.5%) of the remaining 76 students were found to have bleeding disorders, including von Willebrand disease in five (6.5%), platelet function disorder in four (5.2%), and clotting factor deficiencies in two (2.6%). CONCLUSIONS Menorrhagia is a common but mostly unrecognized and untreated problem among university students. Underlying bleeding disorders are not rare and require comprehensive hemostatic evaluation for identification.
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Affiliation(s)
- Turkiz Gursel
- Department of Pediatrics, Medical School of Gazi University, Ankara, Turkey
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Hertweck P, Yoost J. Common problems in pediatric and adolescent gynecology. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.10.9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Inherited platelet function disorders are of variable severity and unknown frequency and may be difficult to diagnose. Nevertheless, they are increasingly recognized as an important cause of bleeding in pediatrics, particularly in adolescent girls with menorrhagia, where they may be more common than von Willebrand disease. This article reviews the presentation of these disorders, summarizes the most common types of platelet function disorders, discusses the challenges in diagnostic testing, and details treatment and supportive care options.
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Affiliation(s)
- Dana C Matthews
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Cancer and Blood Disorders Center, Seattle Children's Hospital MS MB.8.501, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA.
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Mills HL, Abdel-Baki MS, Teruya J, Dietrich JE, Shah MD, Mahoney D, Yee DL, Srivaths LV. Platelet function defects in adolescents with heavy menstrual bleeding. Haemophilia 2013; 20:249-54. [DOI: 10.1111/hae.12293] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 11/30/2022]
Affiliation(s)
- H. L. Mills
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - M. S. Abdel-Baki
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - J. Teruya
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
- Division of Transfusion Medicine; Baylor College of Medicine; Houston TX
| | - J. E. Dietrich
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Department of Obstetrics & Gynecology; Baylor College of Medicine; Houston TX USA
| | - M. D. Shah
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - D. Mahoney
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - D. L. Yee
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - L. V. Srivaths
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
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Seravalli V, Linari S, Peruzzi E, Dei M, Paladino E, Bruni V. Prevalence of hemostatic disorders in adolescents with abnormal uterine bleeding. J Pediatr Adolesc Gynecol 2013; 26:285-9. [PMID: 24012130 DOI: 10.1016/j.jpag.2013.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 05/30/2013] [Accepted: 06/03/2013] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE To evaluate the incidence of hemostatic disorders in a population of adolescents with various patterns of abnormal uterine bleeding (AUB). DESIGN Retrospective observational study. SETTING University hospital. PARTICIPANTS One hundred thirteen adolescents with AUB; mean age at menarche and mean age at the onset of symptoms 12 ± 1.2 years and 13.5 ± 2.8 years, respectively. MAIN OUTCOME MEASURES Data on menstrual history, bleeding symptoms, co-existing medical conditions, and medical therapies were assessed. All patients were screened for hemostatic disorders with laboratory testing. The incidence of the disorders was calculated. Subjects were further divided in 2 groups based on whether the AUB started in the first 2 years from menarche (group 1) or later (group 2). A statistical analysis was performed using a chi-square test to compare incidence of hemostatic disorders between the groups. RESULTS One hundred thirteen adolescents with AUB were identified. Overall, 54 (47.8%) patients had some underlying hemostatic disorder, of which a platelet dysfunction was the most common (17.7%). Von Willebrand disease was detected in 13.3% of cases and a deficiency of a coagulation factor in 12.4%. In 7.1% of patients an isolated increase of bleeding time was observed. When divided in 2 groups, 44.2% of patients in group 1 and 59.2% in group 2 had a coagulation disorders, with no statistically significant difference between the 2 groups (P = .17). CONCLUSION AUB in adolescents is frequently associated with an underlying disorder of hemostasis, most commonly a platelet function disorder. The results highlight the importance of screening for coagulation disorders in adolescents with AUB, independently from the gynecologic age at onset.
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Affiliation(s)
- V Seravalli
- Pediatric and Adolescent Gynecology Unit, Department of Science for Child and Women's Health, University of Florence, Florence, Italy.
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Naik S, Teruya J, Dietrich JE, Jariwala P, Soundar E, Venkateswaran L. Utility of platelet function analyzer as a screening tool for the diagnosis of von Willebrand disease in adolescents with menorrhagia. Pediatr Blood Cancer 2013; 60:1184-7. [PMID: 23335259 DOI: 10.1002/pbc.24456] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/04/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD), and in particular, VWD type 1 and low VW factor (defined as Von Willebrand Ristocetin cofactor activity (RCoF) <30 and <50 IU/dl, respectively with normal multimers) are frequently detected in adolescents with menorrhagia and both groups benefit from similar management. Platelet function analyzer (PFA-100®) is often used as a screening test to detect VWD. We analyzed the utility of PFA-100® as a screening tool in the detection of VWD type 1 and low VW factor (VWF) in an exclusive adolescent population with menorrhagia. METHODS The study population consisted of adolescents with menorrhagia who had simultaneously drawn blood samples for VWD and PFA-100®. Abnormal PFA-100® was defined as values >183 seconds for collagen/epinephrine and/or >126 seconds for collagen/ADP. RESULTS Of a total of 235 patients tested, 23 patients had RCoF <50 IU/dl and normal multimer patterns. Statistical analysis of the utility of PFA-100® in detecting RCoF <50 IU/dl with normal multimers yielded sensitivity, specificity, positive predictive, and negative predictive values of 52%, 89%, 34%, and 95%, respectively. CONCLUSIONS Based on our results, PFA-100® was not sufficiently sensitive to detect RCoF values <50 IU/dl with normal multimer patterns in teen-aged women with menorrhagia. We conclude that in the setting of adolescent menorrhagia, PFA-100® does not have utility as an initial screening test for the diagnosis of VWD and in particular, low VWF and that clinicians need to be aware of this limitation of PFA-100® while evaluating adolescents with menorrhagia.
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Affiliation(s)
- Swati Naik
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Dumont T, Allen L, Kives S. Can von Willebrand disease be investigated on combined hormonal contraceptives? J Pediatr Adolesc Gynecol 2013; 26:138-41. [PMID: 22206686 DOI: 10.1016/j.jpag.2011.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 10/24/2011] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To review the medical literature and determine whether testing for von Willebrand disease can be performed in adolescents using combined hormonal contraceptives (CHC). DESIGN Literature review where Embase and Medline were searched using the key words "von Willebrand factor," "von Willebrand disease," "contraceptive agents," and "menorrhagia." Articles were included in the review if they were controlled trials comparing a current form of CHC versus a control group and testing for von Willebrand factor was performed and reported. MAIN OUTCOME MEASURES Impact of combined hormonal contraceptives on von Willebrand factor antigen. Secondary outcomes included effects on Factor VIII and von Willebrand factor activity known as the Ristocetin cofactor. RESULTS Seven articles met inclusion criteria. All seven assessed VWF Ag with CHC use; six of the seven demonstrated no change and one, Gevers Leuven, demonstrated a significant decrease after CHC use. Three studies measured Factor VIII and showed no significant change with use. One study by Kadir assessed the Ristocetin cofactor and also failed to demonstrate change on CHC. CONCLUSION From the literature it appears that adolescents, assessed for menorrhagia and already on combined hormonal contraceptives, can be tested for von Willebrand disease if this diagnosis is suspected by the physician. By allowing adolescents to remain on combined hormonal contraceptives during testing, one avoids the risk of recurrent and severe menorrhagia which could result in admission and transfusion.
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Affiliation(s)
- Tania Dumont
- Section of Gynecology, Division of Endocrinology, Sick Kids Hospital, Toronto, Canada.
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Chapter 5 Special Scenarios. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013. [DOI: 10.1016/s1701-2163(15)30738-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Khair K, Holland M, Pollard D. The experience of girls and young Women with inherited bleeding disorders. Haemophilia 2013; 19:e276-81. [DOI: 10.1111/hae.12155] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
- K. Khair
- Haemophilia Centre; Great Ormond Street Hospital for Children NHS Foundation Trust; London; UK
| | | | - D. Pollard
- Haemophilia Centre; Royal Free Hospital; London; UK
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Venkateswaran L, Dietrich JE. Gynecologic concerns in pubertal females with blood disorders. J Pediatr Adolesc Gynecol 2013; 26:80-5. [PMID: 23095526 DOI: 10.1016/j.jpag.2012.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/02/2012] [Accepted: 07/03/2012] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The incidence and prevalence of blood disorders varies depending on the underlying etiology, age, ethnicity, family history, and presence of comorbid medical conditions. Gynecologic problems occurring around puberty may cause stress to families and patients, as well as management challenges to providers. RECENT FINDINGS Management strategies in the setting of bleeding disorders include hormonal and non-hormonal options to address problems occurring around puberty. Management strategies in the setting of clotting disorders allow providers to address common problems occurring in adolescence, while minimizing risk of venous thromboembolism. SUMMARY Preparedness is important at this time of life, not only to prevent unwanted gynecologic complications or hospitalizations related to specific blood conditions, but also to identify problems related to reproductive care that may be exacerbated or complicated by an underlying blood disorder.
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Affiliation(s)
- Lakshmi Venkateswaran
- Section of Pediatric Hematology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Amesse LS, Pfaff-Amesse T, Gunning WT, Duffy N, French JA. Clinical and laboratory characteristics of adolescents with platelet function disorders and heavy menstrual bleeding. Exp Hematol Oncol 2013; 2:3. [PMID: 23347697 PMCID: PMC3584827 DOI: 10.1186/2162-3619-2-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 01/19/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platelet function disorders (PFDs) have emerged as an important etiology of heavy menstrual bleeding (HMB) in adolescents. However, neither clinical nor laboratory data have been methodically analyzed in this population subset. The objective of this study was to evaluate these parameters in order to distinguish characteristics of the disorder that in turn will lead to earlier diagnosis and therapy initiation. METHODS Retrospective review of medical records from postmenarcheal adolescents with documented PFDs referred to a hemophilia treatment center and university faculty practices for bleeding diatheses with their clinical and laboratory data evaluated. RESULTS Of 63 teens with documented PFDs, HMB was the most common clinical manifestation of PFD (43; 68.3%). Of these, 37 (86%) were diagnosed with PFD either at or after menarche with the diagnosis based on HMB symptoms alone. Only 6 (14%) were diagnosed with a PFD prior to menarche, based on associated bleeding, i.e., epistaxis, ecchymosis, and all developed HMB after menstruation onset. Interestingly, 20 girls were diagnosed with a PFD prior to menarche and of these, only 6 (30%) went on to develop HMB after pubertal transition, while the majority (14; 70%) did not. The average age-at-PFD diagnosis was 14.5yrs, significantly differing from the 10.9yrs average age-at-PFD diagnosis in their counterparts that, after menarche, did not develop HMB (P<.01) Blood type O occurred significantly more frequently (76%) than national norms (P <.037). Incidence of δ-Storage Pool deficiency (δ-SPD) was significantly higher (74%) than their non-HMB cohorts (45%) (P <.007). Coagulation and von Willebrand factor studies were all normal. Abnormal closure times and aggregation studies were observed in 42% and 60%, respectively, of tested girls. In 25.6% for whom standard platelet studies were normal, electron microscopy detected reduced platelet δ-granules numbers (δ-SPD). CONCLUSIONS Adolescents with PFDs and HMB appear to be clinically distinct from their non-HMB counterparts. This group of girls is characterized by HMB the major bleeding symptom, significantly high incidences of blood group O and the δ-SPD with a PFD diagnosed well after menarche. High false negative standard platelet function study results indicate additional diagnostic strategies, particularly for δ-SPD, should be considered.
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Affiliation(s)
- Lawrence S Amesse
- Division of Reproductive Endocrinology and Infertility, Department of OB-GYN, Section of Pediatric-Adolescent Gynecology, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
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Vo KT, Grooms L, Klima J, Holland-Hall C, O'Brien SH. Menstrual bleeding patterns and prevalence of bleeding disorders in a multidisciplinary adolescent haematology clinic. Haemophilia 2012; 19:71-5. [PMID: 23005346 DOI: 10.1111/hae.12012] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2012] [Indexed: 11/29/2022]
Abstract
Heavy menstrual bleeding (HMB) is a frequent complaint in adolescence. Although HMB is often caused by immaturity of the hypothalamic-pituitary-ovarian axis, bleeding disorders are another common yet often unidentified cause. The aim of this study was to examine the bleeding patterns and prevalence of inherited bleeding disorders among females referred for HMB to a multidisciplinary adolescent haematology clinic. We retrospectively reviewed the first 105 patients (ages 8-18 years) referred to this specialty clinic from February 2009 to December 2011. Using menstrual bleeding questionnaires and medical records, data were extracted regarding demographics, bleeding patterns, frequency and types of bleeding disorders identified, and prescribed interventions. Sixty-two per cent of patients were diagnosed with a bleeding disorder, including platelet storage pool deficiency (36%), von Willebrand's disease (9%), other platelet function defect (8%), Ehlers-Danlos syndrome (7%) and combined bleeding disorders (2%). Comparison of the bleeding profiles for females with and without a bleeding disorder revealed only three factors that were significantly different, including the reported regularity of patients' periods (P = 0.02), description of period flow (P = 0.04) and number of days of each period that the bleeding was described as 'heavy' (P = 0.007). Bleeding disorders are prevalent in adolescent females presenting to a specialty clinic. Specifically, a relatively high proportion of adolescents were diagnosed with platelet storage pool deficiency. In our small population, menstrual bleeding profiles, as examined by a standardized questionnaire, could not identify females with an underlying bleeding disorder, demonstrating the important role of haemostasis testing in the evaluation of adolescents with HMB.
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Affiliation(s)
- K T Vo
- Department of Pediatrics, The Ohio State University/Nationwide Children's Hospital, Columbus, OH, USA
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Successful Management of Acute Catastrophic Juvenile Vaginal Bleeding in Glanzmann's Thromboasthenia by Uterine Tamponade: A Case Report and Review of The Literature. Case Rep Hematol 2012; 2012:530908. [PMID: 22928124 PMCID: PMC3420404 DOI: 10.1155/2012/530908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 01/16/2012] [Indexed: 11/17/2022] Open
Abstract
Glanzmann's thromboasthenia (GT) is a rare platelet disorder, due to membrane defects involving glycoprotein GP IIb/IIIa complex. Symptoms appear in infancy with episodes of bruising, gingival bleeding, epistaxis, or at the time of menarche acute episode of uterine bleeding. Hormonal therapy and antifibrinolytic agents are first-line treatment. Platelet transfusion is given to control hemorrhage when medical treatment fails. However, repeated transfusions may result in development of platelet refractioness, due to development of antibodies against membrane glycoprotein. Activated recombinant FVII is licensed for use in acute control of bleeding in GT. Here we report a case of acute juvenile uterine bleeding at menarche, which responded successfully to uterine tamponade. To our knowledge, this is the first case report on use of balloon tamponade for control of acute catastrophic juvenile bleeding at menarche.
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Revel-Vilk S, Paltiel O, Lipschuetz M, Ilan U, Hyam E, Shai E, Varon D, Revel A. Underdiagnosed menorrhagia in adolescents is associated with underdiagnosed anemia. J Pediatr 2012; 160:468-72. [PMID: 21925680 DOI: 10.1016/j.jpeds.2011.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 06/20/2011] [Accepted: 08/04/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To test the hypothesis that adolescent girls with menorrhagia rarely seek medical attention. STUDY DESIGN A total of 705 adolescent girls attended a lecture on menorrhagia, completed an initial anonymous questionnaire, and were asked to participate in a more comprehensive study comprising a detailed bleeding questionnaire, a pictorial blood loss assessment chart, and blood tests. RESULTS A total of 105 adolescents (15%) reported they had heavy periods on the initial questionnaire. Among the 94 girls who completed the full questionnaire, 34 reported menorrhagia (36%; 95% CI, 26.5%-46.7%). Almost one-third (11 of 34) of these girls did not perceive having menorrhagia according to their response to the initial questionnaire. Menorrhagia was not related to age, years since menarche, or family history of menorrhagia. Among the 62 girls who consented to blood testing, 6 had anemia (9.6%; 95% CI, 3.6%-19.6%), all of whom had bleeding symptoms. CONCLUSION Using standardized questionnaires, we were able to identify adolescents with menorrhagia associated with anemia. Importantly, some of these adolescents were not aware of having menorrhagia and/or anemia. Screening programs for menorrhagia in schools could result in better detection of menorrhagia among adolescents and consequent appropriate referral for medical consultation.
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Affiliation(s)
- Shoshana Revel-Vilk
- Pediatric Hematology/Oncology Department, Hadassah Hebrew University Hospital, Jerusalem, Israel.
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Halimeh S. Menorrhagia and bleeding disorders in adolescent females. Hamostaseologie 2011; 32:45-50. [PMID: 22127528 DOI: 10.5482/ha-1181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/06/2011] [Indexed: 11/05/2022] Open
Abstract
In women, von Willebrand disease (VWD) is the most common inherited bleeding disorder. Since VWD and other inherited bleeding disorders are autosomal disorders, they affect women and men. Menorrhagia, or heavy menstrual bleeding (HMB), is the most common symptom of women with bleeding disorder experience. Objectively, it is defined as bleeding that lasts for more than seven days or results in the loss of more than 80 ml of blood per menstrual cycle. The prevalence of menorrhagia in a woman with a bleeding disorder ranges from 32 to 100% in patients with VWD, from 5 to 98% in patients with a platelet dysfunction and from 35 to 70% in women with a rare factor deficiency. A detailed history and a careful physical exam are the first steps towards a diagnosis in adolescents, adding a PBAC>100 increased the sensitivity of the screening tool further to 95%. Laboratory testing should be made at the time of menstrual bleeding in an effort to capture the lowest level of VWF:Ag and FVIII:C. Treatment options for menorrhagia in VWD: (1) antifibrinolytic therapy with tranexamic acid, (2) the non-transfusional agent desmopressin (DDAVP), (3) purified blood products that contain factor VIII and VWF concentrated from plasma and (4) hormonal preparations.
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Affiliation(s)
- S Halimeh
- Medical Thrombosis and Haemophilia treatment Center, Duisburg, Germany.
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Mikhail S, Kouides P. von Willebrand disease in the pediatric and adolescent population. J Pediatr Adolesc Gynecol 2010; 23:S3-10. [PMID: 20934894 DOI: 10.1016/j.jpag.2010.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/30/2022]
Abstract
Recent studies indicate that bleeding disorders, particularly von Willebrand disease (VWD) is more prevalent than previously thought in adolescents with menorrhagia. Menorrhagia management in undiagnosed disorders of hemostasis may be associated with unwanted risks and complications. The prevalence of symptomatic VWD in the pediatric primary care setting appears to be 0.11% (95% CI, 0.04-0.25%). Studies evaluating the prevalence of VWD in adolescents with menorrhagia have included over 500 patients with a prevalence range from 3 to 36% depending on the clinical setting studied, with the highest prevalence seen in adolescents referred to an outpatient Hemophilia Center, while the lowest prevalence is seen in the acute hospital setting. Recently, the diagnosis of VWD has been facilitated by the use of pediatric bleeding questionnaires that have proved useful in quantifying the severity of bleeding symptoms. Treatment of VWD is often complex because a combination of therapies is often required. Potential treatment options include estrogen-progesterone preparations, desmopressin, antifibrinolytic agents and von Willebrand factor concentrates. More research is needed to evaluate the effectiveness of the various treatment modalities in the adolescent population.
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Affiliation(s)
- Sameh Mikhail
- Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC, USA
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Overview of bleeding disorders in adolescent females with menorrhagia. J Pediatr Adolesc Gynecol 2010; 23:S15-21. [PMID: 20934893 DOI: 10.1016/j.jpag.2010.08.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/23/2022]
Abstract
Women bleed with menses, during childbirth, and after childbirth. Women are more likely to manifest a bleeding disorder as they have more opportunities to experience bleeding challenges in their lifetime. Bleeding disorders such as hemophilia and von Willebrand disease affect 2.5-3 million American women. The most common inherited bleeding disorder in the population is von Willebrand disease with an estimated prevalence of 1-2%. von Willebrand factor (vWF) is required to adhere platelets to exposed subendothelium and protects factor VIII from proteolysis in the circulation. The prevalence of vWF rises in studies involving women with menorrhagia, with estimates ranging as high as 10-20% in white women, and 1-2% among African American women. Other bleeding disorders seen in adolescents with menorrhagia are disorders of inherited platelet dysfunction, clotting factor deficiencies, thrombocytopenia, and disorders of the fibrinolytic pathway. Not only are women more likely to present early in their life with a bleeding disorder, they are also more likely to have other gynecologic manifestations as a result of these disorders. This article presents an overview of the problem and touches upon the different management strategies available.
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Wilkinson JP, Kadir RA. Management of abnormal uterine bleeding in adolescents. J Pediatr Adolesc Gynecol 2010; 23:S22-30. [PMID: 20869283 DOI: 10.1016/j.jpag.2010.08.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey P Wilkinson
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.
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James AH. Obstetric management of adolescents with bleeding disorders. J Pediatr Adolesc Gynecol 2010; 23:S31-7. [PMID: 20934895 DOI: 10.1016/j.jpag.2010.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/10/2010] [Indexed: 12/17/2022]
Abstract
Adolescents with bleeding disorders who become pregnant must contend with the dual challenges of their bleeding disorder and their pregnancy. Adolescents are more likely to terminate a pregnancy than adult women, and when they do carry a pregnancy, they are more likely to deliver prematurely. Otherwise, they are at risk for the same complications that adult women with bleeding disorders experience, particularly bleeding complications postpartum. Since one half to two thirds of adolescent pregnancies are unplanned, issues related to reproduction should be addressed during routine visits with the pediatrician, hematologist or gynecologist. Girls who are at risk of being carriers for hemophilia A and B, severe von Willebrand disease, and other severe bleeding disorders should have their bleeding disorder status determined before they become pregnant. During pregnancy, a plan should be established to ensure that both mother and fetus deliver safely. Young women at risk for severe bleeding or at risk of having a severely affected infant should be referred for prenatal care and delivery to a center where, in addition to specialists in high-risk obstetrics, there is a hemophilia treatment center or a hematologist with expertise in hemostasis. Prior to delivery or any invasive procedures, young women at risk for severe bleeding should receive prophylaxis. Since administration of desmopressin may result in hyponatremia, whenever available, virally inactivated or recombinant clotting factor concentrates should be used for replacement as opposed to fresh frozen plasma or cryoprecipitate.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.
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Abstract
Acquired and inherited platelet disorders can present with bleeding symptoms during adolescence. Platelet disorders include disorders of platelet number and disorders of platelet function. In adolescent females with platelet disorders, menorrhagia is a common presenting bleeding symptom. Other associated bleeding symptoms are also primarily mucocutaneous, including epistaxis and bruising. Excessive bleeding may also occur after hemostatic challenges. Diagnosis of disorders of platelet function usually requires light transmission platelet aggregometry. Management of menorrhagia in the adolescent with platelet disorders requires both hematologic and gynecologic treatment.
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Affiliation(s)
- Claire S Philipp
- University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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Crosnier H, Thibaud E, Duflos C, Polak M. Norethisterone-induced hepatic adenomas can cause life-threatening bleeding in girls with inherited platelet disorders. Fertil Steril 2010; 94:2329.e1-3. [DOI: 10.1016/j.fertnstert.2010.03.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/21/2010] [Accepted: 03/15/2010] [Indexed: 11/16/2022]
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de Raucourt E, Ternisien C. [Appropriate laboratory investigation in women with menorrhagia]. ACTA ACUST UNITED AC 2009; 37 Suppl 8:S317-28. [PMID: 19268209 DOI: 10.1016/s0368-2315(08)74771-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inherited bleeding disorders are potentially causes of menorrhagia and must be investigated if no specific cause is identified. The reported prevalence of inherited bleeding disorders is high in women with menorrhagia compared to the general population. The most frequent disorders reported are von Willebrand's disease and Factor XI deficiency. Menorrhagia is, also, a frequent finding in women with congenital bleeding disorders. Morever, menorrhagia represents the major cause of iron-deficiency anemia among women of reproductive age. Primary evaluation for an underlying disorder of hemostasis in a woman wih menorrhagia is a focused history for familiy and personal history of bleeding symptoms and a complete blood cell count. This will rule out thrombocytopenic bleeding and also assesses for the degree, if any, of anemia. Those women with a positive screen and normal platelet count should be evaluated with laboratory investigation including prothrombin time, activated partial thromboplastin time, factor VIII, VWF ristocetin cofactor and antigen. If initial hemostasis testing above is normal, then further hemostasis testing can be considered, especially in terms of platelet aggregation, in a multidisciplinary clinic.
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Affiliation(s)
- E de Raucourt
- CHI Poissy-Saint-Germain-en-Laye, laboratoire d'hématologie, 10, rue du Champ-Gaillard, BP 3082, 78303 Poissy cedex, France
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Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol 2009; 201:12.e1-8. [PMID: 19481722 DOI: 10.1016/j.ajog.2009.04.024] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 03/05/2009] [Accepted: 04/09/2009] [Indexed: 12/20/2022]
Abstract
Reproductive tract bleeding in women is a naturally occurring event during menstruation and childbirth. In women with menorrhagia, however, congenital bleeding disorders historically have been underdiagnosed. This consensus is intended to allow physicians to better recognize bleeding disorders as a cause of menorrhagia and consequently offer effective disease-specific therapies.
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Sundström A, Seaman H, Kieler H, Alfredsson L. The risk of venous thromboembolism associated with the use of tranexamic acid and other drugs used to treat menorrhagia: a case-control study using the General Practice Research Database. BJOG 2008; 116:91-7. [PMID: 19016686 DOI: 10.1111/j.1471-0528.2008.01926.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether use of tranexamic acid is associated with an increased risk of venous thromboembolism (VTE). DESIGN Nested case-control study. SETTING Database study using the General Practice Research Database for the years 1992-1998. POPULATION Women aged 15-49 years with a diagnosis of menorrhagia. METHODS Multivariate conditional logistic regression was used to estimate the risk for VTE associated with different drug treatments for menorrhagia, adjusting for confounders. MAIN OUTCOME MEASURES Adjusted odds ratios with 95% CI. RESULTS A total of 134 cases of VTE and 552 matched controls were identified. Recent use of tranexamic acid was scarce, yielding an adjusted odds ratio for VTE of 3.20 (95% CI 0.65-15.78). The use of mefenamic acid (ORadj 5.54 [95% CI 2.13-14.40]) or norethisterone (ORadj 2.41 [95% CI 1.00-5.78]) was associated with an increased risk of VTE, as was a recent--in relation to menorrhagia--diagnosis of anaemia or a haemoglobin value <11.5 g/dl (ORadj 2.23 [95% CI 1.02-4.86]). CONCLUSIONS We found that tranexamic acid was associated with an increased risk of VTE, although the risk estimate did not reach statistical significance. Increased risks of VTE associated with other treatments for menorrhagia were observed. The increased risk of VTE observed with a diagnosis of anaemia--a proxy for more severe menorrhagia--suggests that menorrhagia could be a prothrombotic condition. The observed association between VTE, tranexamic acid and other treatments for menorrhagia may thus partly be explained by confounding by indication. The possibility that menorrhagia is itself a risk factor for VTE merits further investigation.
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Affiliation(s)
- A Sundström
- Centre for Pharmacoepidemiology, Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
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