Consensus: Menorrhagia work-up should include consideration of a bleeding disorder

The July 2009 issue of the American Journal of Obstetrics and Gynecology will report the results of a September 2007 consensus conference, with participation by experts in ob-gyn and hematology on the diagnosis and management of reproductive tract bleeding in women with bleeding disorders http://www.ajog.org/article/S0002-9378(09)00410-4/fulltext. The conference was predicated on the belief that the lack of awareness of the potential of bleeding disorders to exacerbate or cause abnormal bleeding leads to underdiagnosis and suboptimal treatment of women with bleeding disorders.
The report brings to light some interesting numbers. For example, the prevalence of menorrhagia in women with von Willebrand Disease (vWD) is between 74 and 92%; conversely, the prevalence of vWD in women with menorrhagia is between 5-24% A study was cited that reported a 33% prevalence of vWD is adolescents with menorrhagia.
The fact that as many as one in every four women with menorrhagia could have a diagnosis of vWD is an impressive one, and surprising. The statistic of one in three for adolescents is even more striking.
The report points out that most women with menorrhagia do not have a bleeding disorder and that even in women with a known bleeding disorder, a gyn evaluation for other causes of bleeding is still mandatory. An underlying bleeding disorder should be considered, however, if any of the following indicators are present:
menorrhagia since menarche
family history of bleeding disorder
personal history of epistaxis lasting more than 10 minutes or necessitating packing or cautery
"notable" bruising without injury
minor wound bleeding, e.g. from trivial cuts, lasting for more than five minutes
bleeding from an oral cavity or GI tract without obvious anatomic lesion
prolonged bleeding after dental extraction
unexpected postsurgical bleeding
hemorrhage from ovarian cysts or corpus luteum, with or without Mittelschmerz
hemorrhage requiring blood transfusion
postpartum hemorrhage, especially when delayed
failure of response to conventional management of menorrhagia
Hematologic evaluation is most sensitive during menstruation, when coagulation factors are at their lowest. However, evaluation should not be delayed until menstruation. Tests can be repeated during menstruation if initial testing is at low normal. Patients should not be removed from contraceptives to permit testing although patients with mild vWD may have normal results when contraceptives are being used. A concluding comment from this article includes the following: "collaboration among obstetrician-gynecologists and hematologists ...could lead to a decrease in the diagnosis of "idiopathic" menorrhagia and allow more effective management of bleeding events." Another conclusion reached is that consideration of bleeding disorders in menorrhagia can lead to improved management of post-partum hemorrhage.