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Presence of bleeding disorders in premenopausal women a rising concern
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Bleeding disorders in premenopausal women are a significant problem that affects approximately 3 million women in the United States. However, many physicians, including hematologists, gynecologists and their patients, are unaware of how to recognize potential disorders.
In a special symposium on bleeding disorders in women’s health at the 48th Annual Meeting of the American Society of Hematology, Vincent Picozzi, MD, hematologist-oncologist at Virginia Mason Medical Center in Seattle, discussed bleeding disorders in premenopausal women, and how physicians should be aware of this new public health crisis.
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“So many women go undetected because they are unaware that their bleeding symptoms are abnormal,” Picozzi said in an interview. “Also, many providers either do not consider the possibility of a bleeding disorder, or consider it unproductive to diagnose as such.”
According to Picozzi, a study of 1,400 Swedish girls found that although less than 1% had a diagnosed bleeding disorder, 10% had three or more bleeding disorder symptoms, and 40% had a history of menorrhagia.
Raising awareness
Detecting potential bleeding disorders in premenopausal women is not solely the responsibility of hematologists and patients. Pediatricians, gynecologists and other physicians play a significant role in identifying potential problems.
“Primary care physicians need to be at least aware of when the possibility of a bleeding disorder in a premenopausal patient might exist,” said Picozzi, who is also chairman of the subcommittee on quality in hematology for ASH. “[PCPs] then need a hematology referral source to pursue the issue diagnostically or therapeutically.”
Raising this awareness is not an easy task, but during Picozzi’s discussion, other physicians also reinforced the importance of raising awareness, and discussed potential approaches to take.
“I think it’s a three-pronged approach,” said Andra James, MD, an assistant professor of obstetrics and gynecology at Duke University. “We can help make potential patients more aware, we can educate our fellow providers, not only in hematology and OB/GYN, but also primary care, and we can elicit the support of policy makers and potential sponsors.”
Clinicians should also consider adding a fifth vital sign for women, along with checking blood pressure, pulse, respiration and temperature.
“Why not ask young women about their periods?” said Margaret Ragni, MD, professor of medicine in the division of hematology/oncology at the University of Pittsburgh. “This is a great way to raise awareness, because it allows the patient to tell you there may be a problem, and you learn early on that there’s a problem.”
Part of the problem is defining what a normal menstrual cycle is. According to James, previous studies evaluated what symptoms correlated with a menstrual blood loss of more than 80 mL per cycle. In one study, 95% of women had blood loss of 60 mL or less during the cycle, and the researchers arbitrarily decided 80 mL was a standard for too much blood loss.
James said another study identified the following signs and symptoms which correlated with a blood loss of 80 mL of more, supporting a diagnosis of menorrhagia: clots one inch or more in diameter, low ferritin in blood tests, and soaking through a pad in one hour’s time or bleeding through night clothes and soaking sheets.
Ragni added many women who have a history of heavy periods are often assumed to have menorrhagia. However, many women with an underlying bleeding disorder do not just menorrhagia, but also have a history of other symptoms such as bruising or nosebleeds.
These are only guidelines, as there are no definitive symptoms or tests for bleeding disorders in premenopausal women. Picozzi said that there are diagnostic tools being developed and research is being conducted to learn more about these disorders that place millions at risk for serious medical complications.
“Patients need to be more aware of the circumstances that might suggest they have a disorder, primary care providers must have a ‘higher index of suspicion’ for these diagnoses in patients at risk,” Picozzi said. – by Emily Shafer
For more information:
- Picozzi V. Bleeding disorders in premenopausal women: another public health crisis in hematology? Presented at: 48th Annual Meeting of the American Society of Hematology; Dec. 9-12, 2006; Orlando, Fla.