The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalities

• Published in: American journal of obstetrics and gynecology Vol. 209; no. 3; pp. 202.e1 - 202.e7
• Main Authors: Knol, H. Marieke, MD, PhD, Mulder, André B., MD, PhD, Bogchelman, Dick H., MD, Kluin-Nelemans, Hanneke C., MD, PhD, van der Zee, Ate G.J., MD, PhD, Meijer, Karina, MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-09-2013
• Subjects: Adolescent; Adult; bleeding disorder; Cohort Studies; factor XI; Factor XI - analysis; Female; heavy menstrual bleeding; Hemorrhagic Disorders - complications; Hemorrhagic Disorders - epidemiology; Hemostasis; Humans; menorrhagia; Menorrhagia - etiology; Middle Aged; Obstetrics and Gynecology; Platelet Aggregation; Prevalence; Prospective Studies; von Willebrand's disease; factor XI; menorrhagia; heavy menstrual bleeding; bleeding disorder; von Willebrand's disease
• ISSN: 0002-9378; 1097-6868
• DOI: 10.1016/j.ajog.2013.05.059

Objective The purpose of this study was to assess the prevalence of underlying bleeding disorders in women with heavy menstrual bleeding (HMB) with and without gynecologic abnormalities. Study Design We performed a single-center prospective cohort study of 112 consecutive patients who were referred for heavy menstrual bleeding. Control subjects were 28 healthy volunteers who reported no HMB. Patients and control subjects had hemostatic testing in the first week after menstruation. Patients underwent gynecologic evaluation. Results The median age was 42.5 years (range, 17–55 years) in patients and 40.0 years (range, 25–55 years) in control subjects. Forty-six percent of patients had anemia; the median pictorial bleeding assessment chart score was 271. Seven percent of the control subjects with a subjectively normal menstruation had anemia. Twenty-six percent of patients had gynecologic abnormalities, which was considered to explain HMB. Overall, we found an underlying bleeding disorder in 29% of the patients, which was comparable for unexplained and explained HMB (31% vs 27%; P  = .75). We diagnosed 6 cases of Von Willebrand's disease, 4 cases of factor XI deficiency, and 1 case of factor VII deficiency. The only abnormalities that we found in control subjects were platelet aggregation defects (11% in control subjects vs 23% in patients). Patients had a significantly longer activated partial thromboplastin time compared with control subjects (26.5 vs 25.0 seconds; P  = .001) that was caused by lower median levels of factor XI (100 vs 124 IU/dL; P < .001). Conclusion Bleeding disorders play an equally important role in the cause of both unexplained and explained heavy menstrual bleeding. A novel finding is the occurrence of low, but not deficient, levels of factor XI.