Menorrhagia Coagulation Workup
Unexplained menorrhagia is a common clinical problem among women of reproductive age, and is the presenting symptom for the majority of hysterectomies performed in the USA. Approximately 20% of hysterectomies are performed for “dysfunctional” uterine bleeding, not attributable to a specific diagnosis. Recent studies have indicated that there is a high incidence of hemostatic disorders among women with menorrhagia. Von Willebrand disease (VWD) is the most common hereditary disorder of hemostasis, affecting approximately 1% of individuals worldwide, and has been reported to be present in 6-20% of women with menorrhagia. Menorrhagia is the most common bleeding symptom in females with VWD, occurring in 93% of adult women with the disease, and is the initial bleeding symptom with onset at menarche in 51% of cases. Platelet function defects are also common in this group of patients – in one study platelet aggregation defects were identified in 47% of women with unexplained menorrhagia; in another study an inherited platelet function disorder was diagnosed in 13% of women with menorrhagia.
In spite of this data, women in the USA with unexplained menorrhagia are rarely evaluated for inherited bleeding disorders. In a recent survey of 1,444 women conducted on behalf of the National Hemophilia Foundation, 10% reported that their periods lasted more than 7 days, and 33% reported their menstrual flow as heavy, however not one of these women was diagnosed with VWD. In another recent survey, 376 US gynecologists reported that 8% of their patients complained of menorrhagia, however only 4% of the physicians considered a diagnosis of VWD for women of reproductive age, and only 16% considered this diagnosis in girls around menarche. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice made the following recommendation in 2001: “Inherited and acquired disorders of coagulation and hemostasis should be considered in the differential diagnosis of menorrhagia and abnormal uterine bleeding”. Prompt diagnosis of VWD or a platelet function defect in women with menorrhagia would lead to appropriate and effective management of bleeding, and avoidance of unnecessary surgery.
A comprehensive diagnostic workup for bleeding disorders can be complex and expensive, however a new convenient screening test is now available for in vitro evaluation of platelet function. This test, known as the platelet function screen or
PFA-100a, is highly sensitive for diagnosis of VWD (88-100% sensitive) and platelet function disorders (>90% sensitive). If a normal result is obtained further testing is usually not indicated. If an abnormal result is obtained further laboratory testing is indicated (VWD panel and platelet aggregation). In a recent evaluation of this assay in women with menorrhagia, the authors concluded that this test offers a simple and relatively inexpensive way to screen for underlying bleeding disorders. One 5mL sodium citrate (light blue top) tube is required. The sample must be received by the laboratory within 3 hours of collection.
