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Women and bleeding
Dr. Nita RadhakrishnanSir Ganga Ram Hospital,
New Delhi, India
Annual Meet WG HFI 6 Dec 2014
Woman
• Challenges in the life of a woman – Many
• Hemostatic challenges in the life of a woman
– Menstruation (Menorrhagia = Heavy menstrual bleeding)– Pregnancy – Childbirth
Bleeding disorders in women
Hemophilia A, B carrier state
Von Willebrand disease
Rare bleeding disorders
Inherited platelet disorders
Royal disease
• Queen Victoria • Had no ancestors with hemophilia • 9 children • Disease appeared in her 8th child Leopold who was
“very delicate” • “We must have some strong blood”
• Spread to the royal family of England • Spread to German, Russian and Spanish royal families
Von Willebrand disease
• Most common bleeding disorder • 1% of the population • Eric von Willebrand
• Index case: 5 year old died eight years later following menstrual bleeding
• 23 affected family members • Her grandmother died following delivery
Menstrual Cycle is a Vital Sign• American College of Obstetricians and Gynecologists• American Academy of Pediatrics
• Normal menstruation – Begins at 11 to 14 years of age– Normal interval is is 21 to 45 days– Normal length of menstrual flow is 7 days or less – Not more than 3-6 pads/ tampons per day
• What is not normal? – Heavy menstrual bleeding
• >7 days • Loss of more than 80 ml per menstrual cycle
– Ovarian cysts with bleeding – Endometriosis – Bleeding following delivery lasting > 24hours
Ovarian cysts with bleeding
• Ovulation with bleeding is never normal• 7% of VWD reported to have bleeding ovarian cysts
• Can bleed into the abdominal cavity• Increases risk of endometriosis
Pregnancy and bleeding
• 4067 deliveries in women with vWd • 2000-2003 (USA)
• Risk of bleeding before delivery 10.2• Risk of bleeding following delivery 1.5• Risk of receiving blood transfusion 4.7 • Risk of death in mother low (but still high than
normal women)
James A 2007
• Childbirth in women with inherited bleeding disorders
Primary PPH Secondary PPH
Normal 5 0.7%
Hemophilia carriers
22% 11%
VWD 19% 29%
It is also not normal
• Prolonged bleeding from cuts• Following surgery• Bruising without any trauma• Nose bleeds• Following tooth extraction• Blood in stools • Anemia requiring blood transfusion
• 7/75 women with menorrhagia had underlying bleeding disorder
N Sherif 2014
• 53% had underlying bleeding disorder Rosa Diaz 2014
• 47.8% had some underlying hemostatic disorder– 17.7% platelet dysfunction – 13.3% Von Willebrand disease – 12.4% factor deficiency
V Serevalli 2013• 14.5% had bleeding disorders– 6.5% von Willebrand disease in five – 5.2% platelet function disorder
Turkiz Gursel 2014
• 120 women with menorrhagia – 19.16% had bleeding disorder – 11.6% VWD – 3.3% Glanzmann thrombasthenia
Sucheta Trasi 2005
Testing for bleeding disorders is a must for
Adolescent girls who present with menorrhagia Adult women with chronic menorrhagia who
have no other cause Women who are about to undergo hysterectomy
for menorrhagia ACOG 2002
• HTCs were originally created to treat men with hemophilia
• Since 1990s almost 9000 women have sought medical care in HTCs across USA
• Indian data?
• 70-100% of those with vWD• 10-70% of those with other inherited disorders • 5-98% with inherited platelet disorders
• Significantly longer, heavier menstruation• Significantly more hysterectomies for
menorrhagia
Health related QOL in VWD
• Women with VWD significantly worse than those of men with VWD
• Almost as low as that of severe hemophilia
• More school absenteeism • Less women likely to undergo secondary
education than men (5.5% vs 35%)
Health related QOL in VWD
• 39% cut down their activities due to menorrhagia
• 39% had to cut down the work that they do• 47% felt they had accomplished less
• 19.3% felt that dysmenorrhea affected their lives• 22.6% did not go to school/work during periods• 48.4% were hospitalized for a heavy menstrual
bleeding Fadhlaoui A 2012
Survey of health related QOL study
• SF 36 v2 survey • 30 subjects
• 3 groups
• Girls (Indian) with bleeding disorders • Girls with leukemia undergoing chemotherapy• Normal age matched controls
Radhakrishnan N (unpublished)
Does health limit you in your activities?1: A lot 2: Little 3: Not at all
FBD
Leukemia
Normal
0 0.5 1 1.5 2 2.5 3
Has you health interfered with social activities?
1:No 5:Very much
FBD
Leukemia
Normal
0 0.5 1 1.5 2 2.5 3
Factors that determined QOL
• Underlying bleeding disorder
• Being female
• Bleeding disorder (VWD) and being female
Surveying gynecologists
• 983 ACOG members surveyed in 1996• 8% of their patients complained about
menorrhagia • 74% patients presumed to have anovulatory cycles • 4% doctors considered VWD as a cause of
menorrhagia • 3% considered referring them to specialists• <1% of women should have a bleeding disorder
VR Byams 2007
Surveying gynecologists
• Repeated the survey in 2009 – 1200 gynecologist interviewed by mail – 42.4% (503) responded to the survey
• >70% enquired about other sites of bleeding • >60% enquired about a family history of bleeding • 77% said they would consider VWD as a cause
• What caused this change?Efforts by hematology providers, community based organizations, government to raise awareness
VR Byams 2012
Surveying gynecologists UK
• > 80% of the respondents considered the prevalence of VWD in women with menorrhagia to be <1%
• 12% and 2% of the respondents would consider testing for VWD in an 18 and a 35 year old
Chi C 2006
Total Score >100 is equivalent to >80ml blood loss per cycle
Total score:
PICTORIAL BLEEDING ASSESSMENT CALENDAR Higham JM, O’Brien PM, Shaw RWAssessment of menstrual blood loss using a pictorial chartBr J Obstet Gynecol 1990; 97:734-9
DayPad 1 2 3 4 5 6 7 8
1
5
20
Daily score
Day Tampone1 2 3 4 5 6 7 8
1
5
20
Daily score
International efforts to raise awareness
• Women bleed too (UK)
• Project Red Flag (USA)
• MyGirlsBlood
• WG HFI
To conclude
• Lets protect girls with any bleeding disorder • Collaborative efforts
Look after menstrual hygieneHeavy menstrual bleeding
Identify potential bleeders from the populationPrevent complications