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Coagulation & its Disorders
Bleeding disorders in adolescents with heavy menstrual bleeding in a multicenter prospective US cohort
Ferrata Storti Foundation
Haematologica 2020 Volume 105(7):1969-1976
Ayesha Zia,1,2,3,4 Shilpa Jain,5 Peter Kouides,6 Song Zhang,1,7 Ang Gao,1,7 Niavana Salas,4 May Lau,1,3,8 Ellen Wilson,1,4,9 Nicole DeSimone1,10
and Ravi Sarode1,10
1The University of Texas Southwestern Medical Center, Dallas, TX; 2Department of Pediatrics, Children’s Medical Center, Dallas, TX; 3Division of Hematology/Oncology, Children’s Medical Center, Dallas, TX; 4Children’s Medical Center, Dallas, TX; 5Hemophilia Center of Western New York, John R. Oishei Children’s Hospital of Buffalo, Division of Pediatric Hematology-Oncology, Buffalo, NJ; 6Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, MN; 7Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX; 8Division of Adolescent Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 9Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX and 10Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
ABSTRACT
Heavy menstrual bleeding is common in adolescents. The frequency and predictors of bleeding disorders in adolescents, especially with anovulatory bleeding, are unknown. Adolescents referred for heavy menstrual bleeding underwent an evaluation of menstrual bleeding pat- terns, and bleeding disorders determined a priori. The primary outcome was the diagnosis of a bleeding disorder. Two groups were compared: anovula- tory and ovulatory bleeding. Multivariable logistic regression analysis of baseline characteristics and predictors was performed. Kaplan Meier curves were constructed for the time from the first bleed to bleeding disorder diag- nosis. In 200 adolescents, a bleeding disorder was diagnosed in 33% (n=67): low von Willebrand factor levels in 16%, von Willebrand disease in 11%, and qualitative platelet dysfunction in 4.5%. The prevalence of bleeding disorder was similar between ovulatory and anovulatory groups (31% vs. 36%; P=0.45). Predictors of bleeding disorder included: younger age at first bleed (OR: 0.83; 95%CI: 0.73, 0.96), Hispanic ethnicity (OR: 2.48; 95%CI: 1.13, 5.05), non-presentation to emergency department for heavy bleeding (OR: 0.14; 95%CI: 0.05, 0.38), and International Society on Thrombosis and Haemostasis (ISTH) Bleeding Assessment Tool score ≥4 (OR: 8.27; 95%CI: 2.60, 26.44). Time from onset of the first bleed to diagnosis was two years in the anovulatory, and six years in the ovulatory cohort (log-rank test, P<0.001). There is a high prevalence of bleeding disorders in adolescents with heavy periods, irrespective of the bleeding pattern. Among bleeding disorders, the prevalence of qualitative platelet dysfunction is lower than previously reported.
Introduction
Heavy menstrual bleeding (HMB) is common in adolescents after menarche.1 Anovulation is the most common etiology of HMB and is expected to persist for up to five years.2 Underlying bleeding disorders (BD) are another important etiology of HMB affecting up to 20% of adults and 13-60% of adolescents.3 A large body of research has focused on the prevalence of BD in adult women and its predictors. In contrast, pediatric literature on BD frequency has only been recently accrued. Most data are retrospective and prevalence studies by and large excluded women with anovulatory bleeding.4-6 Data on predictors of BD in adolescents with HMB, when anovulation is most prevalent, are scant and it is difficult to determine whom to screen for BD.3
Correspondence:
AYESHA ZIA
Ayesha.zia@utsouthwestern.edu
Received: April 29, 2019. Accepted: October 14, 2019. Pre-published: October 17, 2019.
doi:10.3324/haematol.2019.225656
Check the online version for the most updated information on this article, online supplements, and information on authorship & disclosures: www.haematologica.org/content/105/7/1969
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