Pearls of Wisdom: Idiopathic Menorrhagia

Question: Mary is a 34-year-old G2P2 woman with idiopathic menorrhagia. For the past 15 years, she has experienced prolonged menses (≥ 8 days) requiring 7 to 10 pads/d. She is currently taking ferrous sulfate because of recurrent iron deficiency anemia, attributed to her excessive menstrual loss.

Laboratory test results include a normal pelvic ultrasound (conducted 3 times over the past 15 years), normal thyroid function, and normal complete blood count. Her  hemoglobin levels were 9.2 mg/dL prior to iron replacement, and increased to 13.2 mg/dL after iron supplementation. She reports no other abnormal bleeding (eg, extensive bruising, protracted bleeding after trauma or surgery, bleeding while brushing teeth).

She has a younger sister with similar menstrual history.

What lab investigation might be helpful?

1. Plasma homocysteine
2. Platelet morphology assessment
3. Platelet aggregation testing
4. Bleeding disorder screening

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky. MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

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Answer: Bleeding disorder screening

Menorrhagia can range from being a minor nuisance to a life-threatening condition, especially if you consider that many women with unexplained or idiopathic menorrhagia end up having surgical intervention (ie, hysterectomy) to remedy the situation. According to insurance claim databases, as many as 5% of adult women seek medical care for a complaint of menorrhagia.¹

 Technically, blood loss associated with menstruation should not exceed 80 ml (±6 tablespoons), but accurate measurement of menstrual blood loss is uncommonly performed. Rather, patient description and subsequent iron loss measurements (ie, ferritin, iron, iron binding capacity [IBC], mean corpuscular volumne [MCV]) support a diagnosis of menorrhagia when symptom description is appropriate—prolonged menses with excessive blood loss in the absence of other demonstrable causes of pathologies leading to iron deficiency.

Ultimately, a cause for menorrhagia is not found in as many as 50% of women.¹ On the other hand, significant portions of women with menorrhagia have an underlying bleeding disorder, specifically von Willebrand disease. One report indicates that amongst English and Swedish women with menorrhagia, between 17% to 37% may have an underlying bleeding disorder.¹

Menorrhagia & von Willebrand Disease¹

Research

To clarify the issue about the potential for bleeding disorders as a cause of menorrhagia in American women, Dilley et al report² on a case control study of women with menorrhagia (n=244) at mean age 35. Importantly, the desire to seek underlying bleeding disorder was not prompted by a prior history of other abnormal bleeding manifestations. Specifically, in the words of the authors, “No subject reported a previous personal diagnosis of a bleeding disorder.” The laboratory evaluation performed by the investigators included bleeding time, factor VII activity, von Willebrand factors, and factors II, V, VII, IX, XI, and XII. In this United States population, approximately 11% of the women were determined to have a bleeding disorder—primarily von Willebrand disease. The good news is that von Willebrand disease can be effectively treated with desmopressin. 

Study Results¹

One might surmise that persons with inherited bleeding disorders would consistently manifest bleeding from 1 or more of the typical lumps-and-bumps events of life, whether it be a remarkably swollen knee after a roller-skating fall, prolonged bleeding after a dental extraction, etc. As was demonstrated in the trial by Dilley et al,¹ these women with menorrhagia, at age 35, had not manifest any other indication a bleeding disorder.

What’s the “Take Home”?

The cause of menorrhagia is determined in only about 50% of women. Because of the possible need for surgical treatment—with its own inherent potential consequences—identifying a correctable cause is of great value. Women presenting with menorrhagia should be considered for a bleeding profile seeking underlying bleeding disorder, primarily von Willebrand disease, even in the absence of other manifestations of abnormal bleeding.

References:

1. Dilley A, Drews C, Miller C, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol. 2001;97(4):630-636.