BACKGROUND AND PURPOSE:

• Von Willebrand disease, a genetic disorder, results in a quantitative or qualitative deficiency of von Willebrand factor
  • Menorrhagia beginning at menarche is often the first presenting symptom but the underlying cause often goes unrecognized
• ACOG recommends screening for bleeding disorders in adolescents with menorrhagia and ≥1 of the following
  • Menses longer than 7 days or bleeding through a pad or tampon in 2 hours
  • Anemia
  • Family history of a bleeding disorder
  • History of bleeding after a hemostatic challenge (e.g., tooth extraction or surgery)
• Jacobson et al. (Obstetrics & Gynecology, 2018) sought to determine the frequency of von Willebrand disease screening and factors that affect screening frequency in women with heavy menstrual bleeding

METHODS:

• Retrospective cohort study
  • Large database from 14 states in the US (2011-2013)
• Participants: Girls aged 10-17 years with heavy menstrual bleeding
• Diagnoses were based on coding
  • Heavy menstrual bleeding defined as
    • One inpatient or two outpatient codes consistent with heavy menstrual bleeding
  • Severe heavy menstrual bleeding defined as heavy menstrual bleeding plus one of the following
    • Inpatient stay
    • Iron deficiency anemia
    • Blood transfusion
  • Primary Objectives
    • Frequency of von Willebrand disease screening
    • Factors that affect screening frequency

RESULTS:

• 23,888 postpubertal girls and adolescents were identified through the database
  • 23,888 girls and adolescents had heavy menstrual bleeding
  • 986 had severe heavy bleeding
• Von Willebrand disease screening obtained in
  • 8% with heavy bleeding
  • 16% with severe heavy bleeding
• Higher screening rates were associated with
  • Younger age at diagnosis
  • Commercial insurance
  • Living in a metropolitan area
• Those tested for iron deficiency anemia had the highest likelihood of undergoing screening
  • odds ratio (OR) 7.08; 95%, CI 6.32–7.93
• When compared to ObGyn as the initial healthcare provider
  • Family practice
    • Patients were less likely to be screened (3.2% vs 6.0%, OR 0.43, 95% CI 0.34–0.54)
  • Acute care providers
    • Patients ‘modestly’ more likely to be screened (10.4% vs 6.0%, OR 1.22, 95% CI 1.03–1.44)
  • Pediatricians
    • Patients ‘modestly’ more likely to be screened (12.0% vs 6.0%, OR 1.21, 95% CI 1.02–1.42)

CONCLUSION:

• The authors state “that despite more than 15 years of ACOG recommendations, approximately 90% of postpubertal girls and adolescents with heavy menstrual bleeding are not being screened for von Willebrand disease”
• Increased awareness on the part of all healthcare providers taking care of adolescent females is required to improve recognition of Von Willebrand disease

Learn More – Primary Sources:

Patterns of von Willebrand Disease Screening in Girls and Adolescents With Heavy Menstrual Bleeding

ACOG Committee Opinion 785: Von Willebrand Disease in Women

Related ObG Topics:

Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction

IUD, Hysterectomy or Ablation for Menorrhagia?

How does TXA Measure Up as a Treatment for Menorrhagia?