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Grand Rounds

Are We Meeting the ACOG Screening Guidelines for Von Willebrand Disease in Adolescents with Menorrhagia?

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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

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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?

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