#Grand Rounds

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

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

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

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)

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

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