Screening Tool for Bleeding Disorders in Women With Menorrhagia Performs Well

Megan Brooks

January 30, 2011

NEW YORK (Reuters Health) January 30, 2011 — A short eight-question screening tool, coupled with either a serum ferritin level and/or the pictorial blood assessment chart (PBAC) score, can help gynecologists and primary care providers identify women with menorrhagia who should be evaluated for a possible bleeding disorder, a new study finds.

"Undiagnosed bleeding disorders, such as von Willebrand disease and platelet function defects, are common in women with menorrhagia and may impact women's lives adversely because of bleeding complications after childbirth and surgery, blood transfusions, and chronic iron deficiency anemia," the study team notes in the January 19th online issue of the American Journal of Obstetrics and Gynecology.

Dr. Claire Philipp, a hematologist from the UMDNJ-Robert Wood Johnson Medical School in New Brunswick, New Jersey and colleagues point out in the article that most women with menorrhagia seek help from their gynecologist or primary care physician. And despite a high prevalence of hemostatic abnormalities in this population, most of these women are not referred to a hematologist for evaluation.

But determining who to refer can be difficult, they note, and some gynecologists and primary care physicians may not recognize menorrhagia as a symptom of a bleeding disorder. There is also no simple laboratory test to screen for hemostatic abnormalities in these women.

Dr. Philipp's team recently developed a simple, easy-to-administer screening tool for stratifying women with unexplained menorrhagia for hemostatic testing.

Its eight questions fall into four categories: (1) severity of menorrhagia, defined by a duration of menses of 7 days or more and either flooding or bleeding through a tampon or napkin in 2 hours or less; (2) family history of a diagnosed bleeding disorder; (3) personal history of excessive bleeding after specific challenges such as delivery, miscarriage, surgery, tooth extraction; and (4) history of treatment for anemia.

In initial testing in 146 women with unexplained menorrhagia, the screening tool performed well, which led Dr. Philipp and colleagues to test it in a larger prospective study at six centers across the US.

There were 217 women ages 18 to 50 in the study, including 169 white and 35 black women. All of the women had menorrhagia identified by a pictorial blood assessment chart (PBAC) score of 100 or more. The mean hemoglobin level was 12.1 g/dL; more than half of the women were anemic (56%) with a hemoglobin level of less than 12 g/dL. The mean serum ferritin level, obtained in 155 women, was 20.6 ng/mL.

On laboratory testing, 154 of 217 women (71%) had one or more hemostatic abnormalities; 120 (55%) had a platelet function defect, 11 (5%) had low von Willebrand factor, and 11 (5%) had coagulation factor deficiencies.

For hemostatic abnormalities, the screening tool had a sensitivity of 89% and a positive predictive value of 72%, Dr. Philipp and colleagues report.

When the screening tool was combined with a PBAC score greater than 185, sensitivity for hemostatic abnormalities increased to 95% and the positive predictive value remained unchanged.

There was a similar increase in sensitivity (93%) and no change in positive predictive value when the screening tool was combined with a low serum ferritin level (20 ng/mL or less).

The researchers say, "The utility of the serum ferritin level as an adjunct to screening for hemostatic abnormalities has not been demonstrated previously and may provide a similarly effective, but clinically more feasible, supplement to the screening tool than the PBAC score."

Serum ferritin may be less cost-efficient than the PBAC, but it may facilitate a quicker decision about whether to refer as it precludes waiting for a menstrual cycle for a prospectively completed PBAC score.

This study, the researchers conclude, confirms the usefulness of this screening tool for stratifying women with unexplained menorrhagia for hemostatic evaluation.

Am J Obstet Gynecol. Published online January 19, 2011. Abstract

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