Severe Heavy Menstrual Bleeding Research Articles

Rates and Predictors of Prophylaxis in Women with Von Willebrand Disease and Heavy Menstrual Bleeding

Background: Women with von Willebrand disease (vWD) suffer from heavy menstrual bleeding (HMB) often complicated by iron deficiency anemia (IDA) and reduced quality of life. Despite the American Society of Hematology (ASH) recommendations for long-term prophylaxis in patients with severe frequent bleeds, prophylaxis remains under-utilized in women with severe HMB. Given the scarcity of data on management of gynecological bleeding, it is critical to examine our practice patterns and identify factors associated with prophylaxis use. Aims: 1) To evaluate the management and outcomes of gynecological bleeding in vWD, including rates of desmopressin (DDAVP) and vWF prophylaxis for HMB and predictors of their use. 2) To examine the association between prophylaxis and severe HMB. Methods: This retrospective cohort study included women ≥18 years diagnosed with vWD in the Northern Alberta Bleeding Disorders Program. We assessed the rates of HMB, severe HMB and IDA, along with their management strategies. Prophylaxis rates with DDAVP and vWF concentrates, as well as predictors of their use, were examined. Severe HMB was defined as HMB requiring Emergency Department (ED) visits, hospitalizations, blood transfusions, or surgical management (dilation & curettage [D&C], endometrial ablation or hysterectomy). IDA was defined as ferritin <30 mcg/L and hemoglobin <120 g/L. Logistic regression was used to examine factors associated with severe HMB. Variables with P-value <0.20 on univariate regression were included in multivariable regression. Results: 168 women were evaluated with a median age of vWD diagnosis of 27 years (IQR 18-38): 140 (81%) type 1, 23 (13%) type 2, and 5 (3%) type 3 vWD. Among those with type 1 vWD, 43 (31%) had baseline vWF levels <0.30 IU/ml, 94 (67%) had vWF levels of 0.30-0.49 IU/ml, and 3 (2%) had missing values. DDAVP response was assessed in 124/140 (89%) type 1 vWD and 13/23 (57%) type 2 vWD. There were 145 (86%) women with HMB, managed most commonly by tranexamic acid (TXA) (112; 77%), followed by hormonal therapy (73; 50%), subcutaneous DDAVP (40; 28%), and levonorgestrel intrauterine system (39; 26%). vWF prophylaxis was used in only 11 (8%) women. Surgical procedures for HMB were common including hysterectomy (28; 19%), endometrial ablation (15; 10%) and D&C (15; 10%). Over a quarter (39; 27%) received iron infusions. Of the 65 (45%) women with a history of IDA, 6 (9%) had persistent IDA >5 years, 6 (9%) had IDA lasting 2-5 years and 53 (65%) had IDA corrected within 2 years. Prophylaxis rates did not differ between the 68 (40%) women with severe HMB and the 77 (53%) with non-severe HMB, with comparable rates of VWF use (9% vs 6%, P=0.60). Compared with women who never received prophylaxis, those who received DDAVP or vWF prophylaxis were more likely to have received TXA (93% vs 70%, P=0.003), iron infusions (43% vs 19%, P=0.004) and to have been diagnosed before 2000 (22% vs 7%, P=0.03) (Table 1). Though non-significant, a higher proportion of type 3 vWD (9% vs 1%, P=0.06) and higher ISTH-BAT (median 8 vs 7, P=0.07) were observed in prophylaxis recipients. On multivariable logistic regression, time from first bleeding symptom to diagnosis (adjusted odds ratio [aOR] 1.04, 95% CI 1.01-1.07) and prophylactic DDAVP use (aOR 2.4, 95% 1.01-5.6) were associated with severe HMB. There was a non-significant trend towards lower odds of severe HMB in patients diagnosed in 2000-2010 and 2011-2021 as compared to pre-2000 (aOR 0.3, 95% 0.1-1.0). Diagnosis before age 18, vWD type and baseline vWF activity were not associated with severe HMB. Conclusion: Women with vWD experience high rates of HMB and its associated complications. In our study, there was a relatively high uptake of DDAVP prophylaxis, however vWF prophylaxis was under-utilized even in those with severe HMB. We failed to demonstrate an impact of either prophylactic therapy on severe HMB, though this may be due to confounding by indication. There was a significant association between prophylactic DDAVP and vWF with other quality of care indicators including TXA and iron infusions. It is unclear if this association is related to practice patterns or patient factors such as access to care or preference for early definitive treatment. Overall, our findings highlight a need to further understand the barriers to prophylaxis use and to consider earlier prophylaxis for severe HMB to decrease bleeding complications and the need for resource-intensive therapies.

Perimenopausal abnormal uterine bleeding

Abnormal uterine bleeding is a very frequent symptom in the perimenopause. The causes are numerous ranging from physiological reactions due to decreasing/instable ovarian function to premalignant and malignant conditions. Benign findings such as endometrial polyps and myomas are increasing with age, leading to more abnormal uterine bleeding in the perimenopause. Cervical and vaginal causes of abnormal uterine bleeding should also be excluded by speculum examination. Sexually transmitted diseases should be ruled out in the perimenopausal women in new relationships. Measurement of hemoglobine, human chorion gonadotropine and thyreoid hormones are relevant in selected cases. Transvaginal ultrasound is the primary diagnostic tool in perimenopausal abnormal uterine bleeding. Saline or gel contrast sonohysterography improves the diagnostic accuracy. Based on the findings by ultrasound, more invasive procedures such as blind endometrial biopsy or hysteroscopy can be planned. Once premalignant and malignant causes are excluded, the necessity for treatment can be evaluated in collaboration with the individual woman. Severe heavy menstrual bleeding causing anaemia will need immediate treatment. In less severe cases and in intermenstrual bleeding expectant management can be considered. Hormonal medical treatment e.g., progestins or insertion of levonorgestrel-releasing intrauterine system (LNG-IUS) is a possibility in case of anovulatory bleeding interfering with the quality of life. The amount of bleeding can be reduced both by antifibrinolytic and non-steroidal anti-inflammatory drugs and LNG-IUS. In case of focal intrauterine lesions, such as endometrial polyps or submucous myomas, operative hysteroscopic procedures are warranted in the treatment of abnormal uterine bleeding. Other minimally invasive procedures, such as endometrial ablation or endometrial resection, is a good choice in selected cases, but some women will need a hysterectomy as a definite treatment of abnormal uterine bleeding in perimenopause.

Prevalence of Heavy Menstrual Bleeding and Use of Hormonal Therapy Among Women Type 1 Von Willebrand Disease from the Zimmerman Program

Background: Women with von Willebrand disease (VWD) experience substantial reproductive tract bleeding, including heavy menstrual bleeding (HMB). Over 80% of women with VWD experience HMB resulting in morbidity from decreased quality of life, lost productivity, and iron deficiency. Hormonal birth control is a standard treatment and can elevate VW activity (RCo/GPB1M) and antigen (Ag) levels. Little is known about the impact of such therapy on bleeding assessment tools (BATs). We hypothesized that women on hormonal therapy (HT) would have lower ISTH-BAT scores and higher VWD levels than those not on HT. Women who participated in the Zimmerman Program (PPG) for the Molecular and Clinical Biology of VWD, a natural history study (NHLBI HL081588), had demographic, medication history, and laboratory samples collected. We sought to identify differences in patient, disease-specific factors, and BATs between type 1 VWD women on HT and those not on HT. Methods: Women with type 1 VWD and reported menstrual history were selected from the PPG. Women were split into those taking HT (OCPs, injectable progestins, hormone replacement therapy, intravaginal devices, and IUDs) vs. those who were not. Women >50 years of age were excluded from the group analysis due to their assumed postmenopausal status. Descriptive statistics were calculated to characterize the demographics, VWD testing (VWF:Ag, VWF:RCo, GPIbM), and ISTH-BATs (total, HBM, and PPH) of the two groups. Continuous variables were compared between groups using two sample t-test and categorical variables by Fischer's exact test. A two-sided p-value of< 0.05 was considered statistically significant. Results: In the full cohort, 269 women answered yes to experiencing menstrual cycles. The group was predominantly pediatric/young adult with a mean age of 25.3 years (range 11-76). Whites comprise 86% of subjects. Women were further defined by disease laboratory testing with 186 women (69.1%) diagnosed as VWF:Ag 0.3-0.5 IU/mL, 57 women (21.2%) VWF:Ag <0.3 IU/mL, and 26 women (9.7%) clearance type VWD (genetic result). The mean VWF:Ag for the entire cohort was 0.37 IU/mL (Standard Deviation 0.14 IU/mL). The mean VWF: RCo was 0.36 IU/mL (SD 0.15 IU/mL). The ISTH-BAT scores ranged from 0-29, with a mean of 7.6 (SD 5.1). An evaluation of the HMB domain of the ISTH-BAT demonstrated that 94% (253) of women reported HMB with >1 point (on a 4-point scale) overall, 47% (119) of whom reported severe HMB with 3 or 4 points. Of the 269 women, 108 were taking HT at enrollment. The types of HT included OCPs (71), medroxyprogesterone acetate (11), levonorgestrel IUD (11), contraceptive implant (3), and etonogestrel/ethinyl estradiol vaginal ring (1). After excluding women with presumed postmenopausal status, we identified 105 women on hormonal therapy and 143 who were not. Graph 1 provides an overlay of the ISTH-BAT scores by hormone treatment status. Table 1 demonstrates the demographic and disease features of the two groups. On average, women on HT were younger, 20.7 years vs. 24.5 years (p= 0.003), than those who were not. Other disease characteristics, including disease subtype, VWF laboratories (VWF:Ag, VWF: RCOF, VWF GPIbM), and ISTH-BAT HMB and PPH specific domains were not significantly different between the groups. Higher total ISTH-BAT scores were observed for women not on HT (7.4± 5.1) compared to those who were (6.8± 4.2); however, the difference was not statistically significant. Conclusions: For women with type 1 VWD, HMB is widespread, affecting 94% of the subjects enrolled in the PPG. Hormone therapy was common, with 47% receiving treatment. Apart from age, there were no significant differences in the disease characteristics or BATs between women with type 1 VWD who are and are not receiving hormone therapy in this cohort. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Reduced Activity and Quality of Life in Women Soldiers with Heavy Menstrual Bleeding and Dysmenorrhea.

The aim of the study was to examine the effect of heavy menstrual bleeding (HMB) and dysmenorrhea on daily activity and quality of life (QoL) in young women engaged in demanding activities. Cross-sectional study. A total of 422 Israeli women soldiers in combat and non-combat roles. Participants were asked to provide consent and to complete study questionnaires. A pictorial bleeding assessment chart (PBAC), visual analog scale (VAS), verbal multidimensional scoring system for assessment of dysmenorrhea, and approved Hebrew-translated age-appropriate Pediatric Quality of Life Inventory (PedsQL). HMB (PBAC >100) and severe HMB (PBAC >185) were demonstrated in 181 (50%) and 96 (26%) participants, respectively. A high PBAC score was recorded in 20% who answered "no" or "unknown" in the questionnaire on having HMB. Mild, moderate, and severe dysmenorrhea were demonstrated in 80 (21.5%), 115 (31%), and 142 (38%) participants, respectively. The prevalence of HMB and dysmenorrhea was similar in soldiers in combat and non-combat roles. Diagnosis of HMB was related to the lower fitness-for-service score, history of bleeding, and dysmenorrhea. Daily activity and QoL were both affected by the severity of HMB and dysmenorrhea. Underdiagnosis of HMB and dysmenorrhea results from a combination of unawareness from the women's side and inattention from the system. In an era of female empowerment, each woman should be at the optimal physiological and psychological level to start her career; thus, addressing the menstrual burden and providing effective treatment is needed in the military scenario and other settings with demanding activities.

Spotlight on… heavy menstrual bleeding and uterine fibroids

Heavy menstrual bleeding (HMB) is a common condition affecting 20–30% of women of reproductive age.1 In England and Wales, nearly 80 000 women a year are referred to secondary care, with one-third of those subsequently undergoing surgical interventions.1 It is not uncommon for HMB to be associated with fibroid uterus, endometriosis and adenomyosis, and in a minority of cases, it may be an early sign of endometrial hyperplasia or cancer. The national HMB audit also highlighted that almost one-third of women affected by HMB had not received treatment in primary care before referral to secondary care.1 This figure could be quite different during the current COVID-19 pandemic. The audit also pointed out that women from ethnic minority groups and those from more socio-economically deprived areas made more visits to their GP regarding their HMB and saw less improvement in their condition.1 Women from more deprived areas also reported more severe HMB symptoms and poorer quality of life.2 It is therefore important to recognise any intervention should aim to improve quality of life rather than focusing on blood loss.3 Heavy menstrual bleeding is also the most common cause of iron deficiency and iron-deficiency anaemia in premenopausal women, which is frequently overlooked in routine practice (TOG 2017;19:155–61). In the last 10 years, The Obstetrician & Gynaecologist (TOG) has featured a number of articles covering HMB-related topics. A well-established National Institute for Health and Care Excellence (NICE) guideline on assessment and management of HMB was updated in 2018 and 2020.3 Since the first edition published in 2007, there have been very few changes in the medical management of HMB. Carey and Allen (TOG 2012;14:223–8) described the noncontraceptive uses and benefits of combined oral contraception, while Murdoch and Roberts (TOG 2014;16:46–50) explored the mode of action and the potential use of selective progesterone receptor modulators in treating fibroid uterus, although its use on uterine fibroids has been largely halted in the last couple years due to serious health complications.3 Nearly one-third of women with HMB referred to secondary care will subsequently require surgical interventions.1 Saraswat and Cooper conducted an in-depth review of endometrial ablation (TOG 2017;19:37–45), which covers its development, patient satisfaction rates, safety, the long-term sequelae and the cost-effectiveness of first- and second-generation techniques of endometrial ablation. Overall patient satisfaction rates and amenorrhoea rates were up to 80% and 50%, respectively. Nevertheless, around one in six women would still require further surgical intervention within 5 years. Ultimately, only hysterectomy can ensure long term amenorrhoea. The same authors (TOG 2017;19:101–8) also examined different surgical approaches to hysterectomy (laparoscopic, abdominal and vaginal) as well as myomectomy. A recently published multi-centre randomised controlled trial (the HEALTH study)4 concluded that laparoscopic supracervical hysterectomy is superior to second generation endometrial ablation in terms of clinical effectiveness, although the differences were relatively moderate. A laparoscopic approach may and should become the standard approach in performing hysterectomy. Elnasharty and Moustafa provide useful tips and techniques on dealing with the challenges in laparoscopic hysterectomy (TOG 2020; 22:313–7). HMB is often found to be associated with fibroid uterus, although not all women with fibroid uterus complain of HMB. This poses a significant management dilemma, especially among women with a history of subfertility. Younas et al. summarised the recent evidence on managing uterine fibroids including uterine artery embolisation, magnetic resonance imaging-guided focused ultrasonography as well as a different surgical approach on myomectomy (TOG 2016;18:33–42). A similar review was also published in 2018, when Bryant-Smith and Holland predominately explored the techniques and controversies in laparoscopic myomectomy, although they also examined the potential risk of unintentional dissemination of malignant cells during intracorporeal morcellation of undiagnosed leiomyosarcoma (TOG 2018;20:261–8). In the same issue of TOG, Sampat and Alleemudder reviewed the management and outcomes of fibroids in pregnancy (TOG 2018;20:187–95). As mentioned earlier, HMB can be a sign of endometrial hyperplasia or cancer, particularly in women with history of polycystic ovary syndrome and/or being overweight. Jones et al. discussed the diagnostic tools for detecting endometrial cancer (TOG 2021;23:103–12). All of the above contributing authors emphasised the importance of involving patients in the decision-making process, however, Jeffery, Kayani and Garden reminded us of the difficulties in managing menstrual problems in adolescents with learning disabilities (TOG 2013;15:106–12). This article also evaluated the need for different management options. An online collection of TOG articles on heavy menstrual bleeding and uterine fibroids is available at http://onlinetog.org.

The spectrum and severity of bleeding in adolescents with low von Willebrand factor–associated heavy menstrual bleeding

AbstractLow von Willebrand factor (VWF) in adults is associated with significant bleeding, most notably heavy menstrual bleeding (HMB) and postpartum hemorrhage, although this has not been characterized in adolescents. The objectives of this analysis of a multicenter single arm observational cohort study in adolescents with low VWF–associated HMB were to describe the bleeding phenotype, HMB severity, and related complications. Eligibility criteria included postmenarchal females <21 years of age with HMB (Pictorial Blood Assessment Chart [PBAC] score >100) and low VWF (2 values of VWF activity ≥30 and ≤50 IU/dL). Patients diagnosed with other bleeding disorders were ineligible. Clinical phenotype data, including PBAC and Bleeding Assessment Tool (BAT) scores, laboratory data, and HMB management/outcome details, were extracted. Patient demographics and clinical characteristics were summarized as medians with minimum/maximum values or frequencies with percentages. Groups were compared using a Wilcoxon rank-sum test or Fisher's exact test. A total of 113 patients met inclusion criteria, and 2 were excluded. Ninety four percent had a significant bleeding phenotype (BAT score >2), with predominantly mucocutaneous bleeding (32%-44%), postprocedural/surgical bleeding (15%), and severe HMB (BAT HMB domain score ≥2; 90%). Bleeding complications included iron deficiency (60%), anemia (21%), transfusion (12%), and hospitalization (10%). Desmopressin challenge response in subjects tested was good and sustained. Several (48%) required combined therapy for HMB (hormonal/hemostatic), and one third did not show improvement despite therapy. Our results suggest that adolescent females with low VWF have a significant bleeding phenotype and resultant complications warranting a focus on prompt diagnosis, appropriate therapy, and prevention of complications.

Heavy Menstrual Bleeding and Underlying Coagulopathy in an Adolescent Hematology Clinic [19B

INTRODUCTION: Current literature and guidelines suggest evaluation for underlying coagulopathy among adolescents who report heavy menstrual bleeding (HMB). Adolescent women with HMB are found to have higher prevalence of coagulopathy than the general population. Our study highlights the prevalence of hemostatic disorders among adolescents referred to a specialty adolescent hematology clinic for evaluation of HMB. METHODS: This study is a retrospective chart review of women &lt;22 years seen in a joint Adolescent Medicine and Hematology clinic at Children's Hospital Los Angeles from January 1, 2015 to May 22, 2018. The primary inclusion factor was referral for anemia and reported HMB. Following IRB approval, data was collected on menstrual history and diagnosis of coagulopathy. RESULTS: Of 109 referred, 37 (34%) patients were found to have underlying coagulopathy; most commonly diagnosed was von Willebrand Disease (17.4%) then platelet dysfunction (15.6%); 1 patient was diagnosed with hereditary hemorrhagic telangiectasia. Not all patients presented with chronic HMB; 2 patients had histories of a single prolonged menstrual bleeding episode requiring hospitalization, 3 patients had anemia but normal menses, and 3 patients with anemia had prolonged menses but normal flow. The impact of severe HMB on health care utilization was notable; 47 had required prolonged ER stays in the past (43%); 27 required transfusion (25%). CONCLUSION: Our results showed 34% prevalence of underlying coagulopathy among adolescents referred for HMB, which mirrors existing literature. Our findings reiterate the importance of evaluating the source of HMB through formal testing; menstrual history may not be sufficient in the adolescent population.

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

To estimate the frequency of von Willebrand disease screening and factors that affect screening frequency in a national sample of girls and adolescents with heavy menstrual bleeding. In this retrospective cohort study, we used a national claims database for privately and publicly insured patients between 2011 and 2013 for girls aged 10-17 years. Diagnostic criteria of heavy menstrual bleeding were the presence of one inpatient or two outpatient International Classification of Diseases, 9th Revision codes for heavy menstrual bleeding. We defined severe heavy menstrual bleeding as heavy menstrual bleeding plus an inpatient stay for menstrual bleeding, iron deficiency anemia, or blood transfusion. To assess whether patient- or facility-level characteristics affected screening, we performed logistic regression analysis including patient age, health care provider type seen at first visit for menorrhagia, patient residence in a metropolitan statistical area (proxy for urban vs rural inhabitance), and approximate travel time to the nearest hemophilia treatment center. We identified 23,888 postpubertal girls and adolescents with heavy menstrual bleeding (986 with severe heavy menstrual bleeding). Von Willebrand disease screening was performed in 8% of females with heavy menstrual bleeding and 16% with severe heavy menstrual bleeding. Younger age at diagnosis, commercial insurance, and living within a metropolitan statistical area were associated with higher screening rates. Patients who underwent testing for iron deficiency anemia had the highest likelihood of undergoing screening (odds ratio 7.08, 95% CI 6.32-7.93). Among patients living in a metropolitan statistical area, those 60 minutes or more from a hemophilia treatment center were less likely to undergo screening. Despite recommendations by the American College of Obstetricians and Gynecologists for more than 15 years, fewer than 20% of postpubertal girls and adolescents with heavy menstrual bleeding underwent screening for von Willebrand disease in this cohort. Increased clinician awareness and adherence to recommended screening recommendations may increase diagnosis of von Willebrand disease.

Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit

ObjectiveTo examine symptom severity and duration at time of referral to secondary care for heavy menstrual bleeding (HMB) by socioeconomic deprivation, age and ethnicityDesignCohort analysis of data from the National...

Iron Deficiency Anemia in Adolescents Who Present with Heavy Menstrual Bleeding

Study ObjectiveTo assess the clinical severity and initial treatment of iron deficiency anemia (IDA) in female adolescents with heavy menstrual bleeding (HMB) in our center. DesignRetrospective cohort study of electronic medical records via search of administrative records using International Classification of Diseases Ninth Revision codes for IDA or unspecified anemia and disorders of menstruation. SettingChildren's Medical Center in Dallas, Texas. ParticipantsOne hundred seven patients with HMB and concomitant IDA (median age, 14.4 years) who presented to the outpatient, emergency department, and/or inpatient settings. ResultsThe median initial hemoglobin concentration for all patients (n = 107) was 7.4 g/dL, and most (74%, n = 79) presented to the emergency department or via inpatient transfer. Symptomatic IDA was treated with blood transfusion in 46 (43%, n = 46). Ferrous sulfate was the most commonly prescribed oral iron therapy. Seven patients received intravenous iron therapy either initially or after oral iron treatment failure. Combined oral contraceptives were commonly prescribed for abnormal uterine bleeding, yet 10% of patients (n = 11) received no hormonal therapy during their initial management. Evaluation for underlying bleeding disorders was inconsistent. ConclusionSevere anemia because of IDA and HMB resulting in urgent medical care, including hospitalization and blood transfusion, is a common but underemphasized problem in adolescent girls. In addition to prevention and early diagnosis, meaningful efforts to improve initial management of adolescents with severe HMB and IDA are necessary.

Referral Practices in Management of Heavy Menstrual Bleeding in Adolescents

▪Background: Due to the prevalence of mild bleeding disorders (MBDs) among adolescent females with heavy menstrual bleeding (HMB), the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend screening select adolescent patients with HMB for mild bleeding disorders (MBDs) under the guidance of a hematologist, as coagulation labs can be difficult to interpret. The goal of this study was to describe referral patterns for adolescents with HMB and compare evaluation and management practices among different pediatric specialties using Medicaid claims data.Methods: Our patient population comprised 10-17 year old females enrolled in Medicaid in central and southeastern Ohio with at least 2 separate diagnoses of HMB and at least 12 months of continuous enrollment prior to their first HMB diagnosis. While there is no standard definition of “severe” HMB, for this study, patients with iron deficiency anemia, an inpatient hospital stay for HMB, or an outpatient blood transfusion were defined as having severe HMB. Medicaid claims data and electronic medical records from Nationwide Children’s Hospital, the region’s only children’s hospital, were linked to collect study data.Results: We identified 509 patients with HMB. Referral to a pediatric specialist occurred in 17.9% of patients; 39.5% of those with severe HMB and 13.8% of those with non-severe HMB were referred. 10.8% of patients were referred to adolescent med, 6.7% were referred to hematology, and 0.4% were referred to endocrinology. Of the patients seen by a specialist at a children’s hospital, 69% were screened for a MBD. When stratified by specialty, 100.0% of patients seen by hematology were screened for a MBD while 51.0% of patients seen by adolescent medicine were screened for a MBD. Approximately one-third (35.7%) of referred patients were diagnosed with a MBD, most commonly platelet function defects and von Willebrand disease (VWD). 48.3% of patients with severe HMB were diagnosed with a MBD, while 29.1% of patients with non-severe HMB were diagnosed with a MBD. Both hematologists (100.0%) and adolescent medicine doctors (97.0%) almost uniformly prescribed treatment for HMB, most commonly hormonal contraception (95.2%). Patients had significantly higher odds of referral to a pediatric specialist if they had severe HMB [2.3, 95% CI (1.42-3.71)]. Patients had significantly lower odds of referral if they lived farther away from the region’s children’s hospital [0.16, 95% CI: (0.09-0.29)]. There was no significant difference in frequency of referral between patients initially diagnosed by family practitioners, pediatricians, or gynecologists.Conclusions: Despite ACOG and AAP recommendations, we found that only a small percentage of adolescents with HMB are referred to a pediatric specialist. Efforts should be made to increase education regarding which patients are at higher risk of an underlying MBD, and increasing the number of these adolescents who are referred to hematology so that coagulation lab studies can be ordered and interpreted appropriately. Such efforts should be targeted at patients in rural areas, since this population was particularly unlikely to receive care from a hematologist. DisclosuresNo relevant conflicts of interest to declare.

I358 UNDERSTANDING AND MANAGEMENT OF ACUTE AND SEVERE HEAVY MENSTRUAL BLEEDING

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S250-S250 Invited presentations and presentations by organisations and societies I358 UNDERSTANDING AND MANAGEMENT OF ACUTE AND SEVERE HEAVY MENSTRUAL BLEEDING D.A. Tan, D.A. TanSearch for more papers by this author D.A. Tan, D.A. TanSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)60388-9AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S250-S250 RelatedInformation