Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Grand Rounds: Heavy Menstrual Bleeding in Pediatric and Adolescent & Young Adult (AYA) Patients — A Pediatric Hematology Perspective

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Grand Rounds: Heavy Menstrual Bleeding in Pediatric and Adolescent & Young Adult (AYA) Patients — A Pediatric Hematology Perspective · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Brought to you by University Health's new Women's and Children's Hospital and
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the Department of Pediatrics at UT Health San Antonio.
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Today, I'm bringing you Grand Rounds. Let's listen in.
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I was kind of gearing it towards GenPeds, like general pediatrics,
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and maybe like trainees.
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But Dr. Rance just said that he has his, one of his lovely dialysis patients
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has been struggling with it too.
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So I think everybody can probably get something out of it, hopefully.
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So I don't have any disclosures. The goals for today is to define kind of normal
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versus abnormal menstrual bleeding. Because like what even is normal or abnormal?
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Recognize red flags, suggesting that there may or may not be like an underlying bleeding disorder.
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Review some common kind of hematologic causes of heavy menstrual bleeding.
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Discuss diagnostic evaluation and laboratory workup for this issue,
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and then review a little bit about acute and chronic management,
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just touch on those things and talk about kind of the multidisciplinary approach
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to care that these patients can require.
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Also, one of my big goals is to provide just access to some validated tools
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to help out with the evaluation of heavy menstrual bleeding,
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because those are things that I learned in fellowship that I was like,
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man, I wish I'd had before I came here.
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So those are some of the things I'm hoping that you guys are able to get out of it today.
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So why do we care? Why does it matter? So aside from the fact that like 50%
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of the population would potentially have that possibility to have this be an issue for them,
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it is one of the most common gynecologic complaints in adolescent patients.
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And it can be a first manifestation or almost even like an only manifestation,
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but still severe, of an inherited bleeding disorder can tell us that that's what's going on.
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Um, so delayed diagnosis of this issue, um, can impact a patient's quality of life.
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They're the PD in the pediatric or AYA world, their school attendance,
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they can develop iron deficiency and anemia and, uh, so-called related to that.
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And then also can like strongly affect their future reproductive health,
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which is a, is a thing that lots of folks are, are very concerned about.
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Um, so I thought I would kind of give hopefully some evidence-based practice
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information and then kind of sprinkle in just what.
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Just practice things that I have seen and learned over the past few years.
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And I'm sure that that will change as I move through into my career.
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But I wanted to focus on like P's and then also the gynecologists.
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The family medicine folks have their own like series of algorithms and things
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like that, but it's pretty similar to both of these.
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But for us, I think looking at the GMA Pediatrics, one of their big articles
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that they put out in 2020, and then the ACOG has like very specific information
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about screening and management of bleeding disorders in adolescents with heavy menstrual bleeding.
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So that's where most of this evidence-based information is going to come from.
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Okay. So what is normal? What's the menstrual cycle?
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All of those things. I feel like this particular picture is one thing that I
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have never quite liked, even though I'm really interested in women's health and I like helping gals.
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But what are the different reasons why you may or may not develop like abnormal
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menstrual bleeding and then what, you know, is normal and what's not normal.
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So one of the main things that we talk about in pediatrics for sure is going
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to be that like hypothalamic pituitary ovarian axis.
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That's very much the most common cause of it, of having like heavier abnormal
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kind of men's uterine bleeding in our patients.
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And ovulation is really commonly seen in adolescents in associating with their
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ovulatory dysfunction because you really don't have like a functional corpus
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luteum yet and you really don't have the normal kind of,
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LH surge and progesterone surge, all of those things are just immature.
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So that can lead, there's like an imbalance in those hormones and that can lead
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to excessive and or uncontrolled bleeding, particularly kind of in that early
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phase right after monarchy.
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So the hypothalamic pituitary ovarian axis immaturity, even though it is the
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most common cause, is kind of a diagnosis of exclusion because it's not like,
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oh, we're going to go test these hormones and prove that that's the problem.
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Um, so it is the most frequent cause, but it's not the only thing that we talk about. Um.
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So, that's important, I think, to start with. So, to define heavy menstrual
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bleeding, we used to call it menorrhagia.
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I think the main, the kind of the nomenclature has been shifting over the last decade or so.
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And the main thing I hear or I see kind of now in a lot of, especially in like
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the GYN world, seems to be like abnormal uterine bleeding.
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I'll call it heavy menstrual bleeding because that's very much still in our
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lexicon. And that's like something that I think is easy to understand or talk
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about. And abnormal uterine bleeding and heavy menstrual bleeding aren't totally the same.
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So we'll talk about that in a little bit, too. But a clinical definition of
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heavy menstrual bleeding is excessive menstrual blood loss interfering with
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your physical, emotional, social, or material quality of life.
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Um, so common clinical indicators of that would be, um, soaking through your,
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like, your menstrual kind of AIDS, um, very rapidly, uh, bleeding for a longer period of time.
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So greater than, we usually, it's like seven or eight days, different,
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different ones will just say different things, but greater than seven days for sure.
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Um, if you're passing large clots, and we'll talk about what constitutes large
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versus not large, flooding through your clothes or your bedding can be a sign,
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again, of having heavy menstrual bleeding and then developing iron deficiency anemia.
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So iron deficiency anemia is pretty common. I feel like we all probably know that.
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We take care of lots of girls in our practices, GenP's and Hemonks for sure.
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And that would be, if you develop iron deficiency anemia, it's a sign that you're
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losing blood or you're not making enough blood to keep up with your needs.
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And so frequently in menstruating females, one of the first place is that you'll
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think to maybe like, whatever, where are we losing? That's a big place.
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And you can lose more than you think you lose, if that makes sense.
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Again, I talked a little bit about like heavy menstrual bleeding versus this
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abnormal uterine bleeding.
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I put a little like thing at the bottom that just says the abnormal uterine
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bleeding is bleeding from the
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uterus that is abnormal in like regularly volume, frequency or duration.
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So again, it's kind of a little bit of more of an umbrella term.
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And then heavy menstrual bleeding specifically is just you're having like more loss.
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In the gynecology world, this is not really as much something that I have done
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very much of in the last 10 years, but in gyne world, palm coin is something that they talk about.
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And it's like a classification system for the causes of abnormal uterine bleeding,
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specifically in non-pregnant reproductive aged persons.
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So they, like that overall abnormal uterine bleeding, you can have heavy menstrual
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bleeding as a part of it or inter-menstrual bleeding. So you can bleed between
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the times when you would normally have hemencies.
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And then they break it down into structural causes versus non-structural causes.
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And you can see that they're listed there. And that palm coin is there.
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It's just meant to jog your memory about the different reasons why those may be occurring.
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Um, so for, in PD world, um, the structural causes of heavy menstrual bleeding
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are like much less common.
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Um, they occur, they're not, it's not a zero, um, but they're,
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it's very, it's much more common in older folks, um, for them to have these
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like structural causes like polyps or leiomyomas or malignancy and hyperplasia,
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all of those things, not as common in PD world.
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In pediatric world, again, the ovulatory dysfunction is the most common thing
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that can cause the heavy menstrual bleeding in young people.
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And then I put, you know, the three little stars just as a reminder for that.
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And I put the big star next to coagulopathy because that's heme world.
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And then I did say just really quick because even though I'm big H, there's the little O.
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There's malignancy. It's very uncommon in kiddos or young people,
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AYA patients, to have malignancy of, you know, the cervix or the GYN cancers,
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but it's not impossible.
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And so I just, that should still be on the differential.
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And I say that because I have a cervical cancer patient that I take care of,
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and her presenting symptom was heavy menstrual week. Yeah.
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So, this is, so, okay. So, we've gone from, you know, the different reasons why it may be.
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It's less likely to be structural. It's going to be more likely to be something
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like an inherited bleeding disorder, but more likely, again, the anovulatory.
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But we have to prove that it's not the inherited bleeding disorder since it
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can be like a presenting symptom for that.
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Everybody's favorite slide ever, the coagulation cascade.
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But the important thing is like in the general population, inherited bleeding
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disorders are not wildly uncommon.
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You can have, their inherited bleeding disorders are diagnosed at about 10 to
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17 kind of percent of women.
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But in adolescents with heavy menstrual bleeding, it's up to,
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it's between like 20 and 50 percent, Like 21 to 46% is one of the studies that I was reading.
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So many women or many young people who are coming in with heavy menstrual bleeding,
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your index of suspicion should be higher because the odds that it might be an
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inherited bleeding disorder are higher in that group of people as opposed to
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just like the general population, if that makes sense.
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Von Willebrand's disease is the most common inherited bleeding disorder in the
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general population. Yeah.
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And it happens, they were saying, we estimate that it happens at about 1% of
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the general population, which is pretty high, but also, we also estimate that
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it's, like, pretty underdiagnosed.
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It's probably a lot more common than that, actually. Um, it's followed by,
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um, the hemophilia A and hemophilia B.
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Um, we think of those as a bit rare, but we definitely, I think frequently here,
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especially we, we definitely know patients who have these, these,
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um, diseases, uh, about like one in 5,000, one in 10,000 males will have,
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be diagnosed with hemophilia.
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Um, there's other rare bleeding disorders, um, that occur and we can talk a
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little bit more about those in a little bit, but again, like for heavy menstrual
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bleeding specifically, like a third of those patients that come in and who actually
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require like hospitalization.
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So it's a little bit different than who present, but a third of the hospitalized
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patients that come in and need to be inpatient for heavy menstrual bleeding
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will be diagnosed with a bleeding disorder.
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So it's not entirely uncommon, if that makes sense.
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The most common bleeding disorders that these young people are diagnosed with
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is going to be Von Wilbrand's disease.
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So similar kind of, since it's the most common in the GenPOP,
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it's also the most common thing that people who come in with heavy menstrual
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bleeding that have an inherited bleeding disorder will be diagnosed with.
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The next thing that you might see is going to be abnormalities of platelet dysfunction.
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And so I will say, like, I'm including ITP in that. And so von Willebrands,
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platelets, and then we should be thinking kind of hemophilia type.
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Concerns. And then after that, it would be more like the rare bleeding disorders
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factor, inferior deficiencies, things like that.
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So when do we suspect a bleeding disorder? Like people, they've come in,
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they've told you to your clinic, they've told you I'm having bleeding.
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Maybe they're tired, maybe they're fatigued and you're worried about some like
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anemia or something like that.
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When is it, oh, it's heavy, heavy bleeding, heavy menstrual bleeding or regular
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menstrual bleeding or whatever versus like when should I really be worried about a bleeding disorder?
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There's like several slides about this, but I think this slide is a pretty good rundown.
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So it talks about like specific menstrual like history elements and then it
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breaks it down otherwise into the bleeding symptoms that you may be concerned about.
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So there are some tools and I'll go through those. And that's actually that
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those tools are what's going to kind of what this table is based off of.
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But I do think that it's some of the things here specifically that might be
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like of interest would be again, Thank you.
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Something that's important is like heavy bleeding at monarchy.
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Like if the very first time you ever have a period, you end up in the ER,
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that's something that we should be paying attention to.
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Or if the, when I, when the patient comes in or the person comes and tells you
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like, I'm having these heavy periods and you ask them, oh, when did it start?
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They're like, oh, since the very first time I ever had a period when I was 11
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or whatever, then every single period is pretty heavy.
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Then that's something to be mindful of and having you, that should kind of prick
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your ears up a little bit, if that makes sense. So prolonged bleeding makes sense, right?
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Frequent menstrual bleeding. So that's like happening more often than the regular
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kind of 30-ish days, 28 days.
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If you have severe iron deficiency, requiring a transfusion.
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So I think that that's another thing.
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And I see that a little bit more often probably than the average person,
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just because they come to us.
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But if you're needing a transfusion, that's like a lot of bleeding.
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That's abnormal. So we should have our minds thinking like, what is the cause of that much bleeding?
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Other things that are important, like flooding and leaking in your clothes.
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I always ask that as a part of the question. We'll talk about taking a good
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history, but that's important.
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I did say something about like, oh, clots, like little clots or big clots.
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Because that's people will, when you're talking to patients,
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they'll like talk to you about, oh, a little, but nothing crazy.
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So like large clots like I usually
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will talk about it in in the context of coin sizes like
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a dime like a quarter those kinds of things um passing
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a bunch of those you're actually losing like a lot more blood than you think you
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are um something else and then so any of those things are should prick your
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ears up and then if it's in conjunction with any of the other kind of bleeding
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symptoms that are like then you should be like oh yeah I have I have worries
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for an underlying issue so So if they bled a whole bunch after they had their dental procedure,
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all of those, any of those types of things occurred too.
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Again, it's, it's those, it's the gestalt, like the whole picture of the patient
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is going to be what really increases your suspicion.
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Okay, so that's why that's when you should kind of start to be suspicious, I think.
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The most important thing I would say is a really good history.
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And I know that everybody in Gen P's world has all the time in the world to
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spend with during their well child teen check, talking a whole,
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whole bunch about all of this.
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But I would advocate at that point, if somebody does do something like that,
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like, oh, yeah, by the way, I have terrible periods, make its own appointment,
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maybe, because it does take a lot.
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To do these appointments. Y'all probably all know that.
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But asking all of these questions is really important to know where you need
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to look and how you need to look.
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So the first thing I would say is taking a really good menstrual history.
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I think we all learned that pretty well.
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When did you start having your period? How often did they come?
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How long did they last? That kind of a deal.
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And overall, bleeding history is important. And again, I recognize that the
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bleeding histories we take are probably a little bit more involved than the
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bleeding histories other people take potentially, which is super fair.
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But I think something just interesting, again, you're going to ask things like,
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did you ever bleed with surgery? Do you ever have weird bruises?
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Do you get nosebleeds? Stuff like that. I also think it's important to talk
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about like developmental history as a part of your bleeding history.
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So did you come out, you know, was it a vaginal delivery?
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Did you, did the baby have a bleed? If mom or dad's in the room,
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whatever you ask them that, did they have a head bleed maybe? Things like that.
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Did they come out and they were just covered in bruises?
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Did they bleed when they cut their teeth? Those are like some interesting,
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like just some things that I wouldn't have for sure wouldn't have thought about
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before I started speaking to all these families that I think are important and can,
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again, kind of really tip you
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over into being a little bit more concerned about something underlying.
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Family history, I just ask if anybody has bleeding problems and then I'll specifically
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like say certain like bleeding term, like bleeding disorder terms.
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I'll be like, have you ever heard of something called hemophilia?
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If they have, they'll tell you yes. If they haven't, they'll tell you no.
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I usually will say hemophilia or Von Willibrand specifically,
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just because people usually know, if that makes sense.
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I also, like family history-wise, just to like a tidbit, asking if a mom or
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a grandma or whoever is there, I usually ask them about their families,
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kind of other women in their family.
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Have they had heavy bleeding? Have they had hysterectomies?
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Have they had, do they bleed a whole bunch whenever they had their babies? That kind of a thing.
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And families know a lot, like women all know a lot about all the women in their
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family and all of the people who have had these issues and these problems.
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So I think that's a very helpful and useful.
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Tool is your family history. You should always ask your medication history.
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That's important. There are some meds, obviously, I think we know that,
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that can lead to impaired anesthesis.
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So, are they taking a bunch of aspirin or NSAIDs or something?
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Are they taking it on a blood thinner and we, for whatever reason,
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are not in charge of that blood thinner, knowing those things are important.
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The other thing I would say is important is taking a sexual history.
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Just do it. Like, I think in PD world sometimes, especially in,
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I think, subspecialty PD world, at least for us.
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You may not always take the time to do that, but that would definitely be something
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that's important to know.
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So again, clues that again, maybe should make us more concerned about an underlying
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bleeding problem would be that bleeding, heavy bleeding since the very first
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period, family history of anybody, if everybody in the family bleeds a ton,
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that's important to know.
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Has this kid been also having nosebleeds all their life? That's important to
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know. So easy bruising is a weird one because everyone thinks they're,
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most people think that they're easy bruisers.
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So when I ask about bruising, sometimes I'll ask about like atypical kind of
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locations of bruising, which I think is sometimes quite useful.
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So like when you held the baby on their back, did they get fingerprints?
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You know, did they get bruises on their bottom or on their face or on their trunk?
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Those are all places that are not super typical. I think we know that as pediatricians,
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we'll frequently, you know, talk about, oh, yes, they have them on their arms
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and their, you know, anterior shins or legs, things like that.
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But bruising on your actual bottom, like your buttocks is not super,
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can happen, but not as normal.
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So that, again, can be a clue.
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Surgical dental bleeding is huge. That's a big one. Postpartum hemorrhage in
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their relatives is important. And then also just like families,
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patients who have been iron deficient for like ages and they took their iron
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and they would like swear up and down that they did.
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That can be a sign again that they're having losses.
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Like even more than you know, even more than we can understand,
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we just can't keep up for whatever reason.
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Are they bleeding just more? And is it like enough that it's concerning, right?
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So we took a solid history but then also
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all of these things that I just talked about were a lot
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and I didn't it's very hard to remember and like
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jog your own memory about all of these different things you're
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going to take a developmental history and all these things like that's a lot
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right um so there are validated tools to help you to turn like remind you what
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different kind of domains of bleeding you should be asking you can or should
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be asking about um and I think that this is one of the ones that I found really helpful.
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It's, like, very widely used in the hematology world, and I ask everybody about
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this every time they come in for bleeding.
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And so, having, like, a score or a baseline or whatever of this ISTH,
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this bleeding assessment tool, is very helpful. And so, that would be very fancy
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if you, you know, you send your consult and you've got a BAT score already.
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But it's a diagnostic tool. It's been validated. It was originally validated
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for von Willebrand's disease, but we use it pretty widely in,
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like, inherited bleeding disorders.
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And it's used to evaluate bleeding symptoms.
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An abnormal score is dependent upon your age and gender.
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So, like, less than 18 and greater than 18 and female versus male sometimes
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have different, well, they do.
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They have different scores, and that's a different, like, cutoff or abnormal.
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So there is a MedCalc for it. I put that here on this slide and that QR code
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should just take you directly to the MedCalc if you want.
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Also like the website's on the bottom. Also if you just Google it.
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But it's really nice. It's like a 14 symptom kind of questionnaire.
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There's, you can get a score of zero, like one through four for each,
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and then it'll help you kind of score from there. Yeah.
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Again, depending upon the characteristics or the demographic of the person that
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you're scoring, it'll be normal versus abnormal.
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Normal doesn't rule out a bleeding disorder, right? That's, I think,
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a very important thing to say.
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But abnormal will help you know, like, yeah, we definitely should probably do
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a little bit more work up and look into it.
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So I think just some of the domains that they talk about if it's like useful
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to know but I because I think it's useful to know um is that specifically about
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things like epistaxis um,
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cutaneous bleeding like bruising and things like that minor wound bleeding um
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oral cavity GI bleeding uh GU bleeding trauma surgical that kind of stuff um
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and it goes all the way through for the boys,
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they don't have menorrhage, so that's okay, but there is a specific one,
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and then depending upon the severity or the amount of kind of intervention you
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required for each of those.
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Those domains, it will help, again, get that score.
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So, that's the ISTH BAT. I really like it. It's really good.
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10 out of 10 would recommend, and again, I just, I'll say it again,
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I had one more slide here just to say, like, if they have, if a patient has
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a normal score, that doesn't mean that they don't have a bleeding disorder,
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they could never have a bleeding disorder kind of a thing.
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It's really just, it's very dependent
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upon what your bleeding kind of challenges or exposures have been.
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So like, yeah, you're not going to, you can't score high if you've never had
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a surgery or a dental procedure or any of, on all of those domains.
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And so you're not going to, you're not going to score if you're high on those
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things, if you're a boy or if you're a little girl who's premonopol.
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So those are just domains that you can't even, you know, you haven't achieved
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yet, if that makes sense.
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So, we talk about things like bleeding challenges that patients have had,
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and so your BAT score, it can change over time, and it likely will change over time.
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Um, so that's, again, just kind of an important thing. Um, some of the new recommendations
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related to, um, hemophilia has been, have been coming out that we should be
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like rescoring people frequently on their bats, just because again,
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your bleeding challenges and exposures will change over time.
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So bat score, good, helps decide normal versus abnormal bleeding symptoms.
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Um, something that else that I like really don't use that often,
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but I kind of like it, is the, is this, it's a, it's like more of an obstetric
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kind of gynecology tool that they use. It's a, it's a questionnaire.
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I think it's got 12, 12 questions on it, but it's, it's asking specific questions
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related to like the menstrual, your menstrual bleeding.
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So this is, I mean, I don't think it's going to be for the dudes,
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right? But it'll be for the menstruating persons.
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And it, it has some other kind of portions that are really nice.
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So it asks some more questions about family history and things like that as
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a part of the questionnaire.
24:15
It had a really nice sensitivity for if you did like when you fill it out,
24:19
when you score it based on their scoring tool with this tool that you could
24:26
like, it was nice to, it was pretty good about determining like who actually
24:30
requires more workup, who requires,
24:34
you know, like a hemostatic workup.
24:36
They actually did something in where they added the next tool that I'll show you as well.
24:40
And once they did both of those together on their GYM patients that they validated
24:44
this through, it actually had a sensitivity of about 95% to see if you scored on both of those high,
24:52
then you were 95%, you know, sensitivity for finding out who has actually had
24:57
an underlying inherited bleeding disorder. So I think that's a useful tool.
25:02
So I mentioned one more. This is one more thing that I, and this one I use pretty
25:07
frequently as well in our clinic, but it's the, um, the pictorial blood loss
25:13
assessment chart or the PBAC is what people are calling it.
25:16
So it's a validated tool used to help diagnose and quantify like menstrual losses.
25:21
Um, and you score blood stains on like menstrual aids, like pads and,
25:26
and, or tampons or whatever.
25:27
Um, it looks a little wonky here and I have one more and I do have like some,
25:32
Again, I have it linked because I think it's useful and you could potentially
25:36
use it in your own clinic in life.
25:38
But the way that it works is that it has day by day.
25:41
It shows you like a little bit stained, medium stained, totally stained.
25:45
And then it also has a little portion where it talks a bit about the,
25:48
about the like clot size and things like that.
25:55
And through all of those information, you obtain a score and it'll show you how to score it.
26:02
A normal score is less than 100 points. So it's points on this T-back.
26:08
And that score of less than 100 means that it seems like it's a normal amount of blood loss.
26:14
So that meaning less than 80 cc's for that period or for that menstrual cycle.
26:20
If you're greater than 100, then you had more than the 80 and it's more.
26:25
And that's abnormal. That's more than we anticipate or whatever that's what
26:28
that's a kind of the cutoff that's been that's been decided so that's kind of
26:32
like we talked about like what's too much based on like symptoms but like how
26:36
much is too much based on like amounts um.
26:39
I think this is a little bit tricky, just something to have in our mind,
26:44
because it's a little bit hard.
26:46
I don't have, I have not seen, and I'm sure it potentially exists,
26:49
but I just haven't had access to or seen this.
26:51
But I haven't seen non-English versions of this one. And I do have lots of families
26:57
who are non-English speaking and non-Spanish speaking.
27:00
And so trying to explain this sometimes is a little bit challenging.
27:03
But it is like, it can be kind of intuitive once you sit and go through it with folks.
27:10
And then I do say I will say like you do have to be have it be in your mind
27:15
that there's some recall bias that can happen so if a patient hasn't had a period
27:19
and you just bring them to the office to talk about their last period two months
27:22
ago because they have irregular periods too,
27:24
then it can be a little bit hard to know how accurate it's actually going to
27:28
be so sometimes I'll actually send these home with patients and ask them to
27:32
try and keep track like in real time if that makes sense.
27:35
I like this version of it a little bit better. And that's why I put the QR code
27:39
on this one. I think it's a little bit easier to use.
27:43
And so, and again, it's pretty easy to score once you actually just like sit
27:47
down and take a look at it. So if anybody's interested in that, I think it's good.
27:51
And then also, again, when you're like sending people like on for the people
27:55
that we're concerned about, I would say having like a baseline,
27:58
one of these, like having a PBAC from before we started, you know,
28:02
OCPs or whatever is really nice.
28:05
I included this one as well because this is just a nice resource.
28:09
So this is as opposed to doing like kind of the PBAC or the monthly menstrual
28:13
log. This is a daily menstrual log.
28:14
I like this too because it has, it's a little bit more inclusive of other types of,
28:20
menstrual aids, if that makes sense. So like cups and stuff like that,
28:24
there's other ways, because we still are trying to like quantify,
28:26
but how do you quantify if people are using like a cup or the period panties or whatever?
28:30
It gets a little bit harder to do with those things.
28:33
But the Hemophilia Federation of America does have these good trackers that
28:37
you can print out. And there's a whole bunch of different, there's daily,
28:39
there's weekly, whatever.
28:41
It's a cool resource. I do have to tell people who don't have hemophilia,
28:44
but I'm not telling them they have hemophilia. So just as that, that's a caveat.
28:49
Okay. So your patients come in, we talked about their period.
28:53
We've assessed, you know, their symptoms, all of their different bleeding symptoms,
28:56
their family history, all of those things.
28:58
And we've also decided, or we've, you know, quantified the amount of losses
29:03
they're actually experiencing with their period.
29:05
So that's a lot of nice data that we have about the patient already.
29:10
What else do we need to do? You should probably look at them.
29:13
Like, we should probably do a physical exam.
29:15
Physical exam findings are not, again, I feel like the history is a little bit
29:19
more high yield for this patient subset frequently by the time at least they
29:25
get to us, because they're usually not, you know,
29:28
acutely ill if they're coming to my clinic.
29:31
Like, never, but not always.
29:34
But things you might see for a patient on physical exam that may indicate that
29:38
they're having, you know, extreme heavy menstrual bleeding or heavy menstrual
29:41
losses would be signs of anemia.
29:43
So, pallor. You might also see, like, things like bruising and petechia,
29:46
depending upon the reason that they're having those losses, if they're having
29:49
dermocytopenia or something like that.
29:51
Orthostatic signs, so the syncope and presyncope.
29:54
It's not really a physical exam finding, but you can get that and you should
29:57
probably be getting orthostatic vitals on these patients as well.
30:01
I would actually, you should just do that.
30:04
We should also be looking out just for other things. Like there are other reasons
30:07
people have bleeding and we'll talk a little bit about that more.
30:10
But signs of endocrine disorders, you should be, when you're evaluating the
30:13
patient head to toe, you should be looking for all these other things.
30:16
So are they here soon? Are they having skin changes?
30:19
Do you think they have PCOS? Are they hypothyroid? What are we thinking here?
30:24
As far as, like, a GU exam, I think this is an important point.
30:28
An external exam is actually reasonable and appropriate.
30:32
You should be checking TNR stage and you should just be looking to make sure
30:36
that there's no external signs of, like, trauma or anything like that that could
30:39
be leading to vaginal bleeding.
30:41
You know, the TNR stage should match a person who is having,
30:44
who has, you know, achieved that level of adolescence and that,
30:49
you know, sexual maturity and all of those things, they should match.
30:52
You shouldn't have a kid who's like totally pre-pubertal appearing that's having
30:56
vaginal bleeding. That would be very abnormal.
30:59
And it's pretty, the PZ and the, you know, guy in our OB literature really does
31:04
agree that for the most part in adolescent girls who have heavy menstrual bleeding,
31:07
you don't have to do a speculant exam.
31:11
It's not required. Now, like you may find something else on your physical exam
31:16
or on your history checking or whatever that leads you to need to do that.
31:20
That can absolutely occur, but you don't have to do it every time.
31:24
I know that's something that I used to, I definitely used to think,
31:27
and I'm glad to know that we've been doing it right.
31:32
But abnormalities on your physical exam can help us know what do we do with
31:36
our labs, which I know is a big important thing.
31:41
So initial lab evaluation that I would recommend for pretty much everybody.
31:45
And this is, again, borne out.
31:46
This is pretty, the P's, the P's GMO article and the OB-GYN folks pretty much
31:54
agree on where you kind of should start, if that makes sense. So.
32:00
Kind of screening, PT, PTT, and
32:02
a fibrinogen, and then a pregnancy test is always the right thing to do.
32:07
I only say that because every once in a while people won't have had one at all,
32:11
and so my rule that I tell families is usually like 9 to 90,
32:14
pretty much everybody's getting one, just because then it's not anything that
32:18
I'm saying or insinuating or anything like that.
32:21
It's just an important part because you never know somebody's experience.
32:25
So that's initial lab evaluations that people should probably all have.
32:31
There's also really more like the heme-focused labs. So if on any of our history,
32:35
any of those things, all of those things led us to have higher suspicion or
32:38
concern for an underlying bleeding disorder, then we should probably be doing
32:43
more testing to see if that's true or not true.
32:47
So the first, again, being the most common cause, like of underlying bleeding
32:53
disorder cause, would be bimolibrain disease.
32:55
So we would check for that. We have a panel here at UH. Other folks might not have that.
33:00
Our panel includes these three things that I've listed there,
33:03
so the activity antigen and then also the factor 8 activity.
33:06
If you don't have that panel, which is totally fair in the outpatient world,
33:10
you can still get things like Yvonne Willebrand's activity antigen and factor 8 level.
33:14
Frequently, patients that come to us from gynecology who've been referred to
33:19
us from them, they almost always already have these things.
33:24
I also like a peripheral smear. It's nice if somebody's like taking a look at
33:28
the cells, particularly like the platelets, just to make sure that they look
33:30
normal and healthy and not extremely like morphologically wild.
33:37
And then underneath a little bit more, you can do other things.
33:40
And again, we'll talk about that in just a sec, but like platelet function testing
33:43
and then specific kind of other factor assays.
33:48
I kind of broke it up where, like, the first half is, like, the go-for-it labs.
33:53
I think those are very reasonable and appropriate. People who are being,
33:56
you know, evaluated for heavy menstrual bleeding should have those pretty much always.
34:01
The second half, the heme-focused, it's not unreasonable.
34:04
And, again, outpatient folks do this, like, not infrequently.
34:07
And it's nice to kind of have a baseline sometimes of the Von Willebrand testing
34:11
and stuff like that. But I will say the only kind of caveat to that is that
34:15
there's potential spurious results, not uncommon for that to happen either.
34:21
So they have abnormal Von Willebrand testing outpatient, and then they come
34:25
to us and repeat the COAGs in our specific kind of specialty COAG lab,
34:30
and they've normalized or whatever. And so it's not the wrong thing to do at all.
34:35
But it is something just like when you're interpreting those tests and you're
34:38
telling the family, I would say like it is possible for these to have been because
34:42
they're just very persnickety.
34:44
They're very, very sensitive, if that makes sense. That's how I kind of talk about it with families.
34:50
I would probably, the ones on the bottom there, I'd probably just let heen take
34:52
care of it because some of those platelet function, platelet aggregation studies,
34:55
things like that are like, you
34:57
have to like plan and talk to the right people and all of those things.
35:00
And I don't know, you just have to know when to use it kind of a deal.
35:03
And it's really expensive and a big deal.
35:05
So I probably would leave those to the next level.
35:09
The next group. Oh, one more thing that's very important, that's why I put that note there.
35:17
Is it's also important, again, I think when we're interpreting things,
35:21
particularly maybe like in the emergency department setting and things like that,
35:23
is that certain things like when you're like actively bleeding,
35:28
like if you're bleeding and you went to the emergency room because you're bleeding
35:31
and you want to pass out and whatever else, so bleeding,
35:35
you know, inflammation, Those things, they can actually falsely elevate some of these lab values.
35:40
So you check a Von Willebrand's when they're bleeding and they're fine.
35:44
But like at baseline, they're definitely not fine.
35:47
So that, again, can just cycle back into those like results not always being
35:52
completely accurate or whatever, if that makes sense.
35:57
The other thing that's important is having, once we start hormonal therapy on a patient,
36:02
we usually kind of have a little bit of time before some of those tests can
36:05
kind of settle back out because your estrogen and things like that,
36:09
those combined hormonal contraceptives will frequently, they bump up your von
36:14
Willebrand factor levels.
36:16
And so that can also kind of change things too.
36:18
So just again, when you're interpreting, if you've ordered those labs,
36:21
interpreting them is having that in your mind.
36:27
Oh, yeah. Well, I had one more note for myself. As for the ferritin,
36:31
that's a big important part of this is the screening for the iron deficiency.
36:35
I know I don't have like an iron panel on there. I'll be honest,
36:38
I probably would just get the iron panel.
36:40
But ferritin is the one that's listed in all of the resources and all of the
36:44
evidence-based kind of practice guidelines that I'm talking about.
36:47
So ferritin is a nice, you know, screening lab, but it's not,
36:50
again, this can also be a little bit tricky because if you're inflamed or you're
36:54
sick or whatever, your ferritin can be falsely elevated.
36:58
So a low ferritin will always tell you that they have low iron stores,
37:01
but a high ferritin might not be truly reflective of their iron,
37:05
if that makes sense. So again, keeping in mind.
37:09
Okay. So what are the causes? We have decided, you know, we've,
37:13
we've think that this person has an underlying bleeding disorder.
37:16
They've been bleeding a ton, heavy menstrual bleeding that came in.
37:19
What are the most common, again, kind of causes of what that might actually
37:23
be then if it is an underlying bleeding disorder?
37:26
So von Willebrand is, again, the most common overall inherited bleeding disorder.
37:30
About 1% of folks can have it. And again, like up to like 50% of people or 40%
37:36
of people with heavy menstrual bleeding may or may not have it.
37:39
There are different types of von Willebrand's disease. Some of them are qualitative
37:43
dysfunction, some quantitative.
37:48
So just types one, two, and three. But I think just knowing that a person has
37:51
von Willebrand's disease is the first, most important thing for the general person.
37:56
Clinical manifestations of
37:57
von Willebrand's are frequently heavy menstrual bleeding is pretty common.
38:01
Nosebleeds are common. And then mucosal bleeding, like your uterine bleeding is mucosal bleeding.
38:06
The diagnostic testing we talked about a little bit ago, but I listed it there
38:10
as well. And we'll talk about treatment.
38:13
Platelet function disorders are kind of the next thing. We talked,
38:17
I said a little bit about ITP, but ITP was in there. And so I think that's what kind of bumps these up.
38:21
These other platelet disorders, like Glansman's, Bernard Soulier,
38:26
all the storage ones, those are pretty rare, pretty uncommon,
38:30
but they are important to have in our minds.
38:33
I think the clinical clues, what would clue me into this more than the other
38:36
is the mucosal bleeding that's just like wildly out of proportion to their routine
38:41
coagulation test. Like your coags are fine.
38:44
It's those platelets that are not acting normally or not doing their job.
38:48
So that's an important kind of thing to keep in mind as well.
38:51
If you're seeing that, but their PT and their PTT are totally fine,
38:54
you're like, okay, maybe that's the deal.
38:58
And then that's, those are kind of tough to test. So again, if you're starting
39:02
to think about that, send them over to him like ASAP.
39:07
Females with hemophilia and hemophilia carriers, this is my jam.
39:10
I didn't want to do too much, but there is changing terminology.
39:13
I know like in med school, we always talked about how hemophilia is a boy's
39:17
disease, but women can definitely have it.
39:19
And there are symptomatic carriers, so people who have, you know,
39:23
normal factor levels but are not having, but are not having,
39:28
but are having symptoms, if that makes sense.
39:30
So it is important. Why does it matter? Heavy menstrual bleeding is not uncommonly
39:34
a presenting symptom for folks.
39:36
GYN bleeding outside of that, so the postpartum hemorrhage, things like that are pretty common.
39:40
And then, again, factor levels may not correlate well with phenotypes.
39:43
So all of those things are, it's not, you can't not have it, if that makes sense.
39:48
It's pretty underrecognized. recognized in women. And then there's a little
39:50
bit about X chromosome inactivation.
39:52
So you can have one, even though one of your chromosomes is normal,
39:57
that one maybe doesn't work quite as hard as your abnormal one.
40:00
So you may have lower factor levels or more bleeding.
40:02
So that's a group of folks that can definitely be these women or folks who have
40:08
menstrual bleeding that might show up for you.
40:12
Other things, again, rare factor deficiency.
40:15
Oh, thrombocytopenia. Things that I think are really important,
40:19
like when it might be like really serious or what people might be really scared
40:22
of would be things like leukemia or aplastic anemia. That's why you're getting your CBC for sure.
40:26
Don't forget connective tissue disorders. They totally exist and they can totally make you bleed.
40:31
And so I put a little note about like a BITEN score. So if a person is really
40:34
flexible and they bleed, that might be somewhere to start.
40:39
We should be asking about anticoagulation use. And then again,
40:42
the endocrine contributors.
40:44
So, what do we do? To acutely manage, you're going to assess,
40:49
make sure they're hemodynamically stable.
40:50
You'll transfuse based on whatever your institution's transfusional thresholds are.
40:55
We probably transfuse under seven here, and depending upon how they look and how they feel.
41:00
And then hospitalization criteria, I'll go through just an example of,
41:03
like, an algorithm of when you might, of the hospitalization that some people have published.
41:09
Things that you will do in the acute setting, you should probably just go ahead
41:12
and start the combined hormonal therapy.
41:15
Estrogen helps kind of directly act on the endothelial cells.
41:19
It promotes higher synthesis of von Willibrand factor, and it increases some
41:24
of your other clotting factors, too.
41:26
So it can work pretty good. It maybe won't work like this second,
41:29
but you should probably go ahead and start it, even in the acute phase.
41:32
You can get progesterone. We do a great job of getting tranexamic acid here.
41:37
And then I think having iron therapy in our minds, like early on,
41:41
like right off the bat, is an important thing. You'll get the blood products if you need them.
41:44
The condition-specific kind of treatments, including like desmopressin or,
41:48
you know, factor, whatever factor you may or may not need, you should call us for.
41:53
But those are treatments in the acute setting specifically.
41:57
Long-term management, the things we want to do is control your bleeding.
42:00
We want to prevent you from having anemia, like correct and prevent your anemia
42:03
and make your life better. That's an important thing.
42:08
The different ways that we could do that on, in like the long-term goal setting
42:11
would just be like, we can do hormonal suppression. You can have an IUD.
42:15
That's actually one of the like best ways when they've evaluated like a ton
42:19
of folks to, to treat heavy menstrual bleeding. The IUDs work very, very well.
42:24
It's, it's one of those things in PD world we're not going to do quite as often. That makes sense.
42:29
But that's definitely in the GYN literature.
42:31
We're going to replace iron when we need to, and then you're going to follow
42:34
up with heme. Those are all really good ones.
42:36
We know in our adolescent patients that adherence is hard and following up is
42:40
hard, and so trying to provide that structure and support is really important.
42:47
I like this. It's very hard to see, I think, on y'all's screen. So I apologize for that.
42:51
But there are really nice algorithms published for, like, how you should be
42:55
thinking about it in, like, the heavy menstrual bleeding and,
42:58
like, the acute setting and how to treat it and what to do.
43:00
And so I do think that it exists. It's out there.
43:04
And it's really nice. So it'll talk about, like, these are the things you should
43:07
be looking at right away. Look at their vitals, orthostatics, all those things.
43:11
Which labs you should get before you're going to do any treatment,
43:14
how to treat, how to reassess.
43:15
All of those things are, there's some nice published guidelines out there.
43:19
And I would recommend just taking a look if you're like an ER doc or if you're
43:22
going to go work in the ER or in a clinic or whatever.
43:27
The next thing I looked at, because I have had this conversation several times,
43:32
is like, do we need imaging?
43:34
We've done all this work. We've got these labs. We know what to do,
43:36
kind of, we have an idea, but do we need imaging?
43:39
The answer is it depends, which is very annoying.
43:42
But structural abnormalities, like I said way back at the beginning,
43:45
are just a small minority of the cases of heavy menstrual bleeding in adolescence.
43:50
It's a lot more common in the grown-ups.
43:52
So clinical evaluation should really help guide your, whether or not you're
43:56
going to include imaging.
43:58
Some certain things that might tip you over into doing it would be if a person
44:01
is having like a lot of menstrual pain.
44:04
That's refractory, kind of the first line treatments for that.
44:08
Also, any physical exam findings when you're doing kind of your external exam,
44:12
that would be like a pelvic mass or some sort of outflow obstruction.
44:15
You go ahead and get some imaging at that point.
44:18
Most people will start with a transabdominal pelvic ultrasound.
44:22
Which is, like, pretty good if you're looking for, like, a big,
44:25
significant anomaly. You can see most of this.
44:29
But a transvaginal is a lot more sensitive to texmolyx cysts and things like
44:32
that, which can still exacerbate menstrual bleeding.
44:36
But again, I would also still start with the transabdominal just because it
44:42
repeats patients, right?
44:45
I wanted to do just a quick—I'm running talk like little plug about iron deficiency and quality of life.
44:56
Um, cause we talked about fair time. We talked about that iron,
44:59
you know, repletion should be part of your upfront therapy, even though giving
45:03
some iron orally is not going to, you know, increase their hemoglobin of four today.
45:08
Um, but we need to be, that needs to be like kind of forefront in our minds,
45:12
I think for a lot of these women. Um, cause again, you're having ongoing losses regardless.
45:16
Um, and a lot of people are, like many, many, many of these patients are iron deficient.
45:21
And so iron deficiency actually has some pretty significant consequences for
45:27
quality of life, fatigue, cognitive, school impairment.
45:31
They don't play, kids don't play sports as much. It's a lot of psychosocial
45:34
impacts that they've reported in a bunch of different studies.
45:38
Iron deficiency is like a big, big topic right now in heme world.
45:43
And so I just put some of the more like recent articles that have been published.
45:48
And then in that little upper corner, you can see that, like,
45:50
the publications in PubMed, like, skyrocketed.
45:54
So this is something that's very interesting. And people are,
45:58
like, patient, kind of patient-centered outcomes are, like, very important because
46:03
it really negatively affects these young people's lives.
46:08
So one other thing just down at the corner that you can see the ferritin goal
46:12
for menstruating folks or menstruating females or people is actually like higher.
46:17
So when you see your ferritin come back on the computer, it's definitely going to be.
46:22
You know black or not red after whatever
46:25
like 12 or 15 or something like that um but we
46:28
actually have a slightly higher ferritin goal for most of our men's reading females
46:31
um i always i will say like if this is
46:34
not the end-all be-all you have to get to 30 or you're not successful even though
46:38
they're not anemic and their iron is fine um that's okay um but it is something
46:43
like we would try and you know the goal would be to try and get them up especially
46:47
if they're having like ongoing symptoms like they're super fatigued or something like that um,
46:52
Those are a lot of the things that we are thinking about in our iron deficiency kind of world.
46:58
Again, oral repletion is the most physiologic and the best, but IV does exist
47:04
and work quite well as well.
47:07
So that's most of what I had to say about heavy menstrual weeding. It was a lot.
47:12
Some of the take-home messages that I think are most important is that this
47:18
topic, even though it's fairly common, and lots and lots of women and young
47:21
people experience this, report this, come to the doctor for this,
47:25
it does require and warrant kind of like mindful evaluation.
47:29
Um, and then I just unplug that bleeding disorders are relatively common and
47:34
probably significantly underrecognized.
47:36
So just having that in your mind and, and making sure that we're looking in that area and for that.
47:41
Um, and then iron deficiency should be addressed. We should have these gals
47:45
on iron. If it's not working, switch the iron.
47:48
If it's not working, switch the dosing regimen. There's a lot of good information
47:51
about it. And then also, if it's really hard, hematology is there.
47:56
Caring for patients, for kids is like a team sport. I know everybody knows that here.
48:00
And so multidisciplinary care, especially like kind of for this issue, is really important.
48:07
And if we have that option, if we can, utilizing it is really good.
48:12
And it really, really helps these patients. So I think the quarterback of all
48:15
of this is generally like primary care, kind of like first line caregivers kind of ideal.
48:21
I think the next thing would be, you know, it's PT Monk and adolescent medicine
48:25
are really good resources.
48:27
And we can, again, if you find an underlying bleeding disorder,
48:29
definitely, definitely, it's always hemonk, right?
48:31
But I think that the supporting and the iron deficiency and all those things
48:35
are really helpful. And we can do a lot with that.
48:38
Gynecology is, like, super important, and they help these patients very much.
48:42
And then, again, just having in our
48:43
minds that the psychosocial kind of ramifications of this are very real.
48:47
And so if we have, like, support that we can give for that or social work,
48:51
which I know that we have so much extra of that everywhere.
48:55
But if we have those options, I think that's just really helpful and nice for these patients.
49:00
Um, these are my references from today and then the QR codes and everything were there.
49:06
Um, and then I had just a side questions, comments and advice,
49:10
and then a shout out for our South Texas Center for Bleeding Disorders.
49:15
Um, because if you do have a bleeding disorder, it's a good place to come.
49:18
Um, and it's, you know, federally designated and important.
49:22
Dr. Kasun had a really nice point about, particularly in non-ambulatory,
49:26
like kiddos, um, that if you're having these abnormal kind of bruising sites
49:30
and locations that we should be having, we should have, you know,
49:35
abuse and non-accident trauma, like at the forefront of our minds. I super agree with that.
49:39
I think I was kind of focused in my mind on our older kiddos and people, but you're super right.
49:46
Thank you so much for listening to that great talk.
49:49
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49:54
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49:59
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50:02
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50:06
That's also found wherever you listen. Thank you so much for listening.