Evaluation of abnormal bleeding in women.

The evaluation of the woman with abnormal bleeding, particularly menorrhagia, carries a relatively high yield of discovering an underlying disorder of hemostasis. The most common underlying hemostatic disorder would be von Willebrand disease, with an estimated prevalence of 7% to 20%. In addition, preliminary results suggest that another 20% to 30% of patients may have impaired platelet aggregation as another cause of menorrhagia. Disorders of fibrinolysis may be an additional underlying hemostatic disorder. Initial intake should include documentation of menorrhagia by the pictorial chart assessment of menstrual flow. Baseline characteristics of menstrual flow should also be documented including the frequency of changing the sanitary napkin on the heaviest day, use of more than one sanitary napkin at a time, and number of days lost from school or work. Menorrhagia since menarche, a history of surgicalor dental-related bleeding, and a history of postpartum hemorrhage are items of the bleeding symptom audit that appear to predict in part von Willebrand disease in women with menorrhagia. Epistaxis and easy bruising do not appear to be clearly discriminatory symptoms. Initial testing should include the complete blood cell count, protime, activated partial thromboplastin time, iron profile, serum creatinine, thyroid-stimulating hormone level, factor VIII level, von Willebrand factor antigen, ristocetin cofactor, and platelet aggregation studies. Additional hemostatic studies may also include a factor XI level and euglobulin clot lysis time. Intuitively, failure to diagnose an underlying hemostatic disorder may lead to continued menorrhagia and diminished quality of life, as well as unnecessary surgical interventions, which, in turn, may be fraught with increased bleeding.