Iron deficiency and fatigue in adolescent females with heavy menstrual bleeding

Haemophilia ◽  
2012 ◽  
Vol 19 (2) ◽  
pp. 225-230 ◽  
Author(s):  
W. Wang ◽  
T. Bourgeois ◽  
J. Klima ◽  
E. D. Berlan ◽  
A. N. Fischer ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Adolescent Females ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding

Iron Deficiency and Fatigue in Adolescent Females with Heavy Menstrual Bleeding,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 4215-4215
Author(s):  
Wenting Wang ◽  
Tran Bourgeois ◽  
Jennifer Klima ◽  
Elise D. Berlan ◽  
Anastasia N. Fischer ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Blood Loss ◽  
Ferritin Level ◽  
Adolescent Females ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
Menstrual Blood ◽  
Menstrual Blood Loss ◽  
Fatigue Score ◽  
Study Population

Abstract Abstract 4215 Introduction Adolescent females are one of two pediatric populations at greatest risk for iron deficiency. An important risk factor for iron deficiency in adolescent females is excessive menstrual blood loss. Due in part to changes in circadian rhythms and poor sleep hygiene, fatigue is also a pervasive problem in adolescence, and may be exacerbated by iron deficiency secondary to menorrhagia. Clinical trials have shown that non-anemic adult women with low serum ferritin (≤15„30 ng/ml) and unexplained fatigue demonstrate improvement in fatigue with iron supplementation. Similar studies have not been performed in women <18 years of age. Our primary objective was to define baseline ferritin values and fatigue symptoms in a population of young females with a history of heavy menstrual bleeding. Methods The study population included 11,Ÿ17 year old females presenting to an Adolescent Gynecology Clinic or Menorrhagia Clinic for initial evaluation or follow-up of heavy menstrual bleeding. To mirror our clinical practice, the study population included patients who did and did not take iron supplements, as well as those who did and did not use hormonal contraception. To evaluate the degree and effects of menstrual blood loss, we utilized the Ruta Menorraghia Scale (RMS), a subjective measurement of menstrual blood loss and health-related quality of life. Possible responses to each multiple choice question were assigned ordinal scores to produce a total menorrhagia severity score (MSS). We investigated symptoms of fatigue using the Fatigue Severity Scale (FSS), a Likert scale measurement of fatigue's effects, symptoms, and severity (possible responses range from 1 to 7). Hemoglobin and ferritin levels were obtained by venipuncture after the completion of survey instruments. A control population of 12,Ÿ17 year old menstruating females was recruited from a Sports Medicine clinic. These patients completed the RMS and FSS instruments but did not undergo venipuncture. We compared FSS and MSS between the two populations using the Kruskal Wallis test. We evaluated possible predictors of ferritin level (age, body mass index, fatigue scores, and MSS) using generalized linear models. Results A total of 31 adolescents diagnosed with heavy menstrual bleeding and 37 healthy adolescents completed the study. Mean MSS was 39.3 (±17.4) in those with a history of heavy menstrual bleeding, compared to 17.9 (±10.0) in controls (p<.0001). When completing the menorrhagia scale, over two-thirds (71%) of adolescents with heavy menstrual bleeding reported that menses mildly to moderately affected their ability to participate in physical education class or sports, compared to 27% of controls. Thirteen (41.9%) of those with heavy bleeding reported missing at least one day of school with each menses, compared to 8.1% of controls. Mean fatigue score was 4.2 (±1.5) in patients with heavy menstrual bleeding, similar to values reported in adults with sleep-wake disorders. In contrast, the mean fatigue score was 2.98 (±1.1, p=.001) in the control population, similar to values reported in normal healthy adults. Twenty-five of 31 (80.6%) adolescents with heavy menstrual bleeding had ferritin levels ≤30 ng/ml, and ten (32.2%) had ferritin levels ≤15 ng/ml. Our generalized linear models did not identify any significant univariate relationships between ferritin levels and patient age, body mass index, fatigue score, or menorrhagia score. This finding may be due to our small sample size, or the narrow range of ferritin levels in our study population (87% had a ferritin level <40 ng/ml). Discussion Iron deficiency and symptoms of fatigue were common findings in a small population of young women with heavy menstrual bleeding. Fatigue severity scores were significantly higher in our study population as compared to healthy controls. Larger studies are needed to delineate the relationship between menstrual blood loss, fatigue, and ferritin values in adolescents, in order to plan for future intervention trials of iron supplementation. We also identified a high frequency of physical activity limitations and school absence in young women with heavy menstrual bleeding, highlighting the importance of including these types of patient-reported outcomes in the design of clinical trials for this patient population. Disclosures: No relevant conflicts of interest to declare.

Iron Deficiency Anemia in Adolescents Who Present with Heavy Menstrual Bleeding

2017 ◽  
Vol 30 (2) ◽  
pp. 247-250 ◽  
Author(s):  
Amanda G. Cooke ◽  
Timothy L. McCavit ◽  
George R. Buchanan ◽  
Jacquelyn M. Powers
Keyword(s):  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
Deficiency Anemia

scholarly journals Management of heavy menstrual bleeding on anticoagulation

Hematology ◽  
2020 ◽  
Vol 2020 (1) ◽  
pp. 533-537
Author(s):  
Bethany Samuelson Bannow
Keyword(s):  
Iron Deficiency ◽  
Blood Loss ◽  
Oral Anticoagulants ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
School Work ◽  
Medical Interventions ◽  
Recurrent Venous Thromboembolism ◽  
Menstruating Women ◽  
Hormone Therapies

Abstract Heavy menstrual bleeding (HMB) is a common complication of anticoagulation, affecting ∼70% of menstruating women receiving oral anticoagulants. The risk of HMB is lower with apixaban and/or dabigatran than with rivaroxaban. HMB can result in iron deficiency with or without anemia, increased need for medical interventions, decreased quality of life, and missed school/work. Mainstays of treatment include hormone therapies such as the levonorgestrel intrauterine system, subdermal implant, and other progesterone-based therapies, which can result in decreased blood loss and, in some cases, amenorrhea. Combined hormone therapies can be used while patients continue receiving anticoagulation and are also highly effective for decreasing menstrual blood loss. Rarely, procedure-based interventions such as endometrial ablation may be required. Patients should be evaluated for iron deficiency and anemia and offered supportive therapies as needed. Abbreviating the course of anticoagulation or skipping doses can increase the risk of recurrent venous thromboembolism by as much as fivefold, but switching oral anticoagulants may be considered. Awareness of HMB and careful history taking at each visit are crucial to avoid a missed diagnosis.

Population Screening for Von Willebrand's Disease in Adolescents with Heavy Menstrual Bleeding

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 477-477
Author(s):  
Deena Khamees ◽  
Jennifer Klima ◽  
Sarah H. O'Brien
Keyword(s):  
Iron Deficiency ◽  
Electronic Medical Records ◽  
Iron Deficiency Anemia ◽  
Medical Records ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
Treatment Center ◽  
Deficiency Anemia ◽  
Bleeding Disorders ◽  
Study Population

Abstract Abstract 477 Background Heavy menstrual bleeding (HMB) is the most common presenting symptom in women with von Willebrand's disease (VWD), reported in 80–90% of patients. The American Congress of Obstetricians and Gynecologists recommends that VWD screening be performed in all adolescents presenting with severe menorrhagia; however, the frequency of VWD screening in clinical practice remains unknown. Combining administrative health claims data and electronic medical records from a large population of Ohio Medicaid-enrolled adolescents, our objectives were to determine the frequency of 1) VWD screening and 2) new patient evaluations at a hemophilia treatment center in adolescents with HMB. We also sought to determine what patient-level factors predicted VWD screening. Methods The data for this study were obtained from Partners for Kids, an accountable care organization providing health care for Medicaid patients in Central (Columbus, OH and surrounding counties) and Southeastern Ohio (rural counties). Our study population included females 10–17 years of age with two or more ICD-9-CM diagnoses of HMB (626.2, 626.3, 626.8) continuously enrolled in Partners for Kids for at least 6 months prior to and 12 months following first diagnosis of HMB. We defined severe HMB as HMB plus one of the following clinical features appearing in the 12 months following first diagnosis: 1) inpatient stay for HMB, 2) iron deficiency anemia (ICD-9 codes 280.0, 280.8, 280.9), or 3) evidence of blood transfusion (CPT code 36430). We extracted data from Partners for Kids regarding patient age, county of residence, inpatient and outpatient diagnoses and procedures, and laboratory testing. By linking patient name and date of birth to electronic medical records at Nationwide Children's Hospital (the pediatric hemophilia treatment center for Central and Southeastern Ohio), we determined which patients had a hematology visit since time of first HMB diagnosis. Results Our study included 673 patients, 16% of whom met study definition for severe HMB. VWD screening occurred in only 10% of the total study population, but was significantly higher (24%) in patients with severe HMB (p <0.001). Patients living in Central Ohio (location of the region's hemophilia treatment center) were more likely to be screened for VWD (OR 2.1, p <0.03) than patients in Southeastern Ohio. When compared to 15–17 year olds, the youngest patients (aged 10–11 years) were more likely to be screened for VWD (OR 3.6, 95% C.I.: 1.6–8.1, p =0.002), and 12–14 year olds were also more likely to be screened than the oldest patients (OR 2.7, 95% C.I.: 1.5–4.8, p =0.001). Fifty-one (7.6%) patients were seen by the regional hemophilia treatment center. Almost 10% of all patients had a diagnosis of iron deficiency anemia, although only 26% of patients were screened for this common complication of HMB. Though only 3% of the study population (11% of the severe HMB population) was diagnosed with a bleeding disorder within 1 year of diagnosis of HMB, over a third of these (36%) were VWD. The prevalence of platelet function defects was similar to VWD. Discussion Despite recommendations by the American Congress of Obstetricians and Gynecologists, VWD screening is performed in a minority of adolescents with HMB, even among those with the most severe disease. Given the low rates of screening, our population reported frequencies of inherited bleeding disorders in adolescents with HMB are likely under-estimates. The low rate of screening for iron deficiency anemia in adolescents with HMB is also of concern. Future studies are needed to identify and overcome barriers to laboratory screening for inherited bleeding disorders in young women with HMB. 1. Laboratory Evaluation and Final Diagnoses in Adolescents with Heavy Menstrual Bleeding Disclosures: O'Brien: GSK: Consultancy, topic not relevant to this paper Other.

Iron Deficiency without Anemia: A Common Yet Under-Recognized Diagnosis in Young Women with Heavy Menstrual Bleeding

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3510-3510
Author(s):  
Abigail T. Lang ◽  
Stephen Johnson ◽  
Mollie Sturm ◽  
Sarah H. O'Brien
Keyword(s):  
Primary Care ◽  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Young Women ◽  
Household Income ◽  
Adolescent Females ◽  
Bleeding Disorder ◽  
Heavy Menstrual Bleeding ◽  
Deficiency Anemia ◽  
Iron Deficient

Abstract Background Iron deficiency anemia is a common complication of heavy menstrual bleeding (HMB) in adolescents both with and without underlying bleeding disorders. As such, the Centers for Disease Control recommends screening young women with HMB for iron deficiency anemia annually. However, iron deficiency, even without anemia, is also associated with a variety of physical symptoms, including fatigue and decreased tolerance for exercise, as well as neuropsychological sequelae such as irritability, apathy, depressive symptoms, and decreased cognitive function and quality of life. Screening for iron deficiency is routinely tested in the primary care setting with point of care hemoglobin (Hgb) or complete blood count (CBC). However, these tests are unable to identify iron deficiency without anemia. Objectives Given the commonality of iron deficiency without anemia in adolescent females, the primary objective of this study was to determine the percentage of iron deficiency that would have been missed by screening with 1) Hgb or 2) CBC testing with MCV, as compared to performing screening ferritin levels, in a population of young women with HMB. Additionally, we examined potential risk factors contributing to iron deficiency, including age at diagnosis of HMB, presence of an underlying bleeding disorder, body mass index (BMI), and household income. Methods We retrospectively reviewed data for 114 adolescent females ages 9-19 years referred as new patients to the Young Women’s Hematology Clinic at Nationwide Children’s Hospital, Columbus, Ohio, for evaluation of HMB. Exclusion criteria included patients who did not have a CBC and ferritin drawn on the same day or within the preceding month and those patients with histories of prior transfusions, thrombocytopenia, or hemoglobinopathies. Iron deficiency was defined as ferritin <20 ng/mL, anemia as hemoglobin <12 g/dL, and microcytosis as MCV <80. Results The mean age of patients at evaluation for HMB was 14.3 (SD = 2.0) years of age, and 80 (70.2%) were ultimately diagnosed with an underlying bleeding disorder. Fifty-eight (50.9%) patients had ferritin levels indicating iron deficiency, twenty-nine (25.4%) patients were anemic, and 26 (23.9%) patients had microcytic MCV levels. To compare the sensitivities of a Hb vs. full CBC in detecting iron deficiency, only iron deficient patients with full CBC testing results (including an MCV) were included in the analysis (n=54). Of these 54 patients, Hgb correctly identified 42.6% (n=23) of iron-deficient patients vs. 46.3% (n=25) that were correctly identified with CBC (which could show either low hemoglobin and/or microcytosis). Though the CBC captured an additional 2 patients, this was not a statistically significant difference (p=0.5). Patients had significantly higher odds of having iron deficiency if they were overweight or obese [2.81, 95% CI: (1.25, 6.29)] when compared to patients with normal BMIs. Age at evaluation of HMB, the presence of an underlying bleeding disorder, and median household income were not significantly associated with iron deficiency. Discussion Iron deficiency with and without anemia remains a common yet treatable condition in adolescent females with HMB. Iron deficiency with and without anemia was found commonly in our patient population. Our study shows that screening Hgb or CBC alone may miss over half of patients with iron deficiency. We recommend serum ferritin in addition to Hgb as a screening tool for iron deficiency in adolescent females with HMB. Additionally, a higher index of suspicion for iron deficiency should be noted in adolescent females with an increased BMI. Primary care and specialty physicians caring for young women need to be aware that iron deficiency without anemia can lead to clinical symptoms and that adolescent females with HMB are at high risk for iron deficiency. Improved screening strategies will allow for earlier implementation of iron therapy and improvement of symptoms. Disclosures No relevant conflicts of interest to declare.

scholarly journals Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist

Blood ◽  
2018 ◽  
Vol 132 (20) ◽  
pp. 2134-2142 ◽  
Author(s):  
Sarah H. O’Brien
Keyword(s):  
Iron Deficiency ◽  
Bleeding Disorder ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
Laboratory Evaluation ◽  
Hormonal Contraceptives ◽  
First Line Therapy ◽  
Sanitary Products ◽  
Menstrual History

Abstract Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting &gt;7 days, menstrual flow which soaks &gt;5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.

scholarly journals Study of menstrual disorder in adolescent girls at tertiary care centre in rural area

2018 ◽  
Vol 7 (5) ◽  
pp. 1979
Author(s):  
Anubhuti Yadav ◽  
Deepa L. Masand
Keyword(s):  
Rural Area ◽  
Adolescent Girls ◽  
Total Population ◽  
Tertiary Care ◽  
Adolescent Females ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
World Population ◽  
Menstrual Hygiene ◽  
Tract Infections

Background: Total adolescent world population is 16%.  Adolescents (10-19 years) constitute 21.3% i.e. nearly 1/5th of total population of India. 19% of the total population-faces a series of serious challenges not only affecting their growth and development but also their livelihood as adults. The objective of the current study was to observe the menstrual disorders among adolescent females and to observe the demographic profile and assess hygiene practices during menstruation and grade of anemia due to menstrual morbidity.  Methods: A random selection of adolescent’s females were done from gynaecology outpatient department at a tertiary care hospital in rural area. Study done on 180 adolescent girls from January 01, 2016 to June 31st, 2017, it is a descriptive type of observational study. Counseling done of adolescent females on menstrual hygiene and nutrition. Results: Most common menstrual morbidity seen in this study is dysmenorrhea (41.66%) followed by heavy menstrual bleeding i.e 25% and irregular menstrual bleeding (13.33%) subsequently. All these problems are associated with their practices used during menstruation. Poor menstrual hygiene was seen associated with 30 to 35% of abdominal cramps and mood swings, heavy menstrual bleeding and nutritional deficiency leads to moderate anemia (7 to10 gm%) in 83%.Conclusions: Due to unhygienic practices and lack of education and awareness about hygiene many of the girls were suffering from reproductive tract infections and poor nutrition leads to anemia. So, we all need to educate them about hygiene and spread awareness about the various services provided by the government like supplying of sanitary napkins to overcome infections.

Depression in Adolescent Females With Heavy Menstrual Bleeding

2021 ◽  
Author(s):  
Angela C. Weyand ◽  
Kate D. Fitzgerald ◽  
Mary McGrath ◽  
Vibhuti Gupta ◽  
Thomas M. Braun ◽  
...  
Keyword(s):  
Adolescent Females ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding

scholarly journals The Association between Heavy Menstrual Bleeding and Depressive Symptoms in Adolescents

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4230-4230
Author(s):  
Sanila Sarkar ◽  
Laura Benjamins ◽  
Sudad Kazzaz ◽  
Neethu M Menon
Keyword(s):  
Depressive Symptoms ◽  
Blood Loss ◽  
Young Women ◽  
Adolescent Females ◽  
Heavy Menstrual Bleeding ◽  
Menstrual Bleeding ◽  
Chi Square ◽  
Test Of Independence ◽  
Adolescent Population ◽  
Chi Square Test

Abstract Introduction: Heavy menstrual bleeding (HMB) is a type of abnormal uterine bleeding (AUB) that affects 30% of women of reproductive age and up to 40% of adolescents. Furthermore, 10-40% of adolescents with HMB have an underlying inherited bleeding disorder like von Willebrand disease or platelet dysfunction, requiring management by pediatric hematologists. HMB has been described as more than 80 ml of blood loss during one cycle and clinically, it is defined by several parameters such as the length of each cycle, severity of soaking through pads or tampons, size of clots passed and pictorial blood loss assessment chart (PBAC) score. Studies in adult women show a significant impact of HMB on their psychosocial and financial health. However, little is known about the psychological effects of HMB in adolescent females. In the adolescent population, depression is twice as common in females as it is in males, likely due to a combination of biological and social differences. In this study, we examine the association between heavy menstrual bleeding and depressive symptoms in adolescent girls. Methods: We conducted a retrospective records review of adolescent females aged 10-21 years that were seen as new patients at the Adolescent Medicine and Young Women's Bleeding Disorders clinics at our institution between January 1, 2018 and March 31, 2020. Patients were included in the study if they had started menses, and had a doumented menstrual history as well as a completed Patient Health Questionnaire (PHQ-9), a validated screening tool for depression.Patients with a severe underlying chronic medical disorder (Including but not limited to end stage renal disease, Juvenile Rheumatoid Arthritis, Systemic Lupus Erythematosis, severe eating disorder, previously diagnosed bipolar disorder or psychotic disorders) were excluded. HMB was determined by either a PBAC score of &gt;100 or the presence of two or more of the following criteria: Menses lasting &gt;7days Soaking through pad or tampon &lt;1hr Soaking through bed clothes or changing pads at night Passing large clots Low ferritin &lt; 15ng/ml (indicative of low iron stores) Anemia with Hemoglobin &lt; 12g/dl not due to any other cause (e.g. dietary, immunosuppression, medication induced) Depression was determined by a PHQ-9 score of 9 or greater. The two variables were dichotomized, and a chi-square test of independence was performed to test the association with a significance level of p &lt; 0.05. Results: A total of 203 records were reviewed after meeting inclusion and exclusion criteria. The mean age was 15.94 years (median 16, mode 16) with a range of 12-20years. 42 girls (20.7%) had a PHQ-9 score of &gt;9 and 52 (25.6%) had HMB. Eighteen of the 42 patients (42.8%) with elevated PHQ-9 score had HMB and 34/52 patients (65.3%) with HMB had an elevated PHQ-9 score. Pearson's chi-square test of independence showed a significant relation between HMB and PHQ-9 score of 9 or more with χ 2 (1, n=203) = 8.2618, p = 0.004. After the application of Yates correction, the result was still significant with χ 2 = 7.1603 and p = 0.007. Discussion and Conclusions: This study shows a significant association in the adolescent population between heavy menstrual bleeding and moderate or severe depression as defined by the presence of a PHQ-9 score of 9 or more. This retrospective analysis does not establish causation, but demonstrates a clinically noteworthy finding that has not been described before. The PHQ-9 is used widely across this population to screen for depression, but it is also important to screen young women aged 10-21years for HMB as a contributing factor to depression followed by timely and appropriate management of both problems. Additionally, it may be worthwhile to evaluate all young women with HMB through additional methods to diagnose depression as this patient population appears to be at higher risk. Future prospective studies are needed to better characterize this association. Disclosures No relevant conflicts of interest to declare.

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