Objective
To better understand the current evaluation of unexplained menorrhagia by obstetrician-gynecologists and the extent to which a bleeding disorder diagnosis is being considered in this population.
Study Design
A total of 1200 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists were invited to participate in a survey on blood disorders. Respondents completed a questionnaire regarding their patient population and their evaluation of patients with unexplained menorrhagia.
Results
The overall response rate was 42.4%. Eighty-two percent of respondents reported having seen patients with menorrhagia caused by a bleeding disorder. Seventy-seven percent of physicians reported they would be likely or very likely to consider a bleeding disorder as causing menorrhagia in adolescent patients; however, only 38.8% would consider bleeding disorders in reproductive age women.
Conclusion
The current data demonstrate that obstetrician-gynecologists seem to have a relatively high awareness of bleeding disorders as a potential underlying cause of menorrhagia.
Menorrhagia is a common clinical problem that affects approximately 30% of reproductive-age women. Menorrhagia may result from various clinical conditions, including uterine fibroids, endometriosis, and cancer; however, a cause for menorrhagia is never identified in approximately 50% of cases. Underlying bleeding disorders, including von Willebrand disease (VWD), other coagulation factor deficiencies, and platelet disorders, are prevalent among women with menorrhagia. VWD is caused by a quantitative or qualitative defect in von Willebrand factor (VWF) that interferes with the localization of platelets to the site of bleeding. VWD is the most common bleeding disorder; the estimated prevalence is approximately 1% worldwide. Recent studies indicate that between 5% and 24% of women with menorrhagia had previously undiagnosed VWD. Conversely, menorrhagia is the most prevalent symptom among women with VWD; 32-100% of women with VWD reported menorrhagia. VWD and other bleeding disorders have been associated with increased obstetric and gynecologic morbidity, including endometriosis, miscarriage, and postpartum hemorrhage.
Obstetrician-gynecologists are usually the first health care providers to encounter women with menorrhagia. Studies in the US and UK indicate that obstetrician-gynecologists may be unlikely to consider an underlying bleeding disorder as the cause of unexplained menorrhagia. Early identification is important to prevent adverse bleeding events and reduce potentially unnecessary surgical interventions. Studies have shown that women with VWD are more likely to undergo hysterectomy and are significantly more likely to experience surgical bleeding complications ; these complications could be avoided with accurate and timely diagnosis.
The current study was conducted to assess the current state of knowledge of bleeding disorders and practice patterns of obstetrician-gynecologists to better understand the current evaluation of unexplained menorrhagia by obstetrician-gynecologists, and the extent to which a bleeding disorder diagnosis is being considered in this population.
Materials and Methods
In December 2009, the American College of Obstetricians and Gynecologists (ACOG) sent survey questionnaires to 1200 Fellows and Junior Fellows in practice. Six hundred of the recipients were members of the Collaborative Ambulatory Research Network (CARN), a group of practicing obstetrician-gynecologists who volunteer to participate in survey research. The remaining 600 recipients were not CARN members and were randomly selected from College Fellows and Junior Fellows in practice. Three additional mailings of the survey were administered before a Fellow was considered a nonresponder. The study was approved by the ACOG institutional review board.
The survey included questions about physician characteristics, current practice characteristics, and patient population. Respondents were asked to estimate the number of patients who complained about heavy menstrual bleeding each year. Questions were then asked about practice patterns regarding evaluation, testing, and referral of patients with unexplained menorrhagia. Knowledge of VWD among women with menorrhagia was assessed. Respondents also rated their medical training in screening, assessment, and treatment of menorrhagia.
Statistical analyses were performed using SPSS version 16 (SPSS Inc., Chicago, IL). Descriptive data were computed for primary analysis. t tests and χ 2 analyses were used for inferential statistics; statistical significance was defined at ≤ .05. Because age and sex were associated, we controlled for sex when assessing for differences by age and we controlled for age when assessing for differences by sex.
Results
A total of 503 questionnaires were returned for an overall response rate of 42.4% (503/1185); 15 questionnaires were excluded because those physicians could not be reached. The response rate was 56.7% (338/596) for CARN members and 27.8% (165/589) for non-CARN members. Differences between CARN and non-CARN were assessed for all demographic variables including: age, sex, number of patients seen each week, number of patients seen each year, number of deliveries in 2008, number of surgeries in 2008, percent of patient races, primary medical specialty, and residency of patients. Because no differences were found, the samples were combined for analyses. Of this sample, 451 indicated that they provide gynecologic services so all analyses were limited to this sample.
Participant and practice characteristics are shown in Table 1 . Fifty-one percent of the respondents were male. The mean year of birth was 1958; males were significantly older than females (1954 vs 1963; P < .001). Forty-eight percent of participants described their current practice as an obstetrician-gynecologist partnership or group and 78% reported their primary practice as general obstetrician-gynecologist. Seventy-seven percent also perform obstetric services. A plurality of respondents reported that 35% of patients resided in a suburban area. As shown in Table 1 , the average percent of non-Hispanic white patients in each respondents’ practice was 61% (standard deviation [SD] = 27%) and the average percent of African American patients in each respondents’ practice was 15% (SD = 15%).
| Characteristic | Response | No. (%) or Mean (SD) |
|---|---|---|
| Mean year of birth | 1958 (SD = 10.3) | — |
| Sex | Male | 230 (51) |
| Female | 221 (49) | |
| Current practice | Obstetric-gynecology partnership/group | 218 (48) |
| Solo practice | 85 (19) | |
| Multispecialty group | 61 (13) | |
| University full-time faculty and practice | 45 (10) | |
| HMO (staff model) | 10 (2) | |
| Other | 32 (7) | |
| Primary medical specialty | General obstetric-gynecology | 350 (78) |
| Gynecology only | 76 (17) | |
| Maternal-fetal medicine | 4 (1) | |
| Reproductive endocrinology | 7 (1) | |
| Obstetrics only | 1 (<1) | |
| Other | 13 (3) | |
| Residency of patients | Suburban | 158 (35) |
| Urban, noninner city | 113 (25) | |
| Urban, inner city | 65 (14) | |
| Mid-sized town (10,000-50,000) residents | 70 (16) | |
| Rural | 35 (8) | |
| Military | 8 (2) | |
| Other | 2 (<1) | |
| Race/ethnicity of patients | Non-Hispanic white | 60.5% (SD = 27) |
| Hispanic | 15.7% (SD = 20) | |
| African-American | 14.7% (SD = 15) | |
| Asian/Pacific Islander | 4.7% (SD = 7.6) | |
| Native American | 1.4% (SD = 7.2) | |
| Other | 2.0% (SD = 8.7) |
The majority of physicians described their training related to screening of menorrhagia as either comprehensive (33%) or adequate (58%); physicians responded similarly regarding the assessment of menorrhagia (38% and 56%, respectively). Older physicians rated their training significantly less adequate than younger physicians (all P < .001 when controlling for sex). Training was not rated differently by practice location.
The mean number of patients seen per year was 4156 (SD = 2031). The respondents reported that, on average, 198 (4.8%) of their patients complained about menorrhagia each year (SD = 321). Physicians indicated the questions they routinely asked patients when evaluating unexplained menorrhagia. The length of patients’ periods, limitations of periods on daily life, and history of anemia treatment were most commonly asked (100%, 95.3%, and 84.9%, respectively). Approximately 74.7% of respondents asked about bleeding problems, following delivery or miscarriage, 68.3% asked about family history of bleeding disorders, 68.5% asked about bleeding problems after surgery, and 66.7% asked if patients experienced sensation of “flooding” or “gushing.” Only 49.0% of physicians routinely asked about problems with bleeding after tooth extraction or dental surgery. When controlling for sex in a partial correlation, age was significantly correlated with how commonly physicians asked about problems with bleeding after tooth extraction or dental surgery (r = 0.159; P = .001), problems after surgery (r = 0.121; P = .011), and asking about “flooding” or “gushing” during periods (r = 0.245; P < .001), with younger obstetrician-gynecologists being less likely to ask these questions. Differences were also found based on sex in χ 2 analyses when controlling for age. Among the oldest physician group (year of birth 1927-1952), female obstetrician-gynecologists were more likely to ask about family history (χ 2 = 4.4; P = .027), bleeding problems after surgery (χ 2 = 6.9; P = .005), and having bleeding problems after delivery or miscarriage (χ 2 = 6.9; P = .005).
Physicians were asked about the likelihood of ordering specific tests and procedures for women who were experiencing heavy or prolonged menstrual bleeding and were (a) adolescent patients around the age of menarche (1-2 years after menarche) and (b) patients of reproductive age (approximately 15-44 years old) ( Table 2 ). Seventy-seven percent of physicians reported that they would be likely or very likely to consider VWD or another bleeding disorder as causing menorrhagia in adolescent patients; however, only 36.4% of physicians would consider bleeding disorders in reproductive age women with menorrhagia.
| Test | Adolescent patients | Reproductive age patients |
|---|---|---|
| Complete blood count | 412 (91.4%) | 434 (96.2%) |
| Diagnostic D & C | 3 (0.7%) | 78 (17.3%) |
| Endometrial biopsy | 7 (1.6%) | 337 (74.7%) |
| Ferritin | 187 (41.5%) | 237 (52.5%) |
| Hysteroscopy | 10 (2.2%) | 234 (51.9%) |
| Thyroid chemistry | 364 (80.7%) | 407 (90.2%) |
| Papanicolaou smear | 126 (27.9%) | 405 (89.8%) |
| Ultrasound | 294 (65.2%) | 420 (93.1%) |
Eighty-one percent of respondents reported having seen patients with menorrhagia caused by a bleeding disorder. When asked what proportion of patients with menorrhagia are referred to other health care providers, 63% of physicians reported referring up to 25% of menorrhagia patients for further diagnosis or treatment; 33% of physicians did not refer menorrhagia patients to other specialists. Respondents most commonly refer patients to hematology (44%) ( Table 3 ).
| Medical specialty | Likely to refer | Unlikely to refer |
|---|---|---|
| Hematology | 199 (44.1%) | 245 (54.3%) |
| Endocrinology | 79 (17.5%) | 359 (79.6%) |
| Internal medicine | 43 (9.5%) | 393 (87.1%) |
| Oncology | 35 (7.8%) | 401 (88.9%) |
| Primary care | 27 (6.0%) | 409 (90.7%) |
| Family practice | 19 (4.2%) | 416 (92.2%) |
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