Is a family history of von Willebrand disease (VWD) with heavy menstrual bleeding and iron deficiency anemia a reason to refer to hematology?

From the Guidelines

A family history of von Willebrand disease with heavy menstrual bleeding and low iron is a strong reason to refer to hematology. According to the 2008 NHLBI/NIH guidelines, as outlined in the study by 1, a bleeding history strong enough to consider performing initial VWD assays is an indication for referral to a hemostasis specialist. The combination of heavy menstrual bleeding, iron deficiency anemia, and a family history of von Willebrand disease significantly increases the likelihood of the patient having the condition.

Key points to consider in this scenario include:

• The patient's symptoms, such as heavy menstrual bleeding and iron deficiency anemia, which are common presentations of von Willebrand disease, as noted in the study by 1
• The importance of early diagnosis and management to improve quality of life and prevent complications from excessive bleeding, as highlighted in the study by 1
• The role of hematologists in performing specialized testing, including von Willebrand factor antigen levels, ristocetin cofactor activity, and factor VIII levels, to confirm the diagnosis, as outlined in the study by 1

Given the potential for significant morbidity and mortality associated with untreated von Willebrand disease, particularly in the context of heavy menstrual bleeding and iron deficiency anemia, referral to hematology is essential for proper diagnosis and management. This approach is supported by the study by 1, which emphasizes the importance of prompt recognition and treatment of von Willebrand disease to prevent complications and improve patient outcomes.

From the Research

Family History and Referral to Hematology

• A family history of von Willebrand disease (VWD) with heavy menstrual bleeding and iron deficiency anemia is a significant factor to consider when deciding whether to refer a patient to hematology 2, 3.
• VWD is a common inherited bleeding disorder that can cause heavy menstrual bleeding, and women with VWD are at risk for excessive uterine bleeding, such as with menses and childbirth 2.
• The diagnosis of VWD is made by laboratory investigation, including assays to assess VWF levels and functions, and a clinical evaluation using standardized bleeding scores can help determine when screening hemostatic testing is indicated 4.

Heavy Menstrual Bleeding and Iron Deficiency Anemia

• Heavy menstrual bleeding is a common symptom of VWD, and iron deficiency anemia can be a consequence of heavy menstrual bleeding 2, 3.
• The treatment of heavy menstrual bleeding in patients with VWD may include hormonal treatments, antifibrinolytics, and VWF concentrates 2, 3.
• Iron deficiency anemia can be treated with iron supplements, and it is essential to address the underlying cause of the anemia, which in this case may be related to VWD 4.

Referral to Hematology

• Given the family history of VWD and the presence of heavy menstrual bleeding and iron deficiency anemia, it is reasonable to refer the patient to hematology for further evaluation and management 2, 3, 4.
• A hematologist can perform the necessary laboratory tests to diagnose VWD and develop a treatment plan to manage the patient's symptoms and prevent complications 2, 3, 4.
• Genetic testing can also be useful in establishing the VWD subtype and providing accurate reproductive counseling, although it is not required to make a diagnosis 4.