From the Guidelines
Thrombocytopenia can significantly worsen menstrual bleeding, and prompt management with both platelet-increasing therapies and hormonal treatments is crucial to reduce morbidity and mortality. The relationship between thrombocytopenia and menorrhagia is complex, and patients with immune thrombocytopenia (ITP) are at risk of experiencing heavy menstrual bleeding, among other bleeding events such as epistaxis, gastrointestinal hemorrhage, and hematuria 1. According to the American Society of Hematology 2019 guidelines for immune thrombocytopenia, ITP is an acquired autoimmune disorder characterized by a low platelet count, and its clinical course may vary depending on whether it is primary or secondary to other conditions 1.
Key Considerations
- The likelihood of spontaneous remission from ITP is age-related, but the clinical course of ITP may be different depending on the underlying condition or infection 1.
- Bleeding events, including menorrhagia, are often unpredictable, and patients with ITP may not exhibit bleeding beyond bruising and petechiae, but more serious mucosal bleeding can occur 1.
- ITP has a significant impact on health-related quality of life (HRQoL), particularly in the first year after diagnosis, related to restrictions on activities, anxiety due to the risk of bleeding, and the burden of treatment and monitoring 1.
Management Strategies
- For acute management of heavy menstrual bleeding in thrombocytopenia, high-dose combined hormonal contraceptives and tranexamic acid can be used to reduce bleeding 1.
- For long-term management, continuous combined hormonal contraceptives, levonorgestrel IUD, or GnRH agonists may be appropriate, and addressing the underlying cause of thrombocytopenia is essential 1.
- Platelet transfusions are indicated when counts fall below 10,000/μL or below 50,000/μL with active bleeding, and the effectiveness of these interventions stems from hormonal stabilization of the endometrium, antifibrinolytic effects of tranexamic acid, and restoration of adequate platelet counts to support normal hemostasis during menstruation.
From the Research
Relationship Between Thrombocytopenia and Menorrhagia
- Thrombocytopenia, or low platelet count, can increase the risk of bleeding, including menorrhagia (heavy menstrual bleeding) 2, 3, 4, 5, 6.
- Immune thrombocytopenia (ITP) is an autoimmune disease that can cause thrombocytopenia and increase the risk of bleeding, including menorrhagia 2, 3, 4, 5, 6.
- Treatment for ITP, such as corticosteroids, intravenous immunoglobulin, and thrombopoietin receptor agonists, can help increase platelet counts and reduce the risk of bleeding, including menorrhagia 2, 3, 4, 5, 6.
- Menorrhagia can be a symptom of underlying thrombocytopenia, and diagnosis and treatment of the underlying condition can help manage menorrhagia 5.
- In cases of severe bleeding, including menorrhagia, emergency treatment with platelet transfusions, corticosteroids, and intravenous immune globulin may be necessary 5.
Treatment Options
- Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are common first-line treatments for ITP 2, 3, 4.
- Thrombopoietin receptor agonists, such as romiplostim, can be used to increase platelet production and reduce the risk of bleeding 6.
- Splenectomy and immunosuppressive agents may also be used in some cases of ITP 3, 4.
Diagnosis and Management
- Diagnosis of ITP requires excluding secondary causes of thrombocytopenia and may involve a complete blood count, peripheral blood smear, and other tests 5.
- Management of ITP involves tailoring treatment to the individual patient and disease phase, with the goal of elevating platelet counts to a safe level and improving quality of life 4.