Coagulopathy Workup for Dysmenorrhea
When dysmenorrhea is accompanied by heavy menstrual bleeding (menorrhagia), especially with flooding, clots ≥1 inch, or a personal/family bleeding history, a comprehensive coagulopathy workup is essential to identify underlying bleeding disorders that affect up to 16% of these women. 1, 2
Initial Clinical Assessment
Bleeding History
- Document specific bleeding symptoms: flooding (changing pad/tampon more than hourly), clots ≥1 inch diameter, prolonged menses (>7 days), and assess for low ferritin 1
- Obtain personal bleeding history: easy bruising, nosebleeds, prolonged bleeding from minor cuts, heavy bleeding after dental procedures or surgery 3
- Family history of bleeding disorders is critical, as bleeding disorders are often inherited 4
- Medication history: assess for anticoagulant or antiplatelet medications that increase bleeding risk 3
Physical Examination
- Pelvic examination to identify anatomical causes (fibroids, polyps, cervical lesions) 5, 3
- Systemic examination for signs suggesting coagulopathy: ecchymoses, petechiae, hepatosplenomegaly, jaundice, joint hypermobility (Ehlers-Danlos), telangiectasias 3
Laboratory Workup
First-Line Coagulation Testing
The initial hemostasis workup should include: 4, 2
- Complete blood count (CBC) with platelet count to assess for anemia and thrombocytopenia 3, 1
- Prothrombin time (PT) to screen for factor VII deficiency and liver disease 3
- Activated partial thromboplastin time (aPTT) to screen for factors VIII, IX, XI, XII deficiencies 3, 4
- Von Willebrand disease (VWD) panel: VWF antigen (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo), and factor VIII coagulant activity (FVIII) 3, 2
Rationale for VWD Testing
Von Willebrand disease testing is particularly important because 11-16% of women with menorrhagia and normal gynecological evaluation will meet laboratory criteria for VWD, and more than 70% of women with VWD suffer from menorrhagia. 2, 6
Critical Testing Considerations
- Ensure atraumatic blood draw at room temperature when ordering VWD studies 3
- Be aware of factors that falsely elevate VWF levels: acute stress, anxiety, recent exercise, acute/chronic inflammatory illness, pregnancy, estrogen/oral contraceptive use, and blood group O individuals (who have 25% lower baseline VWF) 3
- VWF and factor VIII levels fluctuate during the menstrual cycle and with hormonal therapy, which can complicate diagnosis 6
Second-Line Testing (If Initial Tests Normal)
If initial coagulation studies are normal but strong clinical suspicion persists: 2
- Platelet aggregation and release studies should follow, as an additional proportion of patients may have decreased platelet function 2
- Fibrinolysis assessment may be warranted in select cases, as a smaller proportion may have defects in fibrinolysis 2
When to Refer to Hematology
Immediate hematology referral is indicated for: 3, 1
- HMB with flooding and/or prolonged menses
- HMB accompanied by personal or family history of bleeding
- Abnormal coagulation studies
- Low VWF levels
- Strong bleeding history with normal initial tests
Common Pitfalls to Avoid
- Do not rely on global coagulation tests (bleeding time, platelet function analyzer) as they lack added diagnostic value 4
- Do not exclude bleeding disorder based on normal initial tests alone - patients may still have platelet function disorders or rare bleeding disorders 4
- Do not perform coagulation workup during acute bleeding or hormonal therapy if possible, as this can affect results 6
- Always discuss cases with strong clinical suspicion but normal tests with a coagulation specialist 4
Integration with Gynecological Evaluation
The coagulopathy workup should occur after or concurrent with gynecological evaluation (transvaginal ultrasound, endometrial assessment) to distinguish between structural causes and systemic bleeding disorders 5, 1. The treatment strategy will ultimately depend on whether uterine pathology, ovulatory dysfunction, or coagulation abnormality is identified 1.