48 Chapter 3 Figure 5: Pie diagram, summarizing the distribution of HMB patients with different diagnosis of haemostasis defects. DISCUSSION In our single-centre population-based study, we show a high prevalence of women with impaired platelet function (24%) and a similar high prevalence (29%) of women with reduced TG lag time in women with HMB as measured with a novel high precision testing strategy. In contrast to the high prevalence of women with impaired platelet function and coagulation, the number of patients with reduced VWF responsiveness (found in only two women (3,4%) was less frequent than expected (2). Our findings that impaired haemostasis is highly prevalent in women with HMB is in line with previous recommendations that structured history anamnesis, and primary and secondary haematologic testing is recommended for women with HMB (15, 16, 24). Our findings are further supported by observations that bleeding disorders are frequently found in women of different ages presenting with menorrhagia (12-14, 25, 26). Among women with VWD, 84% complaints of HMB and otherwise VWD are more prevalent in patients with HMB.10,29 Our data indicate that the prevalence of VWD might be higher than in the normal population, although impaired VWF function was not a major determinant of HMB in our study. We used an agonist-induced platelet activation test, which quantifies platelet activation with P-selectin expression, which is a marker of platelet alpha-granule release.19 Using this test, we found impaired platelet function in 14 (24%) women with HMB without other gynaecologic etiology or pathophysiology. Impaired platelet function has emerged as an important etiology of HMB. However, despite accumulating evidence from clinical studies (2, 12, 13, 27) and recommendations from the American Academy of Pediatrics Committee on Adolescence and the American College of Obstetricians and Gynecologists Committee on Adolescent Health care (15, 16), platelet function, VWF levels and function and coagulation testing are not routinely tested in women with HMB. Impaired coagulation response is traditionally diagnosed with full automated and highly standardized coagulation tests, such as the prothrombin time (PT) and the activated partial thromboplastin time (APTT). Both the PT and the APTT have an extremely high reproducibility and have earned
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