In this video lecture, Dr. Bethany Samuelson-Bannow discusses:
- How bleeding disorders uniquely affect women throughout the life course, from menarche to pregnancy and menopause.
- The evaluation and management of heavy menstrual bleeding in women with inherited bleeding disorders.
- Practical approaches to pregnancy, delivery, postpartum hemorrhage, and iron deficiency in patients with bleeding disorders.
Dr. Bethany Samuelson-Bannow is Director of Classical Hematology at the Cleveland Clinic Foundation. Her NIH- and foundation-funded research addresses bleeding disorders in patients who menstruate or become pregnant, with a focus on heavy menstrual bleeding, diagnosis, and management across pregnancy.
(Video Lecture Summary)
Introduction
Dr. Bethany Samuelson-Bannow reviews the unique challenges faced by women with inherited bleeding disorders across the life course. While many bleeding disorders affect men and women equally, women experience additional bleeding risks related to menstruation, pregnancy, childbirth, and menopause. She emphasizes that recognizing these sex-specific manifestations is essential for timely diagnosis, individualized treatment, and improved quality of life.
Understanding Bleeding Disorders
Bleeding disorders comprise a diverse group of conditions characterized by impaired clot formation. Dr. Samuelson-Bannow reviews the three major components of normal hemostasis. Primary hemostasis depends on platelet adhesion and activation and includes disorders such as von Willebrand disease, platelet disorders, and vascular disorders including hereditary hemorrhagic telangiectasia and Ehlers-Danlos syndrome. Secondary hemostasis involves fibrin clot formation and includes hemophilia A, hemophilia B, factor XI deficiency, and other rare coagulation factor deficiencies. She also highlights fibrinolysis, an often overlooked component of hemostasis, noting that abnormalities in clot breakdown may contribute to bleeding disorders of unknown cause.
Von Willebrand Disease
Von Willebrand disease is the most common inherited bleeding disorder, although its diagnosis continues to evolve. Dr. Samuelson-Bannow reviews the current diagnostic framework, noting that VWF antigen or activity levels below 30% establish the diagnosis of VWD. Patients with levels between 30% and 50% require clinical context. Those without abnormal bleeding are generally classified as having low VWF, whereas patients with both reduced VWF levels and a bleeding phenotype are diagnosed with VWD.
She also summarizes the major VWD subtypes. Type 1 represents a quantitative deficiency, while type 2 encompasses several qualitative defects affecting multimer distribution, platelet binding, or factor VIII binding. Type 3 results from virtually complete absence of functional VWF.
Heavy Menstrual Bleeding
Heavy menstrual bleeding is one of the most common and clinically important manifestations of bleeding disorders in women. Rather than relying solely on blood loss volume, current definitions emphasize menstrual bleeding that interferes with a patient’s physical, emotional, social, or material quality of life.
For practical clinical assessment, Dr. Samuelson-Bannow recommends asking about the “7-2-1 rule”: menstrual bleeding lasting more than seven days, changing menstrual protection more often than every two hours, and passing clots larger than one inch. She also encourages asking about flooding episodes, overnight product changes, and iron deficiency, all of which help identify clinically significant bleeding.
She notes that although heavy menstrual bleeding affects approximately one-third of menstruating individuals overall, it occurs in 80% to 90% of women with VWD. Conversely, approximately one in five patients presenting with heavy menstrual bleeding may have an underlying bleeding disorder.
The Impact on Quality of Life
Dr. Samuelson-Bannow emphasizes that heavy menstrual bleeding affects far more than physical health. Chronic blood loss contributes to iron deficiency, anemia, and fatigue, but the effects extend into many aspects of daily life.
Patients frequently miss school or work, incur substantial costs related to menstrual products, withdraw from social activities, and experience stress, stigma, and anxiety surrounding their symptoms. She argues that understanding these broader consequences is essential when evaluating treatment success, since improving quality of life is often the patient’s primary goal.
Treatment of Heavy Menstrual Bleeding
Treatment focuses on controlling menstrual blood loss regardless of the underlying bleeding disorder. Dr. Samuelson-Bannow reviews four major treatment categories: combined estrogen-progestin hormonal therapy, progestin-only therapy, antifibrinolytic therapy, and procedural interventions.
She discusses the advantages and limitations of several hormonal options, including combined oral contraceptives, levonorgestrel-releasing intrauterine devices, contraceptive implants, progestin-only pills, and depot medroxyprogesterone acetate. Levonorgestrel intrauterine systems receive particular emphasis because they substantially reduce menstrual blood loss and frequently induce amenorrhea.
Among non-hormonal treatments, she highlights tranexamic acid as an especially valuable option. By reducing fibrinolysis within the endometrium, tranexamic acid can substantially decrease menstrual blood loss while preserving fertility. She also notes that its effectiveness extends across different causes of heavy menstrual bleeding, including patients with uterine fibroids. Procedural options such as endometrial ablation, uterine artery embolization, and hysterectomy are generally reserved for selected patients who have completed childbearing.
Disease-Specific Therapy
Although VWF replacement is an important therapy for many bleeding manifestations of VWD, Dr. Samuelson-Bannow reviews data demonstrating that recombinant VWF did not outperform tranexamic acid for treatment of heavy menstrual bleeding. Given the substantially lower cost, ease of administration, and similar efficacy of tranexamic acid, she explains why antifibrinolytic therapy is generally preferred for this specific indication.
Pregnancy and Delivery
Pregnancy introduces additional challenges for women with bleeding disorders. During normal pregnancy, VWF antigen, VWF activity, and factor VIII levels rise substantially, often exceeding 200% by the time of delivery. Patients with type 1 VWD usually experience similar increases, although the response may be blunted in those with increased VWF clearance or certain type 2 variants.
Dr. Samuelson-Bannow recommends checking factor levels between 34 and 36 weeks of gestation to guide delivery planning. She also reminds clinicians that antepartum bleeding should always prompt evaluation for obstetric causes such as placental pathology rather than being attributed automatically to the bleeding disorder.
Postpartum Hemorrhage
Postpartum hemorrhage occurs more frequently in women with inherited bleeding disorders than in the general population. Dr. Samuelson-Bannow distinguishes primary postpartum hemorrhage, occurring within 24 hours of delivery, from secondary postpartum hemorrhage, which develops between 24 hours and six weeks postpartum as pregnancy-associated factor levels decline.
Although optimal target factor levels remain uncertain, she aims for factor levels of at least 100% at delivery and maintains hemostatic levels for several days postpartum. Tranexamic acid plays an important role in both treatment and prevention of postpartum bleeding, and she routinely prescribes a two-week supply following hospital discharge.
VWF concentrates are used when necessary, particularly in patients with type 3 VWD or inadequate endogenous responses. In contrast, she rarely uses DDAVP during delivery because of concerns regarding fluid restriction, hyponatremia, tachyphylaxis, and the need for documented pre-pregnancy responsiveness.
Perimenopause and Iron Deficiency
The final life stage discussed is perimenopause, during which anovulatory cycles and structural uterine abnormalities may worsen heavy menstrual bleeding. Evaluation may therefore require additional studies such as pelvic ultrasound or endometrial biopsy.
Throughout the reproductive years, Dr. Samuelson-Bannow emphasizes the importance of monitoring for iron deficiency. She encourages clinicians to assess iron status regularly in menstruating and pregnant patients and to treat iron deficiency aggressively when present. While controlling bleeding remains the ultimate goal, iron replacement—often including intravenous iron when appropriate—plays an essential role in improving patient outcomes.
Conclusion
Dr. Samuelson-Bannow concludes that women with inherited bleeding disorders experience unique clinical challenges throughout their lives. Heavy menstrual bleeding, pregnancy, postpartum hemorrhage, and perimenopause each require individualized management that extends beyond treating the underlying bleeding disorder alone. She encourages clinicians to ask detailed questions about menstrual bleeding, recognize its impact on quality of life, and proactively address iron deficiency and reproductive health. Her closing message reflects this patient-centered approach: always believe women—unless they tell you their periods are normal, in which case ask more questions.