The pathophysiology of bleeding disorders presenting as abnormal uterine bleeding

Area of Science:

• Hematology
• Gynecology
• Pathophysiology

Background:

• Abnormal uterine bleeding (AUB) is a common gynecologic complaint.
• Coagulopathies are frequently the underlying cause of AUB.
• Understanding normal hemostasis is crucial for diagnosing and managing bleeding disorders.

Purpose of the Study:

• To elucidate the pathophysiology of bleeding disorders relevant to AUB.
• To guide obstetricians/gynecologists in diagnosing and treating coagulopathies presenting as AUB.
• To highlight the importance of identifying hemostatic defects for effective patient management.

Main Methods:

• Review of the three phases of normal hemostasis: primary hemostasis (platelet function), secondary hemostasis (coagulation cascade), and fibrinolysis.
• Discussion of diagnostic screening tests (prothrombin time, activated partial thromboplastin time) and specific factor assays.
• Emphasis on clinical presentations and specific disorders like von Willebrand disease and deficiencies in fibrinolytic inhibitors.

Main Results:

• Defects in primary hemostasis (platelets, von Willebrand factor) cause prolonged bleeding time and mucocutaneous bleeding.
• Secondary hemostasis defects (coagulation factors) can manifest as AUB, though joint/soft tissue bleeding is more common.
• Underdiagnosed fibrinolysis disorders (e.g., alpha 2-antiplasmin deficiency) can cause delayed bleeding and are missed by standard coagulation tests.

Conclusions:

• Disorders of primary hemostasis, particularly von Willebrand disease, are key considerations in women with AUB.
• Acquired or congenital deficiencies in coagulation factors or fibrinolytic regulators can present as menorrhagia.
• Accurate diagnosis of bleeding disorders is essential for targeted therapy and impacts overall patient care beyond gynecologic symptoms.