Journal of Thrombosis and Thrombolysis

, Volume 24, Issue 1, pp 39–41

Menorrhagia and minor bleeding symptoms in women on oral anticoagulation

Authors

  • Anders Själander
    • Department of Internal MedicineSundsvall Hospital
  • Britt Friberg
    • Department of Obstetrics and GynecologyLund University Hospital
  • Peter Svensson
    • Department for Coagulation DisordersMalmö University Hospital
  • Lennart Stigendal
    • Coagulation CentreSahlgrenska University Hospital
    • Department for Coagulation DisordersMalmö University Hospital
    • Center for Hemostasis and ThrombosisCopenhagen University Hospital (Rigshospitalet)
Article

DOI: 10.1007/s11239-006-0003-7

Cite this article as:
Själander, A., Friberg, B., Svensson, P. et al. J Thromb Thrombolysis (2007) 24: 39. doi:10.1007/s11239-006-0003-7

Abstract

Background

Oral anticoagulation (OA) is a common treatment with a known risk of fatal or major bleeding, but also minor bleeding symptoms and menorrhagia can cause substantial discomfort and necessitate medical or surgical interventions. The extent of these side effects is however not previously reported. The objective of this study is to assess the frequency of minor bleeding symptoms and menorrhagia attributed to OA treatment.

Methods

Ninety fertile women between 15 and 49 years-of-age on OA treatment completed an inquiry at the anticoagulation clinics of Malmö, Lund and Gothenburg, Sweden.

Results

The frequency of minor bleeding symptoms was significantly increased during OA treatment (P < 0.05) except for hematuria. The incidence of bleeding after tooth extraction (>3 h) increased from 3.0 to 45.2%, easy bruising 17.8–75.6%, epistaxis 11.1–23.6%, gingival bleeding 22.2–48.3% and hematuria 10.0–15.6% (Table 1). Hematemesis was reported in 5.6% prior to as compared to 14.4% during OA treatment, blood in the feces in 8.9 and 18.9%, respectively. Mean duration of menses increased from 5.6 to 6.1 days (P < 0.01) and reported menorrhagia from 44.2 to 70.8% (P < 0.001). Eighteen percent were treated for menorrhagia before and 29.9% during OA treatment (P < 0.01).

Conclusions

OA treatment is known to confer increased risk of fatal or major bleeding. This study shows that fertile women on OA also experience significantly increased minor bleeding symptoms including menorrhagia that may considerably impair quality of life.

Keywords

WarfarinOral anticoagulationMenorrhagiaMinor bleeding symptoms

Abbreviations

OA

Oral anticoagulation

Introduction

In Sweden, almost one percent of the population is under treatment with oral anticoagulants (OA), mostly warfarin [1]. Major bleeding, of which hemorrhagic stroke is most feared, is a known side effect [2, 3]. Minor bleeding symptoms is frequently noted at the anticoagulation clinics, and fertile women may also be at risk of menorrhagia, which may need medical or surgical treatment. Inherited coagulation defects such as von Willebrand disease are known to confer an increased risk of menorrhagia, and OA treatment has also been suggested to increase menstrual blood loss [4]. To what extent OA causes minor bleeding symptoms and menorrhagia in young women has previously not been reported.

Methods

All women between 15 and 49 years-of-age who were treated with OA at the anticoagulation clinics in Malmö, Lund and Gothenburg received a questionnaire. The questionnaire regarded their recollection of menstruation blood loss and minor bleeding symptoms before their OA treatment as well as their present symptoms. A total of 140 women were contacted by mail, 109 replied of which 90 with a mean age of 36.6 years (±SD 7.6 years) accepted to participate in the study and had answered the questionnaire appropriately. One question regarding joint/muscle bleeding was excluded since we have reason to suspect that the participants confused simple hematomas with this serious bleeding event, as 1.1% reported having had “joint/muscle bleeds” before and 20.5% during OA. Mean age at menarche was 13.3 (11.0–17.5) years. Eight women reported having a close relative with increased bleeding tendency. Sixty-nine had taken oral contraceptives at any time before the OA treatment of which 16 due to menorrhagia. Fifty were taking concomitant medication, of which six used platelet aggregation inhibitors such as acetylsalicylic acid or clopidogrel.

Statistics

Statistical analysis was performed by paired T-test or Chi 2 test.

Results

Of the 90 women who participated in the study, 39 had not experienced any minor bleeding symptoms before OA treatment. After OA treatment, only seven were free of minor bleeding symptoms. Of these seven, four reported menorrhagia during OA treatment. Thus only three out of 90 fertile women were unaffected by the OA treatment regarding minor bleeding symptoms or menorrhagia. The frequency of minor bleeding symptoms was significantly increased during OA treatment (P < 0.05) for all types of bleeding except hematuria. The incidence of bleeding after tooth extraction (>3 h) increased from 3.0 to 45.2%, easy bruising 17.8–75.6%, epistaxis 11.1–23.6%, gingival bleeding 22.2–48.3% and hematuria 10.0–15.6% (Table 1). Hematemesis was reported in 5.6% prior to as compared to 14.4% during OA treatment, blood in feces in 8.9 and 18.9%, respectively. The mean duration of the menses was increased from 5.6 to 6.1 days (P < 0.01) and reported menorrhagia from 44.2 to 70.8% of the women (P < 0.001). Fifty-seven (63.3%) reported more menstrual blood loss and 41 (45.6%) longer bleeding period during OA treatment. The proportion of women with more than six bleeding days increased from 20 to 45% (Table 2). Sixteen (17.8%) were treated for menorrhagia before and 26 (29.5%) during OA treatment (P < 0.01). The treatments for menorrhagia during OA treatment consisted of tranexamic acid (38.5%), hormonal therapy (50.0%), intrauterine levongestrel-impregnated device (26.9%), thermal endometrial destruction (23.1%), hysterectomy (7.7%) or combinations of these treatments.
Table 1

Minor bleeding symptoms before and during oral anticoagulation (OA) treatment

Type of bleeding

Before OA (%)

During OA (%)

P-value

After tooth extraction (>3 h)

3.0

45.2

<0.001

Easy bruising

17.8

75.6

<0.001

Frequent epistaxis

11.1

23.6

0.02

Gingival bleedings

22.2

48.3

<0.001

Hematuria

10.0

15.6

n.s.

Hematemesis

5.6

14.4

0.01

Blood in the feces

8.9

18.9

0.05

Menorrhagia

44.2

70.8

<0.001

Table 2

Duration of menstrual bleeding before and during oral anticoagulation (OA) treatment

Duration (days)

Before OA (n = 86)

During OA (n = 73)

≤5

57.0%

38.4%

>5–≤6

23.3%

16.4%

>6–≤7

11.6%

21.9%

>7

8.1%

23.3%

Discussion

Bleeding during OA treatment is a known and hazardous side effect, with major bleeding including hemorrhagic stroke increasing with older age [2, 3]. In a previous study, hemorrhagic stroke occurred almost exclusively in patients over 60 years-of-age [3]. One study found an increased menstrual blood loss in eleven women on oral anticoagulant therapy [4]. This study compared the study population with the general population, and not the same women before and during OA treatment. In two recent large double blind controlled studies, minor bleeding symptoms on warfarin ranged from 20.1 to 27.6% [5, 6], while a third displayed a bleeding frequency of 21% in 18 months also in the placebo group [7]. Since these studies are aimed at reporting bleeding as adverse events, minor bleeding symptoms that occur are registered, although not menorrhagia. In our study, bleedings are reported retrospectively and based on recall rather than an objective quantification which is a major limitation of the study. This recall bias is expected to confer lower bleeding frequencies reported prior to OA treatment. The high bleeding frequencies reported in this study may reflect that our study population consists of only younger fertile women as compared to a mixed older population. The high bleeding frequencies reported in this study shows that younger, fertile women have a substantial discomfort of their OA treatment regarding frequent minor bleeding symptoms and also a large proportion of menorrhagia of which many need medical or surgical treatment. These treatments are in themselves associated with side effects. Almost all women had some bleeding symptoms during OA treatment, easy bruising being the most common with a frequency of 75.6%. Since OA treatment is widely known to be hazardous, minor bleeding symptoms might be a cause of concern for the patients. The high frequency of minor bleeding symptoms or menorrhagia in fertile women on OA treatment should be considered when deciding on beginning or duration of OA treatment in less imperative indications.

In conclusion, our study shows that fertile women experience significantly increased bleeding symptoms during OA treatment. Even if our study did not include a quality of life assessment, it is not far-fetched to conclude that the intensified bleedings significantly will impair the quality of life of these women. Fertile women on OA should be monitored concerning bleeding symptoms that may need treatment and concerning the risk of developing anemia.

Acknowledgments

This study was supported by grants from Research funds from Malmö University Hospital, Lund University and Region Skåne.

Copyright information

© Springer Science+Business Media, LLC 2007