Menorrhagia

Editor—We read with interest the first in your series of articles on common problems in primary care, on the topic of management of menorrhagia.¹ We would, however, like to draw attention to one important aspect that was overlooked, which we believe deserves wider recognition.

Menorrhagia may be a manifestation of an underlying inherited disorder of coagulation. Such disorders are by no means rare. A recent British study found that as many of 17% of women with menorrhagia and no underlying pelvic disease had an inherited bleeding disorder, the most common of which was von Willebrand's disorder.² An earlier study from Sweden also found the prevalence of von Willebrand's disorder among women with menorrhagia to be 20%.³ The history in the initial consultation should therefore include specific questions to elicit features suggestive of an underlying bleeding disorder. These include a history of menorrhagia since menarche, recurrent epistaxis, bleeding after dental extraction, operations, or parturition, and a family history. The Royal College of Obstetricians and Gynaecologists in the United Kingdom has recommended screening of selected women for bleeding disorders in their guidelines on the management of menorrhagia in secondary care.⁴ The identification of inherited bleeding disorders is important not only because these women may have invasive procedures but also for future pregnancies and family members. Women with inherited bleeding disorders may, however, not complain of menorrhagia (which is often socially limiting) because their bleeding is similar to what other family members have experienced. The primary care physician is in the unique position of identifying these patients when they attend for other problems. Referral of patients with suggestive histories to a haematologist should be considered.