Von Willebrand Disorder (VWD) – Special Issues for Women and Girls

Read Female Factors: information for young women with bleeding disorders for updated info on VWD in women and girls  
Heavy bleeding with menstrual periods (menorrhagia) is a common symptom of VWD for women and girls. It may involve:

• Heavy menstrual periods (eg, soaking through a tampon and pad around two hourly, or needing to change during the night)
• Menstrual bleeding for longer than normal (eg, longer than 8 days)
• Bleeding with clots bigger than a 50 cent piece in size

Heavy menstrual bleeding can lead to anaemia (low red blood cell count/low blood iron levels), with symptoms of fatigue, paleness, lack of energy and shortness of breath.

Some women and girls with VWD also experience:

• Pain during their menstrual periods (dysmenorrhoea)
• Abdominal pain and sometimes bleeding during ovulation (when an egg is released from the ovaries, around the middle of the menstrual cycle).

Although these can be symptoms of VWD, they can also be symptoms of a gynaecological disorder, so it is important to consult a gynaecologist.

If you are a woman or girl with VWD, a holistic or comprehensive care approach to your health care can help you to achieve better health and quality of life. Specialist gynaecological care over your lifetime is important to manage any gynaecological issues that occur. These may not be related to VWD, but in some cases VWD may make the bleeding problems worse.

Ideally your medical care team should work together on your health care and should include:

• A gynaecologist
• A haematologist specialising in bleeding disorders
• A GP or paediatrician or obstetrician, if relevant at the time.

HOW IS THIS TREATED?

With diagnosis and appropriate treatment, these problems can be dramatically reduced and sometimes even eliminated. Women who have menorrhagia or abnormal vaginal bleeding need a full gynaecologic consultation before treatment to understand any gynaecological issues.

Bleeding disorder treatments for heavy menstrual bleeding include:

• Tranexamic acid and aminocaproic acid, antifibrinolytic drugs which can reduce bleeding by slowing the breakdown of blood clots
• Oral contraceptives (“the Pill”) combining the hormones oestrogen and progesterone. The hormones increase VWF and factor VIII in the blood and reduce menstrual blood loss. Although it also has the effect of preventing pregnancy, in this case the treatment’s aim is to manage VWD symptoms and so it may also be suitable for teenage girls who are not sexually active and women who are not specifically seeking birth control
• An intrauterine device (IUD), releasing the hormone progesterone which reduces bleeding
• Desmopressin (DDAVP), a synthetic hormone which stimulates the body to release VWF and factor VIII
• Clotting factor concentrate made with von Willebrand factor (VWF) and factor VIII (FVIII), which replaces the missing VWF and FVIII in the blood and helps blood to clot. This clotting factor concentrate is made from the plasma (pale yellow fluid part) in human blood and is produced from blood donations. This clotting factor concentrate is used in uncommon circumstances, such as when other treatments have not been effective, and when the woman is trying to become pregnant, or when it is likely the person will need treatment for more than 2-3 days, and in discussion with the specialist haematologist at the Haemophilia Centre. The treatment is infused (injected) into a vein in the arm
• Iron supplements for anaemia.

Women with bleeding disorders should avoid taking non-steroidal anti-inflammatory drugs for period pain, unless prescribed by a doctor with expertise in VWD (ie, Naprosyn/naproxen, ibuprofen, etc – these have many brand names; ask your local pharmacist to check for you). These medicines can interfere with the way platelets promote clotting and cause bleeding to go on for longer.

Generally, treatment options with medication will be exhausted before considering surgery such as hysterectomy (surgical removal of the uterus) or procedures such as endometrial ablation, where the lining of the uterus is destroyed to reduce menstrual blood loss. Surgery and some procedures have their own risk of bleeding complications for women with VWD.

However, some women with VWD may need to have gynaecological surgery or procedures for other reasons. If this happens, it is important that this is managed in a team, with discussion between the woman, the Haemophilia Centre and the gynaecologist and/or surgeon.

HOW MIGHT THINGS CHANGE OVER A LIFETIME?

Puberty: menstrual bleeding can be especially heavy when a girl first starts having periods. When there is a family history of VWD or it is known that she has VWD, a girl should be followed closely by her medical team during puberty and may need treatment if she has heavy bleeding.

Sexual intercourse: some women with VWD may experience bleeding if there are small tears in their vagina after sexual intercourse. This can happen during their first sexual experience when the hymen is broken. It can also occur after childbirth and menopause when the vaginal wall may be thinner and dryer due to a drop in oestrogen levels – oestrogen creams for the vaginal wall and/or lubricants can help with this.

Pregnancy and childbirth: most women with VWD do not have a problem with delivering a healthy baby. Pregnancy can cause blood levels of VWF to increase, decreasing the likelihood of bleeding complications during pregnancy and delivery. However, this needs to be monitored as women with VWD can have heavy bleeding for an extended period after delivery when their factor levels return to their usual levels.

To minimise the chances of complications:

• Discuss VWD with a genetic counsellor, your haematologist and an obstetrician before you become pregnant
• Before you have any invasive procedure, such as amniocentesis, ask your haematologist if you are at risk of bleeding and whether anything needs to be done to prevent it
• During your third trimester, you should have blood tests to measure VWF to help plan for delivery and for any treatments to prevent potential post-delivery bleeding
• Discuss your choices for anaesthesia, especially an epidural, with your haematologist, obstetrician, and if possible, your anaesthetist
• Unless prenatal testing has shown the opposite, it should be assumed that the baby may have VWD and delivery methods should be as gentle as possible. A caesarean section is not usually required.

Menopause: When a woman begins menopause, her body’s erratic hormone regulation can increase her risk of unpredictable and heavy menstrual bleeding. However, for some women with VWD, levels of VWF rise as they age and normalise so that bleeding problems reduce. Keeping a close relationship with her gynaecologist in the years before menopause will help a woman with VWD be prepared to manage any problems that might occur.

MORE INFORMATION

To understand more about these issues and options and how they relate to your specific situation, talk to your specialist Haemophilia Centre team.

Resources for women with bleeding disorders:

• Coderouge program for women and girls (Canadian Hemophilia Society)
• Victory for Women (National Hemophilia Foundation, US)
• Von Willebrand disease (World Federation of Hemophilia)

Source: Haemophilia Foundation Australia. A guide for people living with von Willebrand disorder. Melbourne: HFA, 2010.