- Email: [email protected]
Recurrent Menorrhagia in an Adolescent with a Platelet Secretion Defect
e102
Poster Abstracts
(continued )
Breast, post-implant Pubic hair, pre-implant Pubic hair, post-implant Mean body mass index, kg/m2 (SD) Pre-implant Post-implant Change Pre-implant workup (%) Counseling Brain MRI Lupron challenge Bone scan GnRH-agonist injections, monthly % who tried injx before implant % who d/c’d injx d/t dislike of injections % who d/c’d injx d/t progression of puberty Other (%) Adopted Implant delayed d/t insurance company
Central precocious puberty
Gender dysmorphia
p values
2.53 (0.92) 2 (0.85)
1 (0) 1 (0)
0.000007 0.00002
2.33 (0.82)
1 (0)
0.000006
19.03 (3.90) 19.83 (3.90) 0.8
18.57 (5.82) 20.4 (7.54) 1.83
0.45 0.45 0.36
0 89.5 84.2 100
100 33 33 100
0.12 0.13 1
42.11
66
0.27
36.84
66
0.24
26.32
0
0.04
21.1 31.58
33 33
0.38 0.049
Conclusions: Children with CPP are significantly more likely to receive Supprelin implants at younger ages, have behavior problems at presentation, be at higher Tanner stages after implant, and have failed suppression of puberty with IM GnRH agonists, than children with gender dysphoria. doi:10.1016/j.jpag.2010.01.066
Recurrent Menorrhagia in an Adolescent with a Platelet Secretion Defect Xiomara M. Santos, MD, Jennifer L Bercaw, MD, Donald L Yee, MD, and Jennifer E Dietrich, MD, MSc Baylor College of Medicine, Houston, Texas
Background: The prevalence of bleeding disorders among women with menorrhagia has been reported to be 10% to 20%. While Von Willebrand disease is the
most common inherited bleeding disorder, platelet function disorders are less well recognized as a cause of bleeding. We present an interesting case of menorrhagia caused by an unsuspected platelet secretion defect. Case: A 13 y/o Asian female, without significant past medical history, presented to the ER with vaginal bleeding for the past 15 days. Menarche occurred at age 10, with regular periods and only 2 episodes of heavy bleeding in the past, lasting up to 10 days. Mom reported a normal pelvic ultrasound a few months prior to presentation. She denied epistaxis, gum bleeding, or easy bruising. Since the patient was adopted, no family history was known. After heavy menses 1 month prior to her presentation, OCPs were prescribed by an outside clinic. When her bleeding became heavier, taper instructions were recommended, with initial improvement in bleeding. After missing several doses, her bleeding resumed, resulting in changing pads every one to two hours. Initial H/H on presentation was 7.1/20.6, platelets 156. She was placed on IV Premarin. Her H/H dropped to 5.8/16.8 less than 12 hours after admission for which she received 2 units of PRBCs. Aminocaproic acid was added but bleeding continued to be heavy for several days. The PFA-100, Von Willebrand panel, thromboelastography and coagulation screening studies were not suggestive of a hemostatic problem and pelvic MRI/MRA did not reveal a structural abnormality. However, due to the requirement for significant blood products and lack of response to IV Premarin, a platelet aggregation study was performed revealing a profound secretion defect. Eventually, bleeding improved, and ceased by day 5. She was discharged home on an OCP taper and remains on extended cycle OCPs without any bleeding since discharge. Comments: Breakthrough bleeding with missed doses of OCPs is a common problem, which we initially believed was the major contributing factor in this case. The prevalence of platelet secretion defects in adolescents with menorrhagia is unknown. However, platelet function abnormalities are likely under-recognized due to mildness of symptoms and absence of surgical or significant hemostatic challenges. In addition, the specialized expertise required to perform and interpret platelet function testing probably contribute to the underdiagnosis of these disorders. Platelet function analyzer (PFA-100) has insufficient sensitivity and specificity to screen reliably for platelet function disorders, especially secretion defects. When other screening tests are normal, yet suspicion remains high for an underlying hemostatic disorder, platelet aggregometry must be performed. doi:10.1016/j.jpag.2010.01.067
Poster Abstracts
(continued )
Breast, post-implant Pubic hair, pre-implant Pubic hair, post-implant Mean body mass index, kg/m2 (SD) Pre-implant Post-implant Change Pre-implant workup (%) Counseling Brain MRI Lupron challenge Bone scan GnRH-agonist injections, monthly % who tried injx before implant % who d/c’d injx d/t dislike of injections % who d/c’d injx d/t progression of puberty Other (%) Adopted Implant delayed d/t insurance company
Central precocious puberty
Gender dysmorphia
p values
2.53 (0.92) 2 (0.85)
1 (0) 1 (0)
0.000007 0.00002
2.33 (0.82)
1 (0)
0.000006
19.03 (3.90) 19.83 (3.90) 0.8
18.57 (5.82) 20.4 (7.54) 1.83
0.45 0.45 0.36
0 89.5 84.2 100
100 33 33 100
0.12 0.13 1
42.11
66
0.27
36.84
66
0.24
26.32
0
0.04
21.1 31.58
33 33
0.38 0.049
Conclusions: Children with CPP are significantly more likely to receive Supprelin implants at younger ages, have behavior problems at presentation, be at higher Tanner stages after implant, and have failed suppression of puberty with IM GnRH agonists, than children with gender dysphoria. doi:10.1016/j.jpag.2010.01.066
Recurrent Menorrhagia in an Adolescent with a Platelet Secretion Defect Xiomara M. Santos, MD, Jennifer L Bercaw, MD, Donald L Yee, MD, and Jennifer E Dietrich, MD, MSc Baylor College of Medicine, Houston, Texas
Background: The prevalence of bleeding disorders among women with menorrhagia has been reported to be 10% to 20%. While Von Willebrand disease is the
most common inherited bleeding disorder, platelet function disorders are less well recognized as a cause of bleeding. We present an interesting case of menorrhagia caused by an unsuspected platelet secretion defect. Case: A 13 y/o Asian female, without significant past medical history, presented to the ER with vaginal bleeding for the past 15 days. Menarche occurred at age 10, with regular periods and only 2 episodes of heavy bleeding in the past, lasting up to 10 days. Mom reported a normal pelvic ultrasound a few months prior to presentation. She denied epistaxis, gum bleeding, or easy bruising. Since the patient was adopted, no family history was known. After heavy menses 1 month prior to her presentation, OCPs were prescribed by an outside clinic. When her bleeding became heavier, taper instructions were recommended, with initial improvement in bleeding. After missing several doses, her bleeding resumed, resulting in changing pads every one to two hours. Initial H/H on presentation was 7.1/20.6, platelets 156. She was placed on IV Premarin. Her H/H dropped to 5.8/16.8 less than 12 hours after admission for which she received 2 units of PRBCs. Aminocaproic acid was added but bleeding continued to be heavy for several days. The PFA-100, Von Willebrand panel, thromboelastography and coagulation screening studies were not suggestive of a hemostatic problem and pelvic MRI/MRA did not reveal a structural abnormality. However, due to the requirement for significant blood products and lack of response to IV Premarin, a platelet aggregation study was performed revealing a profound secretion defect. Eventually, bleeding improved, and ceased by day 5. She was discharged home on an OCP taper and remains on extended cycle OCPs without any bleeding since discharge. Comments: Breakthrough bleeding with missed doses of OCPs is a common problem, which we initially believed was the major contributing factor in this case. The prevalence of platelet secretion defects in adolescents with menorrhagia is unknown. However, platelet function abnormalities are likely under-recognized due to mildness of symptoms and absence of surgical or significant hemostatic challenges. In addition, the specialized expertise required to perform and interpret platelet function testing probably contribute to the underdiagnosis of these disorders. Platelet function analyzer (PFA-100) has insufficient sensitivity and specificity to screen reliably for platelet function disorders, especially secretion defects. When other screening tests are normal, yet suspicion remains high for an underlying hemostatic disorder, platelet aggregometry must be performed. doi:10.1016/j.jpag.2010.01.067