A 28-year-old woman is referred by her General Practitioner as she is complaining of easy bruising and menorrhagia.
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A thorough, detailed history of the bleeding is vital in the assessment of patients with potential haemostatic defects, and it will impact on the extent of investigation.
The duration of bleeding/bruising is important when considering whether the patient is likely to have a congenital or acquired haemostatic disorder. Bleeding since childhood, such as menorrhagia since menarche, would usually suggest a congenital disorder; however, mild congenital disorders of coagulation may present in adult life.1 A family history of abnormal bleeding clearly would also support the presence of a congenital defect.
It is useful to establish the details of bruising, in particular whether it is spontaneous, occurs after minimal trauma or after surgery, and its extent.
Tonsillectomy and dental extraction in particular pose significant haemostatic challenges and if these have not been associated with significant bleeding, a congenital disorder of haemostasis is much less likely.
Bleeding or bruising on multiple occasions and from different sites merits more extensive investigation as this suggests a systemic haemostatic defect. Repeatedly bleeding from one site, such as epistaxis from the same nostril, suggests a structural abnormality.
Mucocutaneous bleeding (epistaxis, bruising, menorrhagia, gastrointestinal bleeding) as in this case suggests a disorder of platelet function.
Coagulation factor deficiencies are more likely to be associated with haemarthrosis, muscle haematoma and post-operative bleeding.
Although menorrhagia is a common gynaecological symptom, a specific cause is identified in less than 50% of affected women.2 Studies have shown that bleeding disorders are found in a substantial proportion of women with menorrhagia and a normal pelvis examination. Inherited bleeding disorders have been diagnosed in 17% of such patients, with von Willebrand’s disease being the most common abnormality.2
Systemic illness, in particular uraemia and liver disease, may cause abnormalities of haemostasis (Table 4.1).
Table 4.1Causes of platelet disorders |Favorite Table|Download (.pdf) Table 4.1 Causes of platelet disorders
|Congenital ||Acquired |
|von Willebrand's disease ||Liver disease |
|Abnormality of platelet membrane glycoprotein (e.g. Bernard–Soulier syndrome, Glanzmann thrombasthenia) ||Uraemia |
|Abnormality of platelet granules (e.g. storage pool disorder, grey platelet syndrome) ||Myeloma/monoclonal gammopathy of uncertain significance |
|Abnormalities of signal transduction and secretion (e.g. defects in arachidonic acid metabolism – cyclooxygenase deficiency) ||Myeloproliferative disorders |
| ||Leukaemia/myelodysplasia |
| ||Sepsis |
| ||Cardiopulmonary bypass |
| ||Drugs |
A detailed drug history is clearly relevant; aspirin and non-steroidal anti-inflammatory agents are common culprits causing platelet function defects, but many drugs are implicated (Table 4.2).
Table 4.2Drugs and other agents known to interfere with platelet function