Severe Anemia May Not Be Obvious at AUB Presentation


CHICAGO — Few symptoms or clinical examination findings distinguished severely anemic patients from other women who presented for urgent evaluation of abnormal uterine bleeding, a retrospective cohort study showed.

Of 350 patients who presented to the emergency department for heavy menstrual bleeding, 122 (35%) were anemic, defined as having a hemoglobin concentration of less than 12 g/dL, while 48 (14%) were moderately to severely anemic, defined as having a hemoglobin concentration of less than 10 g/dL.

Only increasing age (relative risk, 1.04) and the presence of both tachycardia and hypotension (RR, 3.11) were associated with severe anemia, reported Dr. Kristen A. Matteson at the annual meeting of the American College of Obstetricians and Gynecologists.

“Our take-home message is that clinical symptoms and bleeding history are poorly predictive for moderate to severe anemia,” said Dr. Matteson of the department of obstetrics and gynecology at Brown University, Providence, R.I.

Because no presenting symptom or physical finding can rule out clinically important anemia, she suggested that “a low threshold should be maintained for performing a hemoglobin concentration.”

The median age of women in the study was 32 years. Nearly 70% were non-Hispanic white, and 20% were non-Hispanic black. Almost one in four had received outpatient care for abnormal uterine bleeding (AUB) in the prior 3 months, but, 49% had a concurrent medical condition that could affect treatment options for the condition, Dr. Matteson pointed out. These concurrent diagnoses included breast, endometrial, or ovarian cancer; cardiovascular disease; depression; diabetes; gastrointestinal diseases; migraine; seizure disorders; and thromboembolic disorders.

The duration of the current bleeding episode was more than 7 days in 55% of the study population. A combination of heavy and irregular bleeding was reported by 65%, and more than half reported passing clots or flooding. Neither the amount of bleeding recorded on examination nor bleeding patterns described by the patients were associated with moderate to severe anemia.

“We were not surprised that the amount of bleeding actually seen by the provider was scant in the majority of patients because abnormal uterine bleeding can be very unpredictable and episodic,” noted Dr. Matteson. “Diagnosis and management of heavy menstrual bleeding are dependent on what a woman says about her blood loss because clinically we do not have practical means to 'measure' bleeding.”

When a woman reports extremely heavy bleeding that affects her life at home and work, but has little bleeding during a 30-minute medical appointment, the disparity can lead to frustration on the part of both the physician and patient, she said. Studies have shown that such patients “often report dissatisfaction with their interactions with health care providers.”

Dr. Matteson said mild anemia is generally asymptomatic in patients who do not have cardiovascular disease. Severe anemia, on the other hand, can lead to cardiac events in some patients and may require blood transfusions. Anemia that is moderate to severe can cause extreme fatigue, reducing productivity and quality of life.

Dr. Matteson reported no financial conflicts of interest.

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