REVIEW ARTICLE Diagnosis and management of women with bleeding disorders – international guidelines and consensus from an international expert panel A. H. JAMES Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA Introduction Data on the management of women with bleeding disorders are hampered by a lack of randomized trials, case-control studies or even large case series. In the absence of strong evidence to direct practice, govern- ment agencies, patient advocacy groups, professional and scientific organizations have developed consensus guidelines to address issues related to the diagnosis and management of women with bleeding disorders. The purpose of this section is to summarize existing recom- mendations from international guidelines regarding the management of women with bleeding disorders. Methods MEDLINE was searched for published guidelines per- taining to the management of women with bleeding disorders. The search was limited to the previous 10 years – 1 November 1999 through 31 October 2009. A total of 10 guidelines, [1–10] including recently published guidelines from an international expert panel, [10] met previously-described inclusion criteria [11] and were reviewed. Recommendations from these guidelines were then synthesized into the summary that follows and assigned a grade and level of evidence using the United States Agency for Health Care Policy and Research Criteria (Table 1). Evaluation and management of the women with abnormal reproductive tract bleeding Almost all of the guidelines acknowledged that menor- rhagia was the most common symptom that women with bleeding disorders experience, or recognized that men- orrhagia affects a significant portion of women with bleeding disorders [3–5,7,8,12] (Grade B, Level III for von Willebrand disease [13]). Some guidelines also addressed the fact that a significant portion of women with menorrhagia have undiagnosed bleeding disorders [7,8] (Grade B, Level III [14,15]). The international expert panel [10] went a step further and defined the following associations, which were agreed upon as being indicative of significant menorrhagia: (Grade B Level III) • Soaking through a pad or tampon within 1 h [16] • Soaking through bed clothes [16] • Below normal ferritin [16] • Anaemia • Pictorial blood assessment chart (PBAC) score >100 [17] The international expert panel also recommended that women who met any of the following criteria be evaluated for an underlying bleeding disorder: [18,19] (Grade B Level III) • Menorrhagia since menarche • Family history of a bleeding disorder • Personal history of one, but usually several, of the following symptoms o Epistaxis (generally bilateral epistaxis, >10 min duration o Notable bruising without injury (and more than >2 cm in diameter) o Minor wound bleeding (i.e. from trivial cuts lasting for >5 min) o Bleeding of oral cavity or gastrointestinal tract without a lesion o Prolonged or excessive bleeding following dental extraction o Unexpected postsurgical bleeding o Haemorrhage from ovarian cysts or corpus luteum, o Haemorrhage requiring blood transfusion o Postpartum hemorrhage (PPH), especially de- layed PPH (after 24 h) Correspondence: Andra H. James, MD, Box 3967, Duke Univer- sity Medical Center, Durham, NC 27710, USA. Tel.: +1 919 668 0011; fax: +1 919 681 7861; e-mail: andra.james@duke.edu Accepted after revision 28 March 2011 Haemophilia (2011), 17 (Suppl. 1), 3–5 DOI: 10.1111/j.1365-2516.2011.02557.x Ó 2011 Blackwell Publishing Ltd 3