UNCOVERING HIDDEN MORBIDITY: UNDIAGNOSED VON WILLEBRAND DISEASE AND IRON DEFICIENCY IN WOMEN WITH HEAVY MENSTRUAL BLEEDING

Abstract

Background: Heavy menstrual bleeding (HMB) is a common gynecological complaint associated with considerable morbidity. Despite its high prevalence, underlying bleeding disorders and iron deficiency often remain undiagnosed, resulting in delayed diagnosis and suboptimal management. Objective: To determine the prevalence of undiagnosed von Willebrand factor (vWF) abnormalities, anemia, and iron deficiency among women presenting with heavy menstrual bleeding at a tertiary care hospital in Pakistan. Methods: A hospital-based observational study was conducted among 312 women aged 15–49 years presenting with heavy menstrual bleeding at Mardan Medical Complex, Pakistan. Participants underwent standardized clinical assessment using the Pictorial Blood Loss Assessment Chart (PBAC), pelvic ultrasonography, hematological investigations, ferritin measurement, inflammatory marker assessment, and coagulation screening including von Willebrand factor testing where indicated. Data were analyzed using SPSS version 26.0 with nonparametric and categorical statistical tests; statistical significance was set at p < 0.05. Results: Among the 312 participants, anemia (hemoglobin <120 g/L) was identified in 37.3%, while severe anemia was present in 9.5%. Iron deficiency was observed in 43.1% using a ferritin threshold of <15 μg/L, increasing to 72.2% when a cutoff of <30 μg/L was applied. Routine coagulation parameters were normal in nearly all participants; however, abnormal vWF activity was detected in 28 of 306 women (9.2%) without a previously diagnosed bleeding disorder. Women with reduced vWF activity also demonstrated significantly lower factor VIII levels (p < 0.01). Conclusion: Women with heavy menstrual bleeding have a substantial burden of previously unrecognized iron deficiency and von Willebrand factor abnormalities that are not detected by routine coagulation testing. Incorporating ferritin assessment and targeted von Willebrand disease screening into the routine evaluation of HMB may facilitate earlier diagnosis and improve clinical outcomes.