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 Table of Contents  
Year : 2013  |  Volume : 4  |  Issue : 3  |  Page : 118-120

Association between bleeding tendency and endometriosis (Presentation of two cases)

1 Department of Hematology/Medical Oncology, Urmia University of Medical Sciences, Urmia, Iran
2 Department of Obstetrics and Gynecology, Urmia University of Medical Sciences, Urmia, Iran

Date of Web Publication19-Dec-2013

Correspondence Address:
Nasim Valizadeh
Department of Hematology/Medical Oncology, Urmia University of Medical Sciences, Urmia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5127.123315

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Background: Endometriosis is implantation of normal endometrial mucosa in the ectopic sites. Literature review suggests that microscopic internal bleeding follows by revascularization and fibrosis is possible mechanism for endometriosis. There are a few reports regarding association of endometriosis and bleeding disorders. We present two cases with bleeding tendency, one with mild hemophilia A and another with Von Willebrand Disease (VWD) that were presented with heavy menses and endometriosis.

Keywords: Endometriosis, bleeding tendency, ectopic, hemophilia A, VWD

How to cite this article:
Valizadeh N, Bromand F, Ayatollahi H. Association between bleeding tendency and endometriosis (Presentation of two cases). J Appl Hematol 2013;4:118-20

How to cite this URL:
Valizadeh N, Bromand F, Ayatollahi H. Association between bleeding tendency and endometriosis (Presentation of two cases). J Appl Hematol [serial online] 2013 [cited 2023 May 29];4:118-20. Available from: https://www.jahjournal.org/text.asp?2013/4/3/118/123315

  Introduction Top

Endometriosis is defined by implantation of normal endometrial tissue in the ectopic sites. Minimal bleeding followed by inflammatory response and neovascularization and fibrosis is possible mechanism of disease. [1] Although it is common, but the etiology and mechanism of disease is poorly understood. Severe pelvic pain, infertility, dysmenorrhea, dyspareunia, heavy menses, and pelvic mass are common manifestations of disease. [2],[3]

It is generally occurs in pelvic organs including: Ovaries,  Fallopian tube More Detailss, vagina, and cervix; but can occur in unusual sites including: Scars of laparotomy, lungs, pleural cavity, stomach, gallbladder, the kidneys, spleen, nasal cavities, spinal canal, breasts, appendix, and diaphragm; which may manifest with very unusual symptoms such as periodic hemoptysis and catamenial seizures. [3],[4],[5],[6],[7]

Rate of disease is higher in females with heavier menstrual bleeding because of retrograde menstruation a probable mechanism of disease, [8] thus searching for an underlying bleeding tendency and suitable interventions may have beneficial effect in diminishing the rate and relieving the symptoms.

  Cases Presentations Top


A 28-year-old divorced female presented with menorrhagia and iron deficiency anemia, abdominal sonography showed a large mass (9 Χ 6 cm) in the left adnex. Laboratory tests showed normal prothrombin time (PT), bleeding time (BT), and platelet count; but prolonged activated partial thromboplastine time (aPTT). Mixing PTT was normal. Serum factor VIII level was 25% [Table 1]. The diagnosis of mild hemophilia A was made. After factor VIII replacement she underwent ovarian mass resection. Pathological study showed endometriosis.
Table 1: Results of screening test for underlying bleeding tendency

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A 36-year-old married female presented with menorrhagia and abdominal pain. Family history was positive for VWD in her niece. Abdominal sonography showed a large left adnexal mass (5.5 Χ 7 cm). Due to severe adhesions in pelvic cavity only left adnexal mass biopsy (not resection) was done and frozen section was sent to pathology and reported as endometriosis. Platelet count, BT, and PT was normal. PTT was prolonged that was normalized after mixing test. Further assessment of this patient revealed decreased VWF Ag and activity [Table 1]. The diagnosis of VWD was made. After factor replacement therapy with Humate-p. In follow-up visit, we repeated abdominal imaging and the large ovarian mass had been disappeared.

In these cases we found association between endometriosis and bleeding tendency. One of them had mild factor VIII deficiency and another one had VWD. We should perform screening for bleeding tendency in any patients with endometriosis especially in those with heavy menstrual bleeding.

  Discussion Top

Although etiology and pathophysiology of endometriosis is not well-understood, [5] but increased rate of retrograde menstruation in patients with heavier menses, is a possible mechanism of disease. [8] There is a weak evidence that female with bleeding disorder are likely to develop endometriosis. Ferrari et al., described the first association of an acquired inhibitor against factor VIII in a case of severe pelvic endometriosis. [9] Martire et al., reported catamenial hemoptysis from endobronchial endometriosis in a 12-year-old female with type 1 von Willebrand disease (VWD). [10]

In a survey by the US Center for Disease Control of 102 female withVWD, the gynecological problems including endometriosis, fibroids, uterine polyps, and endometrial hyperplasia reported more commonly in females with VWD in comparison to the controls. [11]

Menorrhagia, hemorrhagic ovarian cysts, endometriosis, and postpartum hemorrhage are symptoms of VWD in women. [12],[13],[14]

Although menorrhagia is the most common gynecologic manifestation of a bleeding disorder, but it is not the only manifestation and it seems that females with bleeding tendency have an increased risk of developing hemorrhagic ovarian cysts and probably endometriosis. [15],[16]

Since, underlying bleeding tendency may cause heavy menstrual bleeding, dysmenorrhea, intermenstrual bleeding, and endometriosis; thus coagulation study tests should be considered in women with menstrual abnormalities if they have a positive history of abnormal bleeding. [17]

Here, we presented two patients with bleeding disorders (one with mild hemophilia and another with VWD) in association with endometriosis. In these cases, heavy menstrual bleeding and endometriosis was the first manifestation of bleeding disorder.

Screening for bleeding tendency should be done in females with endometriosis. Finding an underlying bleeding tendency and appropriate management lead to improvement of symptoms in females with endometriosis.

  References Top

1.Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. In: Katz VL, ed. Comprehensive Gynecology. 5 th ed, Ch 19. Philadelphia: Mosby; 2007.  Back to cited text no. 1
2.ACOG practice bulletin. Medical management of endometriosis. Number 11, December 1999 (replaces Technical Bulletin Number 184, September 1993). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet 2000;71:183-96.  Back to cited text no. 2
3.Shepard MK, Mancini MC, Campbell GD Jr, George R. Right-sided hemothorax and recurrent abdominal pain in a 34-year-old woman. Chest 1993;103:1239-40.  Back to cited text no. 3
4.Markham SM, Carpenter SE, Rock JA. Extrapelvic endometriosis. Obstet Gynecol Clin North Am 1989;16:193-219.  Back to cited text no. 4
5.Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am 1997;24:411-40.  Back to cited text no. 5
6.Gustofson RL, Kim N, Liu S, Stratton P. Endometriosis and the appendix: A case series and comprehensive review of the literature. Fertil Steril 2006;86:298.  Back to cited text no. 6
7.Redwine DB. Diaphragmatic endometriosis: Diagnosis, surgical management, and long-term results of treatment. Fertil Steril 2002;77:288.  Back to cited text no. 7
8.Lee CA, Chi C, Pavord SR, Bolton-Maggs PH, Pollard D, Hinchcliffe-Wood A, et al. The obstetric and gynaecological management of women with inherited bleeding disorders--review with guidelines produced by a taskforce of UK Haemophilia Centre Doctors' Organization. Haemophilia 2006;12:301-36  Back to cited text no. 8
9.Ferrari A, Conte E, Troccoli ML, Nobili F, Marziani R, Roberti C, et al. Acquired haemophilia in severe pelvic endometriosis: A new association? Haemophilia 2012;18:e31-2.  Back to cited text no. 9
10.Martire B, Loizzi M, Cimmino A, Peruzzi S, De Mattia D, Giordano P. Catamenial hemoptysis from endobronchial endometriosis in a child with type 1 von Willebrand disease. Pediatr Pulmonol 2007;42:386-8.  Back to cited text no. 10
11.Kirtava A, Drews C, Lally C, Dilley A, Evatt B. Medical, reproductive and psychosocial experiencesof women diagnosed with von Willebrand's disease receiving care in haemophilia treatment centres: A case-control study. Haemophilia 2003;9:292-7.  Back to cited text no. 11
12.James AH. Von Willebrand disease in women: Awareness and diagnosis. Thromb Res 2009;124 (Suppl 1):S7-10.  Back to cited text no. 12
13.James AH. More than menorrhagia: A review of the obstetric and gynaecological mani festations of von Willebrand disease. Thromb Res 2007;120 Suppl 1:S17-20.  Back to cited text no. 13
14.James AH. Von Willebrand disease. Obstet Gynecol Surv 2006;61:136-45.  Back to cited text no. 14
15.James AH. Women and bleeding disorders. Haemophilia 2010;16 Suppl 5:160-7.  Back to cited text no. 15
16.James AH. More than menorrhagia: A review of the obstetric and gynaecological manifestations of bleeding disorders. Haemophilia 2005;11:295-307.  Back to cited text no. 16
17.Kadir RA, Davies J. Hemostatic disorders in women. J Thromb Haemost 2013;11 Suppl 1:170-9.  Back to cited text no. 17


  [Table 1]


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