What are the recommended management strategies for a patient with Von Willebrand Disease experiencing heavy menstrual bleeding?

Management strategies for a patient with Von Willebrand Disease (VWD) experiencing heavy menstrual bleeding (HMB) focus on both addressing the bleeding disorder and the menstrual symptoms to improve quality of life.

Initial assessment should include a detailed history of bleeding symptoms and impact on quality of life, alongside laboratory tests including full blood count and specific coagulation studies to confirm VWD diagnosis and subtype, as recommended by NICE for women with HMB and suspected bleeding disorders ¹.

Pharmacological treatment options include tranexamic acid and hormonal therapies such as the levonorgestrel-releasing intrauterine system (LNG-IUS), which can reduce menstrual blood loss and improve symptoms. The LNG-IUS is effective but may be off-label for HMB; patients should be counselled about expected changes in bleeding patterns and the need to wait several cycles to assess benefit ¹.

Desmopressin (DDAVP) is a key treatment for many patients with VWD, as it promotes release of von Willebrand factor and factor VIII, thereby reducing bleeding. It can be used peri-menstrually or during acute bleeding episodes, tailored to the patient’s VWD subtype and response (Kalvehalli Kashinath and Kouides, 2023).

For women with more severe bleeding or those unresponsive to DDAVP, replacement therapy with von Willebrand factor concentrates may be necessary, often coordinated with a haematologist (Kalvehalli Kashinath and Kouides, 2023).

Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided as they can exacerbate bleeding risk in VWD ².

Multidisciplinary care involving haematology and gynaecology specialists is important to individualise management, especially if surgical options are considered. Surgical interventions such as endometrial ablation or hysterectomy are reserved for refractory cases after thorough discussion about fertility and risks ¹.

Shared decision-making is essential, providing women with information about all treatment options, their benefits, risks, and impact on fertility, to support informed choices ¹.