Evaluation of medical provider practice patterns in the assessment and management in heavy menstrual bleeding for patients on anticoagulation

Abstract Introduction: Heavy menstrual bleeding (HMB), traditionally defined as menstrual blood loss of greater than 80 mL per menstrual cycle, is a common complication for individuals with the propensity to menstruate. For those of reproductive age starting on anticoagulation, rates of HMB have been reported in up to 70% of patients. Assessment of HMB on anticoagulation remains challenging as the standardized bleeding assessment tools may not fully capture these specific bleeding events. As a result, patients may develop severe iron deficiency while on anticoagulation. Although other validated assessment tools, such as the pictorial blood loss assessment chart, may have a higher sensitivity and specificity to capture HMB, their usage may be impractical in certain clinical settings or unfamiliar to healthcare providers. Through a survey, we sought to investigate the practice patterns and strategies providers use to assess and treat HMB in patients on anticoagulation. Methods: Our survey was designed through collaboration with Foundation for Women and Girls with Blood Disorders thrombosis subcommittee and included input from Hematologists, Obstetricians/Gynecologists (OBGYN), and Pediatricians. A 25-question survey was distributed through medical professional organizations' email distribution lists and social media (LinkedIn and Twitter/X). Study data were collected and managed using REDCap electronic data capture tools hosted at Massachusetts General Hospital (MGH). The survey was approved through MGH Institutional Review Board. Results: A total of 108 participants completed the survey. Specialties included Hematology (52), OBGYN (36), Emergency Medicine (EM; 5), and Primary Care Providers (PCP; 15), which comprised of Pediatrics (7), Family Medicine (5), and Internal Medicine (3). Most respondents were from United States (87%) and female gender (86%). More providers reported less than 10 years in practice, 57%, compared to 43% who had more than 10 years. When queried about prescribing anticoagulation, 100% of EM providers reported starting anticoagulation compared to 56% Hematologists, 38% PCP and 0% OBGYN. Of the providers who initiated anticoagulation, 93% of Hematologists asked about menstrual history compared to 47% PCP and 20% EM. Most Hematologist (92%) and OBGYN (92%) asked how HMB affected their patients compared to PCP (60%) and EM (0%). Providers who reported using quality of life (QOL) metrics to assess HMB included 8% Hematologists, 6% OGBYN, 6% PCP, and 0% EM. Barriers to asking about HMB were lack of time (33%), lack of experience (7%), or hadn't thought about the topic (14%). Almost half (44%) reported no barriers. When asked whether restarting or continuing hormonal contraceptives increased the risk of recurrent clot while on anticoagulation, 23% Hematologists, 60% EM, 33% PCP, and 31% OBGYN answered affirmatively. Providers who reported pursuing a bleeding diathesis workup for patients with HMB and on anticoagulation included 83% Hematologists, 60% PCP, 50% OBGYN, and 20% EM. More of the providers reported pursuing this work up for patients with HMB and not on anticoagulation (96% Hematologists, 93% of PCP, 83% OBGYN, and 20% of EM). Types of educational resources used by providers to assess and manage HMB varied and included personal clinical experience (87%), professional guidelines (81%), conferences (61%), journals (56%), consultation within specialty (53%), medical school or residency educational curriculum (49%), consultation with OBGYN (40%), consultation with Hematology (37%), institutional guidelines (16%), and social media (2%). Discussion: Our survey demonstrates substantial differences in clinical practice patterns for the evaluation and management of HMB in patients on anticoagulation amongst numerous specialties. There were variations in rates of inquiry about HMB at the initiation of anticoagulation by provider specialty with the majority being Hematologists. Although many of the specialties reported asking how HMB affects their patients, few used QOL metrics. Moreover, many of the providers regardless of specialty felt that restarting hormonal contraceptives increases one's risk of recurrent VTE even if on anticoagulation, which is not supported by current literature. This project highlights the disparities and gaps in the assessment and management of HMB as well as underscores the need for additional research and opportunities for education in this clinical space.