Combatt HMB-Recon: Combination Therapy in Adolescents to Treat Heavy Menstrual Bleeding-Review of Charts to Observe Treatment Patterns

Heavy menstrual bleeding (HMB) negatively impacts women, disproportionately affecting adolescents. Severe HMB is associated with hospitalization, blood transfusions, and reduced quality of life yet no consensus for standard therapy exists. Combined contraceptive pills (COCPs) alone or in combination with tranexamic acid (TXA) are considered effective first-line treatment for HMB in bleeding disorders. However, safety concerns exist due to the theoretically increased thrombotic risk of combining estrogen and TXA leading to the United States FDA black box warning. No documented thromboembolic events in females with bleeding disorders using COCPs and TXA have occurred. Direct comparison between these treatment options is needed to improve outcomes and quality of life for this underrepresented population. We aimed to determine treatment patterns, effectiveness, and safety outcomes for adolescents with HMB and bleeding disorders.

Our multi-center, retrospective, cohort study conducted at 5 Hemophilia Treatment Centers identified patients using an electronic medical record screening report with the inclusion criteria of female gender assigned at birth, ICD 9/10 codes for eligible bleeding disorder diagnoses, presence of at least one clinical encounter between 1/1/2015 to 4/1/2021, and age <21 years at time of initial encounter. We collected demographics, bleeding disorder diagnosis, characterization of HMB, treatment modalities, outcomes, and safety data. Treatment modalities were grouped as combined estrogen/progesterone therapy (oral, patch, or ring), progesterone therapy (oral, intrauterine device, implant, or injection), TXA therapy alone, or TXA plus estrogen/progesterone or plus progesterone. Statistical analysis was conducted by summarizing patient demographic variables, treatments, and outcomes with mean and standard deviation (SD) or median and quartiles for continuous variables and by frequency and percentage for categorical variables. The repeated outcomes of HMB control, AE, complications, and adherence were compared across treatments by generalized linear mixed-effects models.

221 patients were included. Mean age at diagnosis of HMB of 14.2 years (SD 1.7). Mean duration of HMB at time of initial HMB diagnosis was <3 months in 49%, 95% Confidence Interval (CI) [0.43, 0.56]; 28% [95% CI: 0.21, 0.35] had HMB >6 months at diagnosis. Seventy percent had von Willebrand disease, 20% with platelet function disorders, and 10% with factor deficiencies. At diagnosis of HMB, no patients were on treatment for HMB. During the study period, there were 1478 HMB-related health-care encounters, and most occurred at HTCs (40%) followed by OB-GYN clinics (19%). 474 treatment modalities were identified which consisted of combination estrogen/progesterone in 164 (35%), progesterone alone in 85 (18%), TXA in 64 (14%), estrogen/progesterone plus TXA in 26 (6%), progesterone plus TXA in 23 (5%), and other medications (factor, aminocaproic acid, or desmopressin acetate) in 112 (24%). Median number of treatment regimens per patient was 2 (1,3 for 1^st,3^rd quartiles, range):1-6). No thrombotic events occurred. Adherence was highest for progesterone therapy alone (84.5%), TXA (75%), combination estrogen/progesterone (65%), and least for estrogen/progesterone plus TXA (60%). At ≤3 months of treatment, effectiveness of HMB control occurred in 39% (95%CI: 0.3, 0.48)) on estrogen/progesterone; in 41% (95%CI: 0.28, 0.53) on progesterone, 49% (95%CI: 0.34, 0.63) on TXA, 44% ((95%CI: 0.19, 0.7) on progesterone plus TXA and 69% (95%CI: 0.41, 0.88) on estrogen/progesterone plus TXA. Patients on hormonal therapy (combination estrogen/progesterone or progesterone alone) plus TXA were 3.6 (95% CI 1.0-12.9 p=0.046) times more likely to report HMB control vs. hormonal therapy or TXA alone.

To our knowledge, this is the largest study examining HMB treatment in adolescents with bleeding disorders. Our study suggests that hormonal treatment in combination with TXA controls HMB more effectively than hormonal therapy or TXA alone. Yet hormonal therapy remains the predominant treatment. Despite limited numbers of patients on combination therapy with estrogen/progesterone and TXA, no thrombosis was reported. Larger prospective studies are needed to demonstrate effectiveness and safety seen in combining hormonal therapy and TXA to increase this treatment utilization in these patients.