Heavy Menstrual Bleeding in Adult Women with Sickle Cell Disease

Sickle cell disease (SCD) is an inherited hemoglobin disorder. It is characterized by the presence of abnormal hemoglobin S. SCD leads to chronic hemolysis, vaso-occlusive episodes, various organ complications, and varying degrees of anemia. The prevalence of heavy menstrual bleeding (HMB) is 10-35% in the United States, with a higher prevalence in the Black population. Women with SCD often face challenges with their menstrual and reproductive health. Earlier studies have reported heavy menstrual bleeding as well as dysmenorrhea in adolescent women with sickle cell disease; however, there is limited literature in the adult sickle cell patient population.

The aim of this single institution exploratory cross-sectional study is to determine the incidence of HMB in women with SCD. For the purpose of this study, HMB is defined as changing pads/tampons more frequently than every hour, passing large blood clots (>1in), having to wear several pads to control menstrual flow, and menstruation lasting longer than 7 days, or with two cycles within 21 days. This is a multimethod study with qualitative data from a questionnaire confirming HMB and dysmenorrhea and quantitative data obtained via retrospective chart review. All adult women (>18years) seen between January 2024 andJuly 2024 at the University of Illinois Sickle Cell Center with a diagnosis of SCD were eligible for this study. Exclusion criteria included a history of hematopoietic stem cell transplant and pregnancy. We studied 50 female patients. Data collected included BMI, age, presence of HMB, transfusion history, iron status (ferritin, transferrin saturation), and the distribution of SCD genotypes: Sickle Cell SS (SS), Sickle Cell SC (SC), Sickle Cell Beta+ Thalassemia (S+), and Sickle Cell SS with High Persisting Fetal Hemoglobin (SS HPFH). Patients on exchange were excluded from transfusion correlation calculations.

Of the 50 participants, 24 (48%) reported experiencing HMB. The mean age of these 24 patients was 45.33 years, with a standard deviation of 9.56 years and an age range from 30 to 66 years. A moderate positive correlation (0.39) was found between age and HMB, indicating that HMB occurrence was increasingly likely with age. The BMI ranged from 18.69 to 54.49, with a mean BMI of 26.02 and a standard deviation of 8.2. A moderate negative correlation (-0.31) was found between BMI and HMB. HMB occurrence was most prevalent in patients with the SS genotype (13 out of 24), followed by SC (6 out of 24), SB+ (3 out of 24), and SS HPFH (2 out of 24). In addition, weak positive correlations were found between total number of lifetime transfusions and HMB (0.20), between ferritin levels and HMB (0.27), and between transferrin saturation and HMB (0.21). Regression analysis revealed that iron status was the most significant predictor of transfusion need.

This retrospective study reveals a significant prevalence of HMB among women with SCD, particularly those with the SS genotype, with over half of the participants with SS affected. Furthermore, regression analysis shows a relationship between age, BMI, transfusion requirements, iron status, and the severity of menstrual bleeding. However, the various correlations calculated were not strong enough to imply a direct cause-and-effect relationship, indicating that there may be a multifactorial influence on HMB. Overall, these findings emphasize the importance of regular, comprehensive gynecological care for women with SCD, especially as they age. Healthcare providers should strongly consider HMB in their management plans for women with SCD to improve patient care, limit the burden of transfusions and iron overload, and improve quality of life.