Begging Your Pardon, Ma’am

This past week I received two messages in response to our August issue of PEN, from two different people, both concerned about our predominant use of the word “he” whenever we wrote about hemophilia in the issue. Was it an oversight? Aren’t we aware of the growing movement to get women recognized not just as carriers, but as people with hemophilia? It matters: women as just carriers with symptoms don’t get the same treatment or attention as males with hemophilia. And this can be dangerous.

We certainly recognize this and wrote a full feature article about this in the November 2016 issue of PEN. And just a year ago, this great article below by Paul Clement. On page two of each issue we always state why we predominantly use the word “he”: because mostly it’s men who currently make up the majority of cases of hemophilia, but also, as writers and editors, it’s awkward to write he/she, or even to use “they.” However, back to the editorial board on this one! We will convene as a team, and decide for each article how to include the words she, girl, her more often. We promise. We are grateful to our readers for alerting us to this, and all we can say is, please accept our apologies. We will work to include women as patients, not just parents, more often in our publications.

 

And the Survey Says . . .  Carriers, Get Tested!

Paul Clement

Women have hemophilia too! Although much progress has been made over the past two decades in getting this message out, public awareness of bleeding disorders among women is dismal. Even women who are known carriers of the gene for hemophilia often don’t realize that they can have hemophilia and be at risk of bleeding. Even carriers confirmed to have bleeding problems, and diagnosed as “symptomatic carriers,” have run into roadblocks in accessing proper care.

Why are so many women undiagnosed?

The main reason is that they don’t suspect they have a bleeding disorder and don’t seek medical treatment. In spring 2010, a national study surveyed 1,243 women from the general public, aged 18 to 25, to assess their knowledge, attitudes, health behaviors, and menstrual experiences.1 Many questions were designed to determine if women knew the difference between “normal” and “abnormal” bleeding patterns. The results were disheartening. Most knew that a bleeding disorder is a condition in which bleeding takes a long time to stop (77%), or blood does not clot (66%). But the women surveyed didn’t know much about bleeding disorders, and only a few could identify risk factors for a woman with a bleeding disorder: periods lasting eight days or longer; bleeding through a pad or tampon in an hour or less; feeling a sense of flooding or gushing. Of the women surveyed who were identified as having one or more of these risk factors, only 20% had sought medical attention, and only 2% had been diagnosed with a bleeding disorder. Contrast this with studies showing that on average, 13% of women seeking medical treatment for menorrhagia (heavy periods) have von Willebrand disease (VWD)!2

Bottom line: Most women don’t seek medical treatment for menorrhagia, and if they do, few are correctly diagnosed with a bleeding disorder. To increase awareness, National Hemophilia Foundation (NHF), Hemophilia Federation of America (HFA), and other advocacy organizations have launched multiple programs for women with bleeding disorders. These organizations are now doing a great job providing resources for diagnosed women. But it’s obvious that we must do a better job, to reach more women in the general population—to educate them about the risk factors and encourage them to seek medical treatment.

Lack of physician awareness

What happens when women do seek medical treatment? We’ve made some headway, as results from two different surveys show. A 2002 survey of 376 members of Georgia Chapter of the American College of Obstetricians and Gynecologists wanted to understand methods of diagnosing and treating menorrhagia, and to determine physicians’ experiences and perceptions about bleeding disorders, particularly VWD.3 The results were enlightening—and

shocking. Only 3% of responding physicians considered VWD a likely cause of menorrhagia in women aged 15 to 44. When asked how many women with menorrhagia might have an

inherited bleeding disorder, physicians’ average response was “less than 1%.” Most shocking: after practicing an average of 20 years, 42% of responding physicians reported never

having seen a woman with menorrhagia who had a bleeding disorder. But statistically, each physician annually saw several hundred patients with menorrhagia who had VWD!  Not surprisingly, the survey showed that gynecologists rarely (3%) refer a woman with unexplained menorrhagia to another specialist.

Fast forward a decade. In 2012, a similar survey of 503 ob-gyns had more positive results: nearly 39% of obstetricians and 77% of gynecologists were likely to consider VWD or another bleeding disorder as a cause for menorrhagia.4 And over 80% who had seen patients with menorrhagia attributed the problem to a bleeding disorder. Perhaps most important, instead of referring patients to specialists only rarely, most physicians referred patients with menorrhagia to other healthcare providers, nearly 45% to hematology.

Although it’s hard to compare surveys of different physicians a decade apart, the change in demographics of the patient population at hemophilia treatment centers (HTCs) also reflects an increased awareness in the medical community of bleeding disorders in women. Between 1990 and 2010, the HTC population grew 90% from 17,177 to 32,612—and most of this increase was due to additional VWD patients.5 This increase is expected to continue; unfortunately, these numbers only scratch the surface of the estimated 3.2 million people in the US with VWD, half of them women.6

Hemophilia carriers with low factor levels

The normal range of factor VIII and IX is between 50% and 150%, with most people being close to 100%. Factor VIII levels often vary, and may more than double due to the effects of hormones and other variables, such as stress or pregnancy. Factor IX levels

normally remain fairly stable. Being a carrier for hemophilia puts

a woman at risk of bleeding because of low factor levels. Carriers usually have factor levels between 30% and 70%, with most around 60%. But factor levels in carriers can vary widely, with some in the high-normal range and others below 10% (in extremely rare cases, below 1%). Research shows that even women with mildly low factor levels—40% to 60%—are at risk of bleeding.7 They may experience not only menorrhagia, but bleeding after tonsillectomy, tooth extractions, surgery, or trauma from accidents; and prolonged bleeding from minor cuts or joint bleeds. This isn’t well known among many carriers, so they may not seek treatment.

Every bleeding disorder advocacy organization offers educational materials on this topic, and it’s probably a safe guess that every chapter newsletter has published multiple articles on the risk of bleeding in carriers. Yet for a variety of reasons, the message hasn’t been received by everyone affected.

But simply seeking medical treatment for excessive bleeding may not be enough—you may have to advocate for yourself. Carriers with bleeding problems are often diagnosed as “symptomatic carriers,” and a course of treatment is recommended. Everything should be okay for these women, right? Not necessarily. The word “carrier” often conveys the wrong meaning. In decades past, it meant you had the gene for a disorder, but you yourself didn’t show symptoms of the disorder. Many physicians who are not bleeding disorder specialists still have this definition in mind, but we now know that carriers can indeed have the genetic disorder. We don’t know for sure how many carriers have excessive bleeding, but a common estimate is that about one-third of carriers have factor levels below 50%, placing them at risk. These women have a factor deficiency and mild hemophilia. They have often been diagnosed as symptomatic carriers because some doctors resist using the word hemophilia based on the simplistic notion that “only males can have hemophilia.”

The symptomatic carrier diagnosis must be laid to rest. Not only is it misleading, but it often prevents women from getting the treatment they need. And insurance companies increasingly use a literal definition of “carrier” to deny coverage for treatment, arguing that symptomatic carriers don’t actually have the disorder. If your factor level is lower than 50%, request a diagnosis of mild (6% to 49%) or moderate (2% to 5%) hemophilia!

Knowing your factor level is essential. To rule out low levels, all women who are carriers should have their factor level checked (and if you are a carrier for hemophilia A, checked at least twice). If your levels are below the normal range, request a diagnosis of hemophilia. And get the word out: talk to your peers and let them know that most carriers are at risk of excessive bleeding.

 

  1. Patricia A. Rhynders et al., “Providing Young Women with Credible Health Information about Bleeding Disorders,” American Journal of Preventive Medicine 47, no. 5 (2014): 674–80. 2. M. Shankar et al., “Von Willebrand Disease in Women with Menorrhagia: A Systematic Review,” BJOG 111 (2004): 734–40. 3. A. Dilley et al., “A Survey of Gynecologists Concerning Menorrhagia: Perceptions of Bleeding
Disorders as a Possible Cause,” Journal of Women’s Health & Gender-Based Medicine 11 (2002): 39–44. 4. Vanessa R. Byams et al., “Evaluation of Bleeding Disorders in Women with Menorrhagia: A Survey of Obstetrician-Gynecologists.” American Journal of Obstetrics and Gynecology 207, no. 4 (2012): 269.e1–e5. 5. Judith Baker et al., “US Hemophilia Treatment Center Population Trends 1990–2010: Patient  Diagnoses, Demographics, Health Services Utilization,” Haemophilia 19 (2013): 21–26. 6. F. Rodeghiero et al., “Epidemiological Investigation of the Prevalence of von Willebrand Disease,” Blood 69 (1987): 454. 7. I. Plug et al., “Bleeding in Carriers of Hemophilia,” Blood 108, no. 1 (2006): 52–56.

Originally published in PEN, August 2017

 

 

The Most Famous Hemophilia Carrier

I’m preparing for a visit to Russia next
week, a country I have not been to since 1999. So I’ve been reading two
excellent books to prepare: Peter the Great and Nicolas and Alexandra, both by
Pulitzer-prize winning author Robert K. Massie.

These books, and last week’s post on
hemophilia myths, got me thinking: Do you know who the most famous carrier of
hemophilia was? Hint: It’s why hemophilia is dubbed “The Royal Disease.”
Queen
Victoria of England, one of England’s longest reigning monarch. Her 63-year reign became known as the Victorian era, and was the longest reign until
September 9, 2015, when Queen Elizabeth II surpassed her. Her era saw British
power at its zenith across the globe; Victoria believed that the British Empire
existed to civilize people in less developed countries and to protect them from
their own rulers and the aggression of neighboring rulers. Others saw the
purely commercial aspect of this world domination of lands and trade routes.
Victoria took the throne at age 18, and later married
her first cousin, Prince Albert of Saxe-Coburg and Gotha, in 1840. Over the
next seventeen years, she and Albert had nine children: Albert
Edward, (b. 1841), Alice (b. 1843), Alfred (b. 1844), Helena (b. 1846), Louise (b. 1848), Arthur (b. 1850), Leopold (b. 1853) and Beatrice (b. 1857).
The last child, Beatrice, was delivered under the care of Dr. John Snow, who
later became the founder of modern public health by discovering the
transmission mechanism of cholera (infected water). Snow used anesthesia on
Victoria, thus giving her pain-free childbirth for the first time! While Snow
did not invent anesthesia, he created a more convenient and safer way to administer
it.
When their nine children married into royal and noble families throughout Europe (for mostly
political reasons), Victoria was called “the grandmother of Europe,”
and indeed was called “Granny” by all her grandchildren and their spouses. 
Hemophilia was not known to exist in the
royal family before, but Victoria carried the gene for hemophilia B. Only
Leopold had hemophilia; two daughters, Beatrice and Alice, were carriers. They
later transmitted hemophilia to the Spanish and Russian royal families. 
Leopold grew up to be a tall, intelligent,
affectionate yet stubborn prince, whose willfulness often led to injuries and
bleeds, according to author Massie. The Queen was unusually attached to her
son, and worried over him incessantly. Victoria reported in one letter that
Leopold had been at death’s door four or five times. Eventually Victoria tried
to keep him confined to the upper floors of Buckingham Palace for his own
protection, even as a man! But he managed to get away to Paris for two weeks.
Eventually at age 29, he fell in love with a German princess, Helen of Waldeck.
They had a daughter. When Helen was pregnant a second time, Leopold fell,
suffered a brain hemorrhage and died at age 31.
 There was no treatment for hemophilia then, of course. Victoria was informed by telegram that her youngest son had died in Cannes. He was “the dearest of my dear
sons,” she lamented.
According to one of her
biographers, Victoria wrote an average of 2,500 words a day during her adult
life, and kept a detailed journal, which eventually encompassed 122 volumes. From this we
learned a bit about hemophilia in those days.  The
Queen didn’t know what type of hemophilia her son had or if there even were
types; only much later, through genetic testing, was the family found to have
hemophilia B. While the mechanisms weren’t entirely understood, the royal
family knew that hemophilia could be passed down from generation to generation.
And it was; when it hit the Russian royal family, it would change the world.

For more information, read Robert K. Massie’s excellent books, or view “Nicolas and Alexandra,” a major motion picture and excellent portrayal of the last years of the Russian monarchy. Available on Amazon.com.  Robert K. Massie also has an adult son, Robert K. Massie, Jr., who was later cured of his hemophilia through a liver transplant. His life is exquisitely portrayed in the book Journey.