The aortic window: a temporal framework for acute type A aortic dissection.

Heavy menstrual bleeding (HMB) resulted in the death of 14-year-old Hjördis after her fourth menstrual cycle because of von Willebrand disease (VWD), the most common bleeding disorder (BD), first described in 1926 []. This historical case and several others demonstrate the strong association between HMB and BDs. Globally, the prevalence of HMB varies between 20% and 51%, with higher numbers reported in low- and middle-income countries [, , , ]. Approximately 34% to 58% of menstruating adolescents report HMB, and 21% to 46% of these adolescents have an underlying BD [, , , ]. Of adolescents hospitalized for HMB, ∼33% have a BD []. The most common causes of HMB in adolescence are anovulatory cycles and BDs [,]. In females with a BD, ∼75% to 80% have HMB [,]. The initial question posed to an adolescent, “” often elicits a “,” possibly due to discomfort in discussing menstrual issues with providers or family members and comparison to relatives who may also have an underlying BD, thereby masking the definition of “normal.” The lack of open-ended questions and ready acceptance of this response results in early dismissal of the adolescent without further evaluation. In a European survey, it was noted that 46% of women had never sought medical attention for HMB []. Physician survey data indicate that comprehensive menstrual history intake is performed in <10% of consultations by pediatricians and family practitioners []. HMB and BDs are underestimated in part due to the absence of standardized definitions and limited provider awareness that HMB is a significant hallmark symptom of an underlying BD. Gynecology providers (GYNs), including adult obstetricians and gynecologists (OB/GYNs), pediatric and adolescent gynecologists, and adolescent medicine physicians, frequently encounter HMB yet do not always pursue systematic evaluation for a BD in adolescents [,]. Additionally, gaps in knowledge and variability in training among hematologists further contribute to underdiagnosis and delayed referral. Prolonged and recurrent HMB in BD patients is a common cause of iron deficiency (ID) and/or iron deficiency anemia (IDA), resulting in poor quality of life (QoL) [,]. Increasing awareness and education among the community and providers about HMB is imperative for early diagnosis, identifying underlying etiologies, and initiating prompt and appropriate treatment. Notably, the past decade has seen a significant shift in both hematologists and GYNs toward greater emphasis on menstrual health, driven by publications, dedicated sessions at national and international conferences, increased research studies, the advancement of new therapeutics for HMB and BDs, and the emergence of combined subspeciality clinics aimed at improving overall health outcomes [, , ].