Hematologist Pediatrician Hotel Dieu de France Saint Joseph University Beirut Lebanon / CHU Lilles France /Lebanese Hemophilia Association Lille, France
Menopause marks a significant transition in women's aging process, accompanied by various changes and an increased risk of comorbidities. With aging coagulation factors increase. In bleeding disorders, they increase also, and bleeding patterns change. However, the bleeding phenotype may not necessarily improve, which can complicate diagnosis and the assessment of bleeding risk. Using a lifetime history of bleeding symptoms to determine bleeding scores may not accurately reflect the current bleeding risk. Therefore, a new Bleeding Assessment Tool, focused on the past five to ten years, needs to be developed. Musculoskeletal problems, such as osteoporosis, osteoarthritis, and fractures, are important problems at menopause. They are more prevalent among women with hemophilia and von Willebrand disease. Women with bleeding disorders experience joint bleeding leading to decreased range of motion, irreversible joint damage, low bone mineral density and a greater risk for osteoporosis. FVIII and FIX deficiencies disrupt the RANK/RANKL/OPG signalling pathway and affect bone metabolism. Thrombin deficiency, immobilization and reduced weight-bearing on bones, modify cytokine profiles and alter osteoblast and osteoclast activity . Cytokines produced from recurrent intra-articular bleeding also play a role in bone metabolism. In a large database of women, the prevalence of conditions such as vitamin D deficiency, obesity, hypothyroidism, smoking, diabetes mellitus, hypocalcemia, corticosteroid use, malignancy, renal failure, and NSAID use was significantly higher among bleeding disorders compared to controls. There is an ongoing prospective study evaluation bone health in symptomatic 50 years and older women with hemophilia. To prevent osteoporosis in women with bleeding disorders , it is recommended, since young, to engage in appropriate weight-bearing exercises and ensure adequate intake of vitamin D and calcium. Hemophilia Treatment Centres should focus on bone health during routine comprehensive visits and be vigilant about other risk factors. A DEXA scan to assess bone density and osteoporosis risk should be considered, although the optimal timing remains unclear. Hormone replacement therapy is the gold standard treatment for aging women at risk of osteoporosis. There is limited data on the effectiveness of anti-osteoporotic treatments in bleeding disorders. Clinical studies to better understand the management of osteoporosis are urgently needed.
Learning Objectives:
If coagulation factors increase in aging women with bleeding disorders and bleeding patterns change, the bleeding phenotype may not necessarily improve. Current BAT assessment tools may not accurately reflect the current bleeding risk and, a new BAT, focused on the past five to ten years, needs to be developed.
Musculoskeletal problems, such as osteoporosis, osteoarthritis, and fractures, are important problems at menopause. and more prevalent among women with hemophilia and von Willebrand disease.
Hemophilia Treatment Centres should focus on bone health, since young age, during routine comprehensive visits and be vigilant about other risk factors.
Clinical studies to better understand the management of osteoporosis are urgently needed.
