Biological Abnormalities of Hemostasis in Patients with Epistaxis or Menorrhagia in Yaoundé, Cameroon

Introduction In Cameroon, screening and diagnosis of minor hemorrhagic syndromes remain difficult and few research studies have been done to assess the magnitude of future bleeding risk and the burden of these disorders on quality of life. Epistaxis and menorrhagia are the two leading causes of bleeding disorders in the world population. Aim The aim of this study was to investigate the biological abnormalities of hemostasis in patients with epistaxis and menorrhagia. Method From January to December 2021, we conducted a cross-sectional study in six hospitals with a gynecology and ENT department. We selected patients who presented epistasis or menorrhagia through clinical file and made them pass an interview and biological exams. Venous blood collected on EDTA tube allowed us to measure full blood count, thin blood smear, and blood grouping. PT, APPT, and fibrinogen assay were measured from citrate platelet-poor plasma. This plasma stored at −20°C for a maximum of 3 months allowed us to measure vWF : Ag and vWF : CBA ELISA. The bleeding time was measured at the time of sampling. Result In total, our study population consisted of 60 patients aged 01–45 years. Epistaxis (40%) and menorrhagia (29%) were the two main causes of bleeding complaints in our study, in addition to gingivorrhagia (15%) and prolonged bleeding after injury (03%). Almost 60% of the population had at least one abnormal hemostasis parameter. The main abnormalities found were low von Willebrand factor (30.19%), presence of macroplatelets (16.98%), prolonged bleeding time (15.09%), prolonged PT (15.09%), and low platelet count (¬07.55%). Conclusion In Cameroon, bleeding disorders manifested by epistaxis and menorrhagia are mainly caused by abnormalities of primary hemostasis.


Introduction
Minor hemorrhagic syndromes (MHSs) are hemostasis disorders characterized by a "mild" or "moderate" tendency to bleeding and can have consequences on the quality of life of individuals [1].In Cameroon, screening and diagnosis of MHS remains challenging and assessing the magnitude of future bleeding risk and the burden of these disorders on quality of life has been poorly studied and tends to be local practice based rather than guided by clinical, laboratory, or genetic criteria [2,3].Te prevalence of MHS in patients with abnormal hemostasis varies according to published studies.Tis variability is partly related to the lack of a clear defnition of minor bleeding disorders and the criteria used for diagnosis in the various studies [4,5].Tese disorders must indeed be distinctive enough to be considered a disease, but with less severity compared to major bleeding disorders; and in case of major disorders, by the absence of spontaneous episodes [6,7].
A recently published study (2018) on the diagnosis of MHS showed that of 240 people reporting having bleeding disorders, only 8.8% actually presented with hemostasis abnormalities [8].Epistaxis and menorrhagia were the main bleeding disorders reported with, respectively, 24% of all participants and 59% among female participants.Epistaxis is the most frequent clinical pathology in Ear, Nose, and Troat (ENT) practice (60% of adults).It accounts for 15% of manifestations in patients with hemorrhagic syndromes and is the 3rd symptom of rare bleeding disorders [9][10][11].In the general population, menorrhagia represents 12% of specialized gynecological consultations.Also, 44% of women mention sufering from it and 5-20% of women aged between 30 and 49 consult for excessive blood loss [12,13].
It is with a view to having a better knowledge of the causes of MHS in Cameroon that we proposed to study the biological abnormalities of hemostasis in patients presenting with epistaxis or menorrhagia and visiting the main hospitals in the city of Yaoundé.Specifcally, it was to describe the sociodemographic characteristics of patients presenting with epistaxis or menorrhagia to identify the bleeding manifestations that accompany these bleeds and to determine the type and frequency of biological abnormalities of hemostasis in these patients.

Methodology
Tis is a cross-sectional, descriptive study that took place between January and December 2021 in six (06) hospitals in the city of Yaoundé with a gynecology department and an ENT department.Tese were the Yaoundé University Teaching Hospital, the Yaoundé Central Hospital, the Yaoundé General Hospital, the Yaoundé Gyneco-obstetrics and Pediatric Hospital, the Yaoundé Military Hospital, and the Essos Hospital Center.Te biological tests were carried out at the hematology laboratory of the Yaoundé University Teaching Hospital.Tese are reference hospitals at the national level with a comprehensive care ofer and a capacity of more than 300 hospital beds.

Participants.
Te study population consisted of any patient presenting with epistaxis or menorrhagia and seen as an outpatient in the gynecology or ENT departments in one of the listed hospitals.Tose included in our study were patients who were medically followed in one of the hospitals, who had a complete clinical fle, and who had given their informed consent to participate in the study.Tose excluded from the study were patients with bad specimens and patients who had fever and who were under treatment that could infuence the parameters of hemostasis.
2.2.Procedure.We regularly consulted the outpatient registers of the gynecology and ENT departments of health facilities in order to identify patients complaining of epistaxis and/or menorrhagia.We then selected those with a complete clinical fle and contacted them by phone to involve them in the study.We went to meet the patients who agreed to participate in the study in order to interview through the standard questionnaire for the study and to do the biological samples.Tese involved blood samples from each participant at the bend of the elbow through the Vacutainer vacuum system successively using dry tubes, 3.2% sodium citrate anticoagulant tubes, and EDTA anticoagulant tubes.Te samples were kept and transport in a portable insulated cooler at a temperature between 2 and 8 °C for a maximum of 4 hours to be analyzed.Te analyses performed with whole blood with EDTA anticoagulant tubes were full blood count, thin blood smear, and blood grouping.Platelet-poor citrated plasma was obtained after centrifugation at 2500 g for 15 minutes of venous blood sample mixed with the anticoagulant sodium citrate (concentration 0.109 M) at the rate of 9 parts of blood for 1 part of anticoagulant and was used for PT, APPT, and fbrinogen assay.Te World Federation of Hemophilia (WFH) recommends the use of platelet-poor plasma in most coagulation tests in order to avoid any platelet interference in the in vitro analytical process [14].Platelet-poor citrated plasma was then used for determination of VWF antigen (vWF : Ag) and measurement of VWF adhesive properties (vWF : CBA Collagen Type I).TECHNOZYM ® vWF : Ag ELISA and TECHNOZYM ® vWF : CBA ELISA Collagen Typ I are the reagents we used in this study, and its manufacturer (Technoclone) recommends storing the samples at −20 °C for 3 months to guarantee the quality of analyses.In this study, we stored the samples at −20 °C and analyzed them every 3 months in order to respect these recommendations while optimizing reagent consumption because for fnancial reasons we could not aford to do ELISA tests at a lower frequency.Note that the examination of the bleeding time (BT) was carried out immediately after the blood samples of each participant.
As part of this work, we did not use a control population because we initially have the reference values generated by the laboratory concerning the assayed parameters, to which we compared all our results.
Te interpretation of the results was specifc to each analysis technique used.Tus, a prolongation of the BT was defned by a value of the BT greater than 5 minutes; thrombocytopenia was defned by a platelet level below 150 G/L; von Willebrand factor defciency was defned by a vWF : Ag value less than 0.5 U/ml (reduced level) for people with blood groups A, B, or AB and less than 0.35 U/ ml for those with blood group O; von Willebrand factor defciency was also defned by an isolated vWF : CBA value less than 0.6 U/ml (reduced level); PT prolongation was defned by a PT value less than 70%; aPTT prolongation was defned by a patient aPTT/control aPTT ratio greater than 1.2; and fbrinogen defciency was defned as a fbrinogen level less than 200 mg/dl.Te biological data of the participants used to support the conclusions of this study have been deposited in the archives of the hematology and blood transfusion service of the Yaounde University Teaching Hospital.

Circumstances of Bleeding Discovery.
During the study period from January to December 2021, we recruited 60 participants.Epistaxis accounted for 70% (36 participants) of the circumstances of bleeding discovery compared to 30% for menorrhagia (24 female participants).Te median age of onset of bleeding was 18 years and 75% of the population had an age of onset of less than 22 years (IQR � (13-22 years)).

Frequency and Intensity of Reported Hemorrhagic
Complaints.As shown in Figure 1, epistaxis (40%) and menorrhagia (29%) were the two main causes of bleeding complaints reported in our study, in addition to gingival bleeding (15%), prolonged bleeding after injuries (04%), and metrorrhagia and rectal bleeding (03%).

Frequency and Intensity of Bleeding.
Eighty percent (48 participants) of the participants in our study reported moderate (31 participants) or major (17 participants) bleeding.Also, 48.33% of the participants had only one bleeding episode in the past six months, compared to 46.67% who had more than four episodes (Table 1).

Sociodemographic Characteristics of the Study
Population.Te age of our study population was between 01 and 45 years old.Te median age was 23.5 years old (IQR � (20-29.75years)) and the most represented age group was (20-24).Students were the most represented profession (n � 25; 45%) and women were more numerous than men (sex ratio � 0.33).Table 3 summarises the sociodemographic characteristics of our study population.

Discussion
During the study, we recruited 60 participants.Epistaxis (70%) and menorrhagia (30%) were the only causes behind the discovery of bleeding disorders in our population because they were the hemorrhagic manifestations retained as the selection criterion for participants.However, 41% of female participants mentioned menorrhagia as a circumstance of discovery of bleeding; Tosetto et al. found similar data (47%) in 2013 [15].Similarly, although 75% of the participants had an age of discovery of bleeding less than 22 years, the median age was relatively high (18 years).Tossetto et al. explained that the risk of bleeding is much lower during the frst years of life and that even by modeling an exponential increase in the risk of bleeding with age (assumption made to take into account the specifc problems of women and traumatic bleeding or surgical procedures, leading to a higher risk of bleeding in adults than in infants [16]), the probability of having a minor bleeding symptom by the age of 30 can be as high as 33% [15].
In addition, more than 80% of the participants declared as being "moderate" or "high" the intensity of the bleeding disorders from which they sufered.Even more, we found a marked diference between participants who experienced only one bleeding episode in the past six months (48.33%), those who experienced 2 or 3 (5%), and those who experienced more than four (46.67%).Tis can be explained by the fact that the lack of standard measurement criteria retained for the identifcation of bleeding episodes, it is possible that trivial (nonsignifcant) bleeds that should not be taken into account have been added to bleeds true bleeding that may be representative of an underlying disease.Indeed, some patients often have a more subjective perception of hemorrhagic manifestations and generally declare them more often than they actually have [2,6].
Nearly 60% of the patients had at least one abnormal hemostasis parameter, mainly parameters exploring primary hemostasis (75.5%).Tese results are rather consistent with the type of bleeding found (mainly mucosal bleeding).Indeed, these are distinctive enough to be considered a disease, but with less severity compared to major bleeding disorders which mainly afect the skin tissue and joints and are generally caused by abnormalities in plasma coagulation [2].However, these data difer from those of Vries et al. in 2018 who found a proportion of 8.8% of the participants with at least one abnormal hemostasis parameter [8].Mokhtar et al. had obtained a proportion of 23.3% [12].Te signifcant diference in proportion of our study can be explained by our recruitment method, which notably consisted in calling the participants through their phone number, whereas Primary hemostasis abnormalities accounted for 75.5% (37 abnormalities) of the abnormal parameters found.Among other things, it was von Willebrand factor defciency which was found in 16 participants (30.19%).Other primary hemostasis abnormalities were presence of macroplatelets (16.98%), prolonged bleeding time (15.09%),low platelet rate (07.55%), and platelet aggregates (07.55%).Similar results had been found in many studies although with diferent proportions [12,17,18].Tus, Saxena et al. reported in 2003 that von Willebrand's disease is the most common inherited pathology of hemostasis found in women in India with menorrhagia (11.9%), as reported in the Caucasian population [18].Mouktar et al. demonstrated that platelet abnormalities (72.7%), mainly thrombocytopenia (54.3%), are the main hemostasis abnormalities responsible for bleeding disorders during a study that identifed 2,949 patients over 16 years of hematological consultations in a clinic in Egypt [12].
Te population consisted of females, 45 participants (75%) compared to male, 15 participants (25%).Indeed, as reported by Vries et al. in 2018 [8], women are more likely to complain of a bleeding disorder (71%).In addition, Fontana and Boehlen reported in 2007 that 65% of women and 35% of men answered "yes" to the question "Do you have a bleeding problem?" [6].As for the average age of our study population (IQR � (20-29.75years)), it corresponds to that of young adults and corroborates with the professional category mainly found among our participants (students at nearly 50%).

Conclusion
Tis study is a frst in Cameroon reporting biological abnormalities of hemostasis in patients with minor bleeding disorders.It appears that patients with epistasis or menorrhagia mainly present biological abnormalities related to primary hemostasis, the most common being von Willebrand's disease.Tis disorder, very little studied in Cameroon because of the difculty of diagnosis, must, however, retain special attention because of the complications it can cause on the quality of life of individuals.

Study Limitations
Our study concerns a small size (60 participants) of the population studied.Studies on large populations should be carried out in order to verify the observations made within the framework of this work.Also, other biological parameters could be explored to have a better appreciation of hemostasis abnormalities in patients with epistaxis and menorrhagia.Specifcally, platelet functional defciency is one of the coagulation abnormalities most frequently found in our study and indeed deserves greater visibility and better exploration.Unfortunately, we did not carry out the additional tests necessary for its exploration within the framework of this study and could be the subject of a further relevant study.
Method.Te data for this study were collected using Microsoft Ofce Excel 2013 software and statistical analysis was performed using Epi Info 7 software.Te graphs were created using Microsoft Ofce Excel 2013 software.Position parameters such as the mean and median, and dispersion parameters such as standard deviation and 2 Advances in Hematology interquartile ranges, were used for the description of continuous variables.Te categorical variables were described in terms of number and percentage.Tis study received ethical clearance from the Institutional Research Ethics Committee of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé 1 (Ref.: 476/UY1/FMSB/VDRC/DAASR/CSD of February 14, 2020) and research authorisations from the diferent general managements of the hospitals where the study took place.

Table 1 :
Mokhtar et al. and Vries et al. recruited participants in their respective studies at the time of the consultation.It could turn out that Frequency and intensity of bleeding.

Table 2 :
Interpretation of biological abnormalities of hemostasis.

Table 3 :
Sociodemographic characteristics of our study population.