Understanding Why When There’s HMB: A Multidisciplinary Approach

May 6, 2019

Kerry Funkhouser and Ayesha ZiaWhen Ayesha Zia, MD (pictured, right, with FWGBD Executive Director Kerry Funkhouser) was growing up in Pakistan, family dinner table conversations did not shy away from the oft taboo subject of menstruation. “Both my parents are physicians, and my mom is an OB/GYN,” she explains. “In many cultures, talking about your period isn’t allowed; but we talked about this stuff at home: periods, hormones, DNCs and bleeding after childbirth. Maybe that’s why I’m comfortable in this space.”

Dr. Zia pursued a career in hematology, though she hasn’t strayed at all from women’s health. Since 2014, she’s been leading “The Young Women’s Blood Disorders Program” at Children’s Health, Dallas — with two clinics per month — and her approach is somewhat unique: “Many combined clinics are seeing patients after diagnosis of a bleeding disorder. I have access to patients before diagnosis,” she says. “The main problem adolescents face with heavy menstrual bleeding (HMB) is underdiagnosis. I wanted a pathway for girls with HMB to see a hematologist, not just a gynecologist.”

At Zia’s multidisciplinary clinic, girls with HMB are seen by two of the three physicians who are part of the program: an adolescent physician, a gynecologist, and a hematologist (Dr. Zia herself). Her rationale for this approach stems from three lessons learned during the course of her medical training, fellowship research, clinical pioneering, and membership with the WGBD (Women/Girls Bleeding Disorder) Learning Action Network (LAN):

Things aren’t always what they seem.

While examining the risk of blood clots in adolescent girls who start birth control, as a research fellow at Children’s Hospital of Michigan, she observed a routine treatment protocol for HMB: prescribing birth control pills. “The knee-jerk response to HMB was to suppress the periods,” she says, further explaining that the possibility of bleeding disorder was hardly considered. Thus, no family histories were solicited from patients, and possible blood disorders weren’t being identified. Zia observed a system in which the symptoms of anemia, fatigue and HMB in adolescent girls were being deemphasized.

Three heads are better than one.

“At the University of Texas Southwestern (UTS), I pitched the idea that there needs to be a platform for these girls,” Zia says of the teens with HMB. “I got complete institutional support and collaboration has never been a problem.”

However, Zia’s focus and passion led her to overlook one aspect of holistic patient care: psychology. “With one patient, I was so focused on periods and family history and then my adolescent medicine physician went in and she found the patient was cutting herself,” Zia says. “I was ashamed. How did I miss this?”

The intersection of hematology, gynecology and adolescent medicine enabled this clinical team to appropriately diagnosis and treat this teen. She’d been prescribed birth control for HMB and had gained a lot of weight. Her resulting depression incited self-mutilation. With multiple pathologies in play, she needed multidisciplinary medical diagnosis, treatment, and management.

Being part of a network is essential.

Zia decided to host the fifth annual FWGBD LAN meeting at UTSW in the fall of 2018. “I thought if I hosted the LAN, I could introduce this different model,” she says. “I think it’s very possible we’ll have a new genre of medicine soon. People lump HMB into gynecology, but often there’s a bleeding disorder.”

Knowledge is growing, Zia asserts, noting that her experience with the LAN has opened new opportunities for spreading her methodology, as well as learning from other hematologists what’s working for them and their patients. “Now I’m comfortable that if my clinic is full, I can make a referral. At least there’s somebody who is not going to let this girl (I can’t treat)  fall through the cracks.”

With an OB/GYN role model in her mother and a mission to provide thorough and effective diagnosis and treatment to adolescent girls with HMB, it’s a marvel Dr. Zia has stuck to the path of a hematologist. She laughs about this: “My colleagues think I’m a closeted OB/GYN. Outside of LANs, nobody wants to hear about girls’ periods.

“But I’m a stickler for details. Even if I’m a hematologist, I need to figure out if my patients’ heavy periods are due to an underlying bleeding disorder or if it’s hormonal. I admire my mother for delivering babies at odd hours, but I didn’t think I could do this, even though I’m very comfortable with pediatrics and I love taking care of children.

“Hematology has a lot of detective work; weeding through multiple possibilities at once,” she explains. “I have always wanted to understand ‘the why.’ You have to have investigative enthusiasm. That’s what makes our clinic such a success.”