Subjective assessment
A careful history can successfully and accurately steer the diagnostic process. Focus on the duration and severity of the bleeding as well as associated symptoms, such as pain or cramping. Duration may be especially helpful in narrowing the differential diagnoses. Menorrhagia that has been present since menarche suggests a bleeding disorder, while menorrhagia with onset after age 40 is more likely an anatomic lesion or perimenopause. The most frequent cause of sudden-onset acute menorrhagia is an accident or complication of pregnancy.
Investigation of the patient's medical and family history should focus on likely causes of menorrhagia: coagulopathies, thyroid disease, endometrial or uterine cancers, fibroids, and liver or renal disease. It may be helpful to ask whether the patient's mother or any sisters had a hysterectomy prior to menopause. Currently 20%-30% of hysterectomies are performed for a chief complaint of menorrhagia, and this number may have been higher in the past.
A careful medication inventory may reveal an iatrogenic cause of menorrhagia (e.g., daily aspirin or other prescription, OTC, or herbal anticoagulants). Many patients on regimens of fish oil or other OTC anti-inflammatories do not recognize the potential effects of these medicines on menstrual flow (Table 2). Steroid hormones and chemotherapy agents may also disrupt the menstrual cycle. Women who have recently stopped using injectable or oral progestins, oral contraceptives (OCs), or other hormonal birth control methods may notice a marked increase in their monthly flow. A copper IUD can also cause excessive menstrual bleeding. Some women will experience menorrhagia for up to a few months following medication abortion. These effects should be self-limiting unless another underlying cause for menorrhagia is present.
Social history should focus some attention on the patient's quality of life to determine how much the menorrhagia is interfering with her daily activities. The social history should also focus on possible risks for sexually transmitted infection (STI) exposure. Chlamydia, gonorrhea, and trichomoniasis can all cause cervicitis resulting in abnormal bleeding. In these circumstances, review of systems may also reveal postcoital bleeding, abnormal vaginal discharge, abdominal pain, or dyspareunia. Screening for abuse and trauma should be included in the social history as well.
The review of systems is among the most potentially revealing components of the menorrhagia workup. This should include signs of underlying causes of menorrhagia (e.g., bleeding disorders) and its sequelae (e.g., anemia).
Inquire about other evidence of abnormal or prolonged bleeding, such as easy bruising, gingival bleeding after tooth brushing, prolonged epistaxis, or uncontrolled bleeding with superficial cuts. Prolonged bleeding after surgery (including dental extractions) may signal a coagulopathy. Signs and symptoms of thyroid disease (e.g., heat or cold intolerance, mood changes, and weight or appetite changes) should be investigated. Even subclinical cases of hypothyroidism can produce heavy menstrual bleeding. In women who may be experiencing menopause, inquire about vasomotor symptoms, difficulty sleeping, and changes in libido. Women with an anatomic lesion (i.e., fibroids) may note dysmenorrhea, abdominal or back pain, or difficulty with bowel movements.
In severe or ongoing menorrhagia, signs and symptoms of anemia may be present. Patients should be asked about such symptoms as shortness of breath, heart palpitations, light-headedness, dizziness, fatigue, pallor, and nausea or vomiting. It is also important to ask whether the patient is using iron supplements or taking a multivitamin routinely.