Objective assessment
A full head-to-toe physical, prioritizing the assessment of hemodynamic stability, should be conducted on all women complaining of menorrhagia. Gait and affect should be observed for possible evidence of dizziness, fatigue, or shortness of breath. Vital signs, including height, weight, heart rate, BP, and temperature, if indicated, should be recorded.
Carefully examine the patient's skin for pallor and for petechiae, ecchymoses, or other evidence of a coagulopathy. Note any signs of thyroid disease and carefully palpate the thyroid gland. If you suspect liver or renal disease, assess for skin changes, organomegaly, and other clinical manifestations.
Pelvic examination should include both a speculum exam to assess the integrity of the cervix and vagina and a careful bimanual exam to check for cervical motion tenderness and uterine or adnexal masses. Depending on what the history and exam reveal, cervical cultures, cervical cytology (Pap smear), pelvic ultrasonography, or other diagnostic procedures may be indicated.
Diagnostic testing
Urine human chorionic gonadotropin is the first-line test to rule out pregnancy or spontaneous abortion. If spontaneous abortion is suspected, any collected tissue may be sent for pathologic examination.
Women with signs or symptoms of anemia, as well as those with severe or long-standing menorrhagia, should be evaluated with a hemoglobin and hematocrit determination or a complete blood count.
Coagulopathy studies are recommended for women whose menorrhagia dates back to menarche or remains idiopathic after a full workup, those who have a suspicious personal or family history, and patients undergoing hysterectomy for menorrhagia.7 Platelet count, prothrombin time, partial prothrombin time, and bleeding time are appropriate first-line studies. The most common coagulopathy is von Willebrand disease, which is present in 11%-16% of women with menorrhagia; coagulopathy screening should therefore include early testing for von Willebrand factor.8
Other serology, such as thyroid-stimulating hormone, liver function testing, blood urea nitrogen, and creatinine should be considered, depending on the patient history and exam.
Endometrial biopsy is warranted for women at high risk of endometrial hyperplasia or uterine cancer. This includes patients who have had bleeding after menopause or who used exogenous estrogen therapy without opposing progesterone, those with a history of polycystic ovary syndrome or a family history of uterine cancers, and those who are obese or older than 35 years.
Pelvic ultrasound is indicated if bimanual exam reveals abnormal uterine size or shape. Some experts also recommend pelvic ultrasound as a first-line screening for endometrial cancer; biopsy is advisable if the endometrial stripe measures >12 mm.
Ultrasound may reveal fibroids or adenomyosis. Myomas, or fibroids, are common benign uterine growths that occur in up to one third of women.9 Though many women with fibroids never experience symptoms, heavy menstrual bleeding is the most common complaint among those who do. Submucosal fibroids that distort the uterine cavity or protrude into the cavity are most likely to cause abnormal bleeding. Because fibroids are common and are frequently asymptomatic, it is important to exclude other concomitant causes of menorrhagia, even after a diagnosis of fibroids is made.
If an intracavitary growth, such as a submucosal fibroid or a uterine polyp, is suspected, saline infusion sonohysterography (SHG) should be conducted. SHG consists of infusing sterile saline fluid into the uterus while capturing a real-time image of the uterine cavity on ultrasound. Hysteroscopy with directed biopsy may be indicated if SHG and/or endometrial biopsy reveal a need for further investigation.