History
Symptoms related by a patient with menorrhagia often can be more revealing than laboratory tests. Considering the lengthy list of possible etiologies that contribute to menorrhagia, taking a detailed patient history is imperative. Inquiries that should be included are discussed below/
Exclusion of pregnancy
This is the most common cause of irregular bleeding in women of reproductive age.
Pregnancy should be the first diagnosis to be excluded before further testing or medications are instituted.
Quantity and quality of bleeding
Quantity is a very subjective issue when considering vaginal bleeding. Best estimates usually are the only source clinicians have available to consider. Helpful references for totaling blood loss may include that the average tampon holds 5 mL and the average pad holds 5-15 mL of blood. Asking the patient what type of pad (liner vs overnight) was used and if it was soaked may add some insight into what the patient believes to be heavy bleeding.
Quality of bleeding involves the presence of clots and their size.
Patient age
Young patients, from menarche to the late-teen years, most commonly have anovulatory bleeding due to the immaturity of their hypothalamic-pituitary axis. If bleeding does not respond to usual therapy in this age group, a bleeding disorder must be considered.
Women aged 30-50 years may have organic or structural abnormalities. Fibroids or polyps are frequent anatomical findings. Organic causes can be anything from thyroid dysfunction to renal failure.
Postmenopausal women with any uterine bleeding should receive an immediate workup for endometrial cancer.
Endometrial hyperplasia must be considered in women who are obese, aged 70 or older, nulliparous, or have diabetes.
Pelvic pain and pathology
Knowing if a patient has any long-standing diagnosis or known pathology (eg, fibroids) is helpful.
Records from other physicians or hospitalizations may prevent redundancy in ordering lab work or diagnostic imaging.
Menses pattern from menarche
If a young patient has had irregular menses since menarche, the most common etiology of her bleeding is anovulation.
Anovulatory bleeding is most common in young girls (aged 12-18 y) and common in obese females of any reproductive age.
If a patient's bleeding normally occurs at regular intervals and the irregularity is new in onset, pathology must be ruled out, regardless of age.
Sexual activity
Simple vaginitis (eg, candidal, bacterial vaginosis) may cause intermenstrual bleeding, while gonorrhea and chlamydia may present with heavier bleeding attributed primarily to the copious discharge mixed with the blood.
Chlamydia is a common cause of postpartum endometritis, leading to vaginal bleeding in the weeks following a delivery.
A postpartum infection (eg, endometritis) also may be due to organisms unrelated to sexual activity.
Contraceptive use(intrauterine device or hormones)
Commonly, an intrauterine device (IUD) causes increased uterine cramping and menstrual flow.
If a patient has recently discontinued birth control pills, she may return to her "natural" menses and report an increase in flow. This actually is normal because most oral birth control pills decrease the flow and duration of a woman's menses.
Presence of hirsutism (polycystic ovarian syndrome)
These patients commonly are obese and in an anovulatory state. When they do have a period, it may be very heavy and cause concern for the patient.
The etiology of this is explained in the Introduction to this article.
Galactorrhea (pituitary tumor)
Any patient complaining of a milky discharge from either breast (while not pregnant, postpartum, or breastfeeding) needs a prolactin level to rule out a pituitary tumor.
Systemic illnesses (hepatic/renal failure or diabetes)
As explained in the Introduction, organic diseases may affect either the hormonal or hematologic pathways that are involved in the manifestation of menorrhagia.
If either the hypothalamic-pituitary axis or the coagulation paths are disrupted, heavy bleeding may result.
Symptoms of thyroid dysfunction
The alteration of the hypothalamic-pituitary axis may create either amenorrhea (hyperthyroidism) or menorrhagia (hypothyroidism).
Excessive bruising or known bleeding disorders
This is especially important in a young patient who does not stop bleeding during her first menses.
This is a very common presentation for an undiagnosed bleeding disorder (von Willebrand disease) in a young girl.
Current medications (hormones or anticoagulants)
Any medication that prolongs bleeding time may cause menorrhagia.
A patient treated with any progestin therapy may have a withdrawal bleed after cessation of the medication. This bleeding often is heavy and worrisome to patients if they are not forewarned.
Previous medical or surgical procedures/diagnoses
This also is helpful in preventing duplication of testing.
Physical
The physical examination should be tailored to the differential diagnoses formulated by the results of the patient's history.
Initial inspection should include evaluation for the following:
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Signs of severe volume depletion (eg, anemia): This may help confirm the patient's history of very heavy bleeding and/or prompt immediate inpatient care.
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Obesity: This is an independent risk factor for endometrial cancer. Adipose tissue is a locale for estrogen conversion. Therefore, the larger the patient, the more increased the risk (and the higher the unopposed estrogen level on the endometrium).
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Signs of androgen excess (eg, hirsutism): This usually points to polycystic ovarian syndrome (PCOS), leading to anovulatory bleeding (see Presence of hirsutism).
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Ecchymosis: This usually is a sign of trauma or a bleeding disorder.
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Purpura: This also is a sign of trauma or a possible bleeding disorder.
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Pronounced acne: This is a sign of PCOS.
General examination should include evaluation of the following:
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Visual fields
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Bleeding gums
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Thyroid evaluation
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Galactorrhea
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Enlarged liver or spleen
Pelvic examination should evaluate for the presence of external genital lesions.
Vaginal/cervical discharge: Look for a copious discharge indicating infection, and confirm the actual site of the bleeding (if present). Assess as follows:
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Uterine size, shape, and contour: An enlarged irregularly shaped uterus suggests fibroids if the patient is aged 30-50 years. An enlarged uniformly shaped uterus in a postmenopausal patient with bleeding suggests endometrial cancer until proven otherwise.
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Cervical motion tenderness: This is a common symptom of pelvic inflammatory disease (PID) that usually is caused by gonorrhea or chlamydia. This is an important diagnosis to exclude, especially in young nulliparous women, because it can lead to pelvic adhesions and infertility.
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Adnexal tenderness or masses: This is especially concerning in patients older than 40 years. Ovarian cancer may present with intermenstrual bleeding as its only symptom. Rare but deadly ovarian tumors also can present in teenage girls. Any suspicion of an adnexal mass should prompt an immediate pelvic ultrasound.
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Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.
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Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.
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Flow chart continued from the previous image.
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Flow chart continued from the previous 2 images.
