Laboratory Studies
CBC count
The CBC count may be used as a baseline for hemoglobin and hematocrit or to rule out anemia. Use the platelet count in conjunction with a peripheral smear if a coagulation defect is suspected.
Iron studies
Total iron-binding capacity (TIBC) and total iron are used to assess iron stores.
Coagulation factors
These studies are used to rule out von Willebrand disease; ITP; and factor II, V, VII, or IX deficiency. These tests should be ordered sparingly because they are expensive tests for rare disorders (usually in the adolescent age group). [25]
Human chorionic gonadotropin
Pregnancy remains the most common cause of abnormal uterine bleeding in patients of reproductive age. Bleeding usually denotes threatened abortion, incomplete abortion, or ectopic pregnancy.
Thyroid function tests and prolactin level
These tests can rule out hyperthyroidism or hypothyroidism and hyperprolactinemia. All of these conditions cause ovarian dysfunction leading to possible menorrhagia.
Liver function and/or renal function tests
Order liver function tests (LFTs) when liver disease is suspected, such as in persons with alcoholism or hepatitis.
BUN and creatinine tests assess renal function.
Dysfunction of either organ can alter coagulation factors and/or the metabolism of hormones.
Hormone assays
LH, FSH, and androgen levels help diagnose patients with suspected PCOS.
Adrenal function tests (eg, cortisol, 17-alpha hydroxyprogesterone [17-OHP]) delineate hyperandrogenism in women with suspected adrenal tumors. Congenital adrenal hyperplasia (CAH) is diagnosed primarily by testing 17-OHP.
Other tests
Papanicolaou (Pap) smear test results for cervical cytology should be current.
Cervical specimens should be obtained if the patient is at risk for an infection.
Imaging Studies
Small, focal, irregular, or eccentrically located endometrial lesions may be missed by an in-office endometrial biopsy (EMB). The findings yielded from pelvic examinations may be limited if patients are obese. These limitations can lead to further imaging studies to inspect the uterus, endometrium, and/or adnexa.
Pelvic ultrasound is the best noninvasive imaging study to assess uterine shape, size, and contour; endometrial thickness; and adnexal areas. [26]
Sonohysterography (saline-infusion sonography): Fluid infused into the endometrial cavity enhances intrauterine evaluation. One advantage is the ability to differentiate polyps from submucous leiomyomas (ie, fibroids).
MRI as a second-line test is to be used when the diagnosis from pelvic ultrasonography is unclear. In fact, adenomyosis is best diagnosed by MRI, although it can be detected with transvaginal ultrasonography. [27]
Procedures
Because routine EMB and conventional imaging studies may miss small or laterally displaced lesions, superior methods of assessment must be used in high-risk patients. In addition, performing an in-office biopsy or imaging studies may be limited by patient problems such as obesity or cervical stenosis.
Hysteroscopy
This can be done in the office but may require anesthesia if the patient has a low pain tolerance or adequate visualization is not obtainable.
This technique is used to directly visualize the endometrial cavity by close contact. A biopsy sample should be taken, regardless of the endometrial appearance. The histologic diagnosis is missed in less than 2% of patients who undergo hysteroscopy with directed biopsy. [28]
Endometrial biopsy
This procedure is used in women who are at risk for endometrial carcinoma, polyps, or hyperplasia.
High-risk patients who should be biopsied include those with hypertension, diabetes, chronic anovulation (eg, PCOS), obesity, atypical glandular cells (AGUS) on Pap smear, new-onset menorrhagia, and those older than 70 years or any woman older than 35 years with new-onset irregular bleeding (especially if nulliparous).
EMB findings are used to assess the stage and proliferation of the endometrial stroma and glands. Many studies have been done to compare the results of EMB and dilatation and curettage (D&C). Both tests are accepted as equal in value and are approximately 98% accurate. [28]
Histologic Findings
Understanding EMB results is essential for any physician treating menorrhagia.
If no tissue is returned after an EMB is performed, most likely the endometrium is atrophic and requires estrogen.
Simple proliferative endometrium is normal and does not require treatment.
Endometrial hyperplasia (except atypical adenomatous) requires progesterone on timed 12-day regimens outlined in the Treatment. Endometrial hyperplasia with atypia (especially atypical adenomatous hyperplasia) generally is considered equivalent to an intraepithelial malignancy, and hysterectomy usually is advised.
Any biopsy that reveals endometrial carcinoma should prompt immediate referral to a gynecologic oncologist for treatment outlined by current oncology protocols associated with the grade and stage of the cancer.
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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.
