Heavy Menstrual Bleeding Initial Assessment

The main goals of diagnosing heavy menstrual bleeding are to confirm heavy menstrual bleeding, rule out endometrial hyperplasia or cancer, and identify other pathology.

In history taking, one should be able to identify the nature of bleeding, the presence of any underlying pathology, and other features (including family history of pathology) that may determine future action or treatment. It is important to inquire about the frequency, duration, amount of bleeding, and timing of changes in menstrual patterns.

Features suggestive of excessive blood flow include changes in sanitary pads and tampons every 1-2 hours or at night; consuming more than 20 pads or tampons/cycles; passing a >1-inch blood clot; bleeding for more than 7 days; and with or without iron-deficiency anemia (IDA). Intermenstrual and postcoital bleeding may be suggestive of an anatomical cause. Menstrual blood loss as a problem should be asked of the patient since direct (alkaline hematin) or indirect (pictorial blood loss assessment chart) measurement is not routinely recommended.

Coagulation disorder may be suggested by the following: Heavy menstrual bleeding since menarche; history of easy bruising (bruises >5 cm) or bleeding from mucosal surfaces (epistaxis once a month); personal or family history of coagulopathy; history of postpartum hemorrhage; and bleeding from surgery or dental procedures. Pressure symptoms (eg urinary and bowel symptoms) may indicate a fibroid. Abdominopelvic pain may be due to infections or structural lesions.

Evaluation should be done through observation, abdominal palpation, visualization of the cervix, and bimanual (internal) exam and identifies any underlying pathology, indication for further investigation, and possible treatment options. The size of the uterus and location of fibroids, if present, should be assessed. Assessment of hemodynamic instability (eg orthostatic blood pressure, pulse rate) should be done in the presence of acute heavy menstrual bleeding. Examine for the presence of anemia, coagulopathy, or thyroid disease.