Laboratory Tests and Ancillaries
Laboratory tests are not always recommended but may be useful in excluding other diagnoses. A complete blood count (CBC) should be carried out on all women with heavy menstrual bleeding to assess the presence of anemia and, in parallel with HMB treatment, to monitor response. Coagulation studies should be done in patients with a history suggestive of a coagulation disorder. Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT) may be initial screening tests for suspected bleeding disorders. This usually includes assessment of quantity and activity of von Willebrand’s factor (VWF) and factor VIII. Von Willebrand (VWD) is seen in the majority of cases.
Ferritin level is the most accurate test for determining iron deficiency anemia (IDA) but is not routinely requested; a normal level does not rule out heavy menstrual bleeding. Hormonal examination (eg luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) should not be routinely performed in women with heavy menstrual bleeding. A thyroid function test is recommended only in patients with signs and symptoms suggestive of thyroid disease. Hypothyroidism can cause menstrual irregularities and heavy menstrual bleeding. A pregnancy test should be done if pregnancy is a possibility or suspected.
Endometrial Biopsy
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Endometrial biopsy should be done to exclude endometrial cancer or atypical hyperplasia with 91% sensitivity. This is recommended in women ≥45 years old with continuous intermenstrual bleeding or with treatment failure, in younger obese patients with prolonged periods of anovulation or unopposed estrogen stimulation, in women with ≥12-mm transvaginal endometrial thickness, or in younger women with endometrial cancer risk factors.
Imaging
Imaging studies should be carried out in patients with abdominally palpable uterus, pelvic mass of unknown origin seen on vaginal exam, or failed medical treatment.
Ultrasound (US)
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An ultrasound is the primary diagnostic imaging used for identifying structural abnormalities that is 60% sensitive and 93% specific. This is useful if physical exam findings are abnormal or doubtful due to the woman's habitus or if reassurance and no treatment are needed. An ultrasound may be required in women who have an increased risk of malignancy based on history (eg with risk factors including a personal or family history of endometrial or colorectal cancer, older age, use of unopposed estrogen or Tamoxifen, obesity, young age at menarche or older age at menopause, nulliparity, diabetes, or endometrial hyperplasia); features suggestive of pathology on examination (eg enlarged or irregular uterus suggestive of fibroids); symptoms including dyspareunia, severe dysmenorrhea, or secondary HMB; and not responding to a reasonable duration of medical management. An ultrasound can also detect small ovarian cysts, leiomyoma, endometrial hyperplasia, or carcinoma. Transvaginal ultrasound is the first-line imaging procedure for abnormal uterine bleeding. Transvaginal US depicts the endometrium better than transabdominal US.
Hysteroscopy
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Hysteroscopy is used when the ultrasound results show intrauterine abnormalities or are inconclusive, or when initial treatment has failed. This detects intrauterine lesions definitively with 86% sensitivity and 99% specificity. Saline infusion sonohysteroscopy/sonohysterography/infusion sonography detects fibroids with a sensitivity of 87% and specificity of 92% and polyps with a sensitivity of 86% and specificity of 81%. Hysteroscopy should not be used as an initial diagnostic tool.
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging is used if menstrual bleeding is secondary to leiomyomas and myomectomy is contemplated; the ultrasound is uncertain in differentiating adenomyosis from leiomyomas when malignancy and adnexal pathology are suspected, or when the ultrasound or instrumentation of the uterus (eg congenital anomalies) cannot be performed. Magnetic resonance imaging should not be used as an initial diagnostic tool.