HISTORY MENORRHAGIA DDx: (to keep in mind while taking history) Local anatomical Regular bleeding: fibroids, endometrial/cervical

cal polyp, adenomyosis, endometriosis Irregular bleeding: endometrial/cervical carcinoma, ovarian tumour, chronic PID Systemic thyroid, haematological disorder e.g. von Willebrands, warfarin therapy Unexplained - dysfunctional uterine bleeding (DUB) 1) Name, Age (>40 risk of fibroids), Ethnicity (Afro-Caribbean risk of fibroids) 2) PC + Duration of problem 3) Menstrual Hx: Age of menarche Duration of cycle + Bleeding days Regular/Irregular cycle No. of sanitary towels/tampons used per day + Double padding? Passing any clots or flooding? 1st day of LMP Post-coital bleeding (PCB)? Intermenstrual bleeding (IMB)? Post-menopausal bleeding (PMB) if relevant to age 4) Associated symptoms: Pain during periods (dysmenorrhoea) Feeling tired/fatigued (anaemia due to losing blood) Urinary symptoms dysuria (large fibroid pressure effect) Bowel symptoms constipation (large fibroid pressure effect) 5) Gynae Hx: Last smear date, results, any previous abnormalities? Vaginal discharge 6) Sexual & Contraception Hx: Dyspareunia Type of contraception IUD specifically 7) Obs Hx: (perhaps can wait till later because not really related to menorrhagia?) Been pregnant? No. of pregnancies? Any complications? TOP/Miscarriage 8) PMH: Bleeding diathesis? Thyroid problems? Cancer? cervical, endometrial

9) FH: Fibroids? Bleeding diatheses? Thyroid problems? Cancer? cervical, endometrial 10) DH: Warfarin/Heparin? Recent antibiotics can interact with OCP leading to onset of normal erratic menstruation 11) SH: Smoking Alcohol

History
A detailed menstrual history to establish the nature and extent of uterine bleeding is crucial in determining the likelihood of an underlying cause and the extent of the impact on the patient's quality of life. Use of a pictorial blood assessment chart (PBAC) may be helpful. [16]

Age. In the first year of menarche, as well as in perimenopausal years, heavy bleeding associated with irregular cycles may be due to anovulatory bleeding. Cycle regularity. Anovulatory bleeding is a common physiological manifestation in the perimenarchal and perimenopausal extremes of the reproductive cycle. Irregular cycle length and absent signs of ovulation (no cervical mucus thinning, no breast tenderness, no mittelschmerz pain) may suggest that abnormal bleeding is due to anovulatory cycles. Periods of amenorrhoea may be interspersed between bleeding. Metrorrhagia (irregular menstrual bleeding) may be present due to endometrial polyps. Parity. Endometrial adenomyosis is associated with multiple pregnancies. Fatigue, dyspnoea on exertion, and orthostatic symptoms may suggest anaemia. Cold intolerance, weight gain, and hair and skin changes may suggest hypothyroidism. Bleeding diathesis. Easy bruising, bleeding gums, epistaxis, and prolonged bleeding after minor wounds may suggest a coagulation disorder. If menstrual bleeding has been excessive since the onset of menses, consideration for a bleeding disorder is heightened. There may be a family history of bleeding disorders. Unexplained weight loss raises concern about malignancy or chronic illness. Medication history. Possible iatrogenic causes include use of anticoagulants, tamoxifen, hormonal therapies, and copper intrauterine devices. Herbal supplements (e.g., ginseng, ginkgo, and soya) may cause menstrual irregularities by altering oestrogen levels or coagulation parameters. [14]

Laboratory evaluation

A serum or urine pregnancy test is the first test performed in women of childbearing age. A nFBC is useful to evaluate for the presence of anaemia.

TSH is indicated when weight gain, cold intolerance, and other factors raise suspicion for hypothyroidism. It is reasonable to consider this test in women of childbearing age, even without the classic symptoms. Serum free testosterone may be indicated when signs of androgen excess such as hirsutism, worsened acne, or mood changes are present. PT/aPTT may indicate coagulopathy, but is rarely sufficient to rule-in most bleeding disorders. Specific testing for von Willebrand disease (vWd) includes von Willebrand factor antigen (vWF:Ag), ristocetin cofactor activity (vWF:RCoF), and factor VIII activity. [17] The American College of Obstetricians and Gynecologists (ACOG) recommends testing for vWd in the following situations: [18] adolescents presenting with severe menorrhagia; before hormonal therapy is initiated; adult women with menorrhagia without another cause; when menorrhagia is the only indication for a hysterectomy.

Imaging
Imaging of the uterine cavity is an integral part of evaluating excessive uterine bleeding. Imaging will be needed when there is suspicion of underlying structural lesions, such as uterine leiomyomas [19] or polyps. Ultrasound is helpful in excluding other uterine wall and uterine cavity disorders, such as endometrial polyps and fibroids, as underlying causes of uterine bleeding. An endometrial thickness of >15 mm usually warrants further evaluation with endometrial biopsy followed by hysteroscopy in the surgery, with directed endometrial biopsy if the blind endometrial biopsy is negative. Other, less-invasive tests include hysterosalpingography (HSG) and ultrasound examination with saline sonohysterography of the uterus. Presence of active bleeding contraindicates HSG and sonohysterography. View imageView image

Endometrial biopsy
Endometrial biopsy is done to diagnose underlying serious pathology, such as endometrial hyperplasia and endometrial cancer. The histological type of endometrium (proliferative or secretory) may help in confirming the diagnosis of anovulatory or ovulatory dysfunctional uterine bleeding (DUB), respectively. This may be of value in determining the most appropriate type of treatment. [11] DUB associated with very thick endometrium warrants this procedure. It can be done in the surgery, followed by hysteroscopic visualisation of the uterine cavity for definitive diagnosis and possibly dilatation and curettage (D and C). [11]

Hysteroscopy
Hysteroscopy is recommended when endometrial cavity pathology is suspected (e.g., endometrial polyp, submucous leiomyomas, or endometrial cancer). With pathological examination, it is the most sensitive and specific diagnostic test for diagnosing uterine cavity disorders. [11] It can be performed in patients with active bleeding, although adequate visualisation may be more difficult when this is the situation. Sampling endometrial cavity tissue is sometimes indicated, particularly in cases at high risk of endometrial hyperplasia or endometrial cancer. [11] Symptomatic postmenopausal polyps should be excised for histologic assessment. [20]