What is the workup for prolonged menstrual bleeding, also known as menorrhagia (prolonged or heavy menstrual bleeding)?

From the Guidelines

The workup for prolonged menstrual bleeding should begin with a thorough history and physical examination, followed by laboratory tests and imaging studies to identify underlying causes, and treatment should be guided by the most recent evidence, which recommends considering hormonal treatment, such as combined oral contraceptives, or non-hormonal options like tranexamic acid or NSAIDs, as stated in the 2024 US Selected Practice Recommendations for Contraceptive Use 1. The initial step in evaluating prolonged menstrual bleeding involves a comprehensive history and physical examination to identify potential underlying causes, such as fibroids, polyps, or hormonal imbalances. Laboratory tests, including complete blood count, pregnancy test, thyroid function tests, and coagulation studies, should be performed to rule out other conditions that may be contributing to the bleeding.

• Transvaginal ultrasound is the first-line imaging study to evaluate the endometrium and identify structural abnormalities like fibroids or polyps, as recommended by the American College of Radiology 1.
• If the patient is over 35 or at risk for endometrial hyperplasia, endometrial sampling should be performed to rule out malignancy or hyperplasia, as suggested by the American College of Obstetricians and Gynecologists 1. Additional testing may include saline infusion sonohysterography or hysteroscopy to better visualize the uterine cavity.
• Treatment depends on the underlying cause, but may include hormonal options like combined oral contraceptives (20-30 μg ethinyl estradiol) daily for 3 months, or levonorgestrel IUD insertion, as recommended by the 2024 US Selected Practice Recommendations for Contraceptive Use 1.
• Non-hormonal options include tranexamic acid 1300 mg three times daily during menses or NSAIDs like ibuprofen 600 mg every 6 hours during bleeding, as suggested by the American College of Radiology 1. The workup is essential because prolonged bleeding can lead to anemia, affect quality of life, and may signal underlying pathology including malignancy.
• Surgical interventions like endometrial ablation or hysterectomy are considered for women who have completed childbearing and have failed medical management, as recommended by the American College of Obstetricians and Gynecologists 1.

From the Research

Prolonged Menstrual Bleeding Workup

Prolonged menstrual bleeding, also known as heavy menstrual bleeding (HMB), is a common complaint among reproductive-aged women. The workup for HMB typically involves a comprehensive medical history, physical examination, and laboratory tests to rule out underlying causes.

Medical Management of HMB

The medical management of HMB usually provides effective control of symptoms, irrespective of the underlying cause 2. The following medical treatments are available for HMB:

• Levonorgestrel-releasing intrauterine system (LNG-IUS): reduces menstrual blood loss by up to 90% 3
• Combined hormonal contraceptives: effective in reducing HMB, but may have hormonal side effects 2
• Tranexamic acid: reduces menstrual blood loss, but may have gastrointestinal side effects 4
• Oral progestogens: may be effective in reducing HMB, but may have hormonal side effects 4
• Nonsteroidal anti-inflammatory drugs (NSAIDs): may be effective in reducing HMB, but may have gastrointestinal side effects 5

Comparison of Medical Treatments

Studies have compared the effectiveness of different medical treatments for HMB:

• LNG-IUS vs. oral medroxyprogesterone acetate: LNG-IUS reduces menstrual blood loss more effectively and has a higher likelihood of treatment success 6
• LNG-IUS vs. other medical therapies: LNG-IUS may improve HMB and quality of life compared to other medical therapies 3
• Cyclical progestogens vs. other medical therapies: cyclical progestogens may be inferior to other medical therapies in reducing menstrual blood loss 4

Key Findings

Key findings from the studies include:

• LNG-IUS is a highly effective treatment for HMB, reducing menstrual blood loss by up to 90% 3
• Combined hormonal contraceptives and tranexamic acid are also effective in reducing HMB, but may have side effects 2, 4
• Oral progestogens may be effective in reducing HMB, but may have hormonal side effects 4
• NSAIDs may be effective in reducing HMB, but may have gastrointestinal side effects 5