From the Guidelines
Menorrhagia is diagnosed through a comprehensive approach that includes clinical evaluation, patient history, physical examination, and laboratory tests, with a focus on identifying underlying structural or nonstructural causes, as outlined in the ACR Appropriateness Criteria for abnormal uterine bleeding 1. The diagnostic process begins with a detailed menstrual history, emphasizing the frequency, duration, and volume of bleeding, as well as the impact on daily life and potential symptoms of anemia.
- A thorough physical examination, including a pelvic exam, is essential to identify anatomical abnormalities such as fibroids or polyps.
- Laboratory tests, including a complete blood count, thyroid function tests, coagulation studies, and pregnancy tests when appropriate, are crucial in assessing the patient's overall health and potential underlying conditions.
- Imaging studies like transvaginal ultrasound can help detect structural abnormalities, while endometrial biopsy may be necessary to rule out hyperplasia or malignancy, particularly in women over 35 or those with risk factors, as suggested by the ACR Appropriateness Criteria 1. Key considerations in the diagnosis of menorrhagia include:
- The PALM-COEIN classification system, which categorizes causes of abnormal uterine bleeding into structural (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia) and nonstructural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) etiologies, as described in the ACOG guidelines 1.
- The potential for underlying conditions such as polycystic ovary syndrome, thyroid disorders, or bleeding disorders to contribute to heavy menstrual bleeding. By taking a comprehensive and structured approach to diagnosis, healthcare providers can effectively identify the underlying causes of menorrhagia and develop an appropriate treatment plan to improve patient outcomes and quality of life.
From the Research
Diagnosis of Menorrhagia
To diagnose menorrhagia, the following steps can be taken:
- A pelvic examination should be performed on all patients 2
- If the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out 2
- Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma 2
- Sonohysterography or hysteroscopy can be used to diagnose endometrial polyps and fibroids 2
- A differential diagnosis approach can be used to guide the types of historical data obtained from the patient, focus the physical examination, and alert the practitioner to the most appropriate laboratory and radiologic evaluation 3
- The platelet function analyser (PFA-100) may be useful in stratifying women with menorrhagia for further von Willebrand testing 4
Diagnostic Considerations
When evaluating a patient with menorrhagia, the following should be considered:
- Inherited bleeding disorders, such as von Willebrand's deficiency and platelet function defects, are prevalent in women presenting with menorrhagia 5, 4
- Pregnancy-related causes, hormonal problems, iatrogenic etiologies, mechanical intrauterine disorders, infections of the lower genital tract, and gynecologic cancers should be included in the differential diagnosis 3
- A history and physical examination, including a pelvic examination, may reveal the cause of menorrhagia 3, 6
- Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected, as endometriosis is a common cause of secondary dysmenorrhea 6