What diagnostics would be ordered in the Emergency Room (ER) for a patient with menorrhagia (heavy menstrual bleeding) but no dysmenorrhea (pain)?

From the Guidelines

For a patient presenting to the ER with heavy menstrual bleeding without pain, I would order a complete blood count (CBC) to assess for anemia and platelet abnormalities, coagulation studies including PT/INR and PTT to evaluate for bleeding disorders, a pregnancy test to rule out pregnancy-related complications, and a basic metabolic panel to assess overall health status. A pelvic ultrasound should be performed to evaluate for structural abnormalities such as fibroids, polyps, or endometrial hyperplasia, as recommended by the American College of Radiology 1. Thyroid function tests (TSH, free T4) are important as thyroid dysfunction can cause menstrual irregularities, and should be considered in the initial workup 1. If the patient is of appropriate age, consider endometrial biopsy to rule out endometrial cancer, especially in patients over 45 or with risk factors, as suggested by the American College of Obstetricians and Gynecologists 1. Iron studies including ferritin, iron, and total iron binding capacity should be ordered to assess iron stores if anemia is present. These tests are crucial for determining the underlying cause of the bleeding, which could range from hormonal imbalances to structural abnormalities or systemic conditions, and are in line with the recommendations for the evaluation of abnormal uterine bleeding 1. Prompt diagnosis allows for appropriate management, which may include hormonal therapy, antifibrinolytics like tranexamic acid, or surgical interventions depending on the cause and severity of bleeding. Some key points to consider in the diagnostic workup include:

• Medical history and physical examination to identify potential causes of bleeding
• Laboratory tests such as CBC, coagulation studies, and thyroid function tests to evaluate for underlying conditions
• Imaging studies such as pelvic ultrasound to assess for structural abnormalities
• Endometrial biopsy to rule out endometrial cancer in patients at risk
• Iron studies to assess iron stores and guide management of anemia.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnostic Approach

To diagnose heavy menstrual bleeding in a patient with no pain, the following steps can be taken:

• Obtain a thorough menstrual and gynaecological history to identify any underlying causes of bleeding 2, 3, 4
• Perform a pelvic examination to rule out any underlying pathology 2, 3, 5
• Order laboratory tests, including:
  • Complete blood count (CBC) to check for anemia 5
  • Pregnancy test to rule out pregnancy 5
  • Coagulation studies to check for any bleeding disorders 2, 3
• Consider imaging studies, such as pelvic ultrasound, to evaluate the uterus and ovaries 3, 5

Laboratory Tests

The following laboratory tests may be ordered to evaluate heavy menstrual bleeding:

• Hemoglobin and hematocrit to check for anemia 5
• Ferritin level to check for iron deficiency 2
• Coagulation studies, such as prothrombin time (PT) and partial thromboplastin time (PTT), to check for any bleeding disorders 2, 3
• Bleeding score to distinguish those women who require additional haematological investigations 3

Imaging Studies

The following imaging studies may be ordered to evaluate heavy menstrual bleeding:

• Pelvic ultrasound to evaluate the uterus and ovaries 3, 5
• Hysteroscopy or hysterosonography to evaluate the uterine cavity 5
• MRI may not be recommended as a first-line procedure, but may be considered in certain cases 5