From the Guidelines
The initial workup for a 45-year-old female presenting with menstrual concerns should begin with a comprehensive history and physical examination, including a thorough evaluation of menstrual changes, medication use, medical conditions, and family history, as recommended by the most recent guidelines 1. The history should focus on the specific menstrual changes (such as frequency, duration, flow volume, and associated symptoms), and a physical examination including vital signs, weight, thyroid examination, and pelvic examination should be performed.
- Laboratory testing should include:
- A complete blood count to assess for anemia
- Thyroid function tests (TSH, free T4)
- Pregnancy test if appropriate
- Depending on the specific presentation, additional tests may include:
- Follicle-stimulating hormone (FSH) and estradiol levels to evaluate for perimenopause
- Prolactin levels if galactorrhea is present
- Endometrial sampling if abnormal uterine bleeding is concerning for hyperplasia or malignancy Pelvic ultrasonography is often indicated to evaluate the endometrial thickness and identify structural abnormalities such as fibroids or polyps, as suggested by the American College of Radiology 1. For heavy menstrual bleeding, initial management options include nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen 600mg three times daily during menses, hormonal contraceptives such as combined oral contraceptives (30-35mcg ethinyl estradiol with progestin) daily, or the levonorgestrel intrauterine system, as recommended by the U.S. Selected Practice Recommendations for Contraceptive Use 1. This comprehensive approach allows for accurate diagnosis and appropriate management of menstrual disorders, which may range from normal perimenopausal changes to pathological conditions requiring specific interventions.
From the Research
Initial Workup for Menstrual Concerns
The initial workup for a 45-year-old female presenting with menstrual concerns involves a comprehensive approach to identify the underlying cause of the symptoms. The following steps are recommended:
- Obtain a detailed medical history, including menstrual history, to identify any potential causes of abnormal uterine bleeding 2, 3
- Perform a physical examination, including a pelvic exam, to assess for any anatomical abnormalities or signs of infection 2, 4
- Order laboratory tests, such as:
- Complete Blood Count (CBC) to evaluate for anemia 2, 3
- Serum pregnancy test to rule out pregnancy 2, 3
- Thyroid function tests to evaluate for thyroid disorders 2, 3
- Liver and kidney function tests to evaluate for chronic diseases 2, 3
- Follicle-stimulating hormone (FSH) and prolactin levels to evaluate for endocrine disorders 2, 3
- Consider imaging studies, such as ultrasound or hysteroscopy, to evaluate the uterus and identify any anatomical abnormalities 2
Additional Considerations
- Evaluate for bleeding disorders, such as coagulation disorders, and consider referral to a hematologist if suspected 5
- Consider the use of medical treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs), hormonal therapy, or antifibrinolytics, to manage symptoms 2, 5, 6, 3
- Surgical options, such as dilation and curettage (D&C) or hysterectomy, may be considered if medical management is unsuccessful or if an anatomical abnormality is identified 2, 3