What is the initial workup and management for a patient with heavy menstrual bleeding?

Initial Workup and Management for Heavy Menstrual Bleeding

The initial workup for heavy menstrual bleeding should include pregnancy test, complete blood count, thyroid function tests, prolactin levels, and transvaginal ultrasonography, followed by first-line treatment with a levonorgestrel-releasing intrauterine system (LNG-IUS) which provides a 71-95% reduction in menstrual blood loss. 1

Diagnostic Approach

Classification and Initial Assessment

• Use the PALM-COEIN classification system to categorize causes:
  • Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
  • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 1

Laboratory Tests

1. Pregnancy test - rule out pregnancy-related bleeding
2. Complete blood count - assess for anemia
3. Thyroid function tests - identify thyroid dysfunction
4. Prolactin levels - evaluate for hyperprolactinemia
5. Blood typing and cross-matching - if severe bleeding is present 2, 1

Imaging and Additional Testing

1. Transvaginal ultrasonography - evaluate for structural causes 1
2. Saline infusion sonohysterography - better visualization of intracavitary lesions 1
3. Endometrial biopsy - for women ≥35 years with recurrent anovulation or risk factors for endometrial hyperplasia/cancer 1

Clinical Indicators of Potential Bleeding Disorders

• Clots ≥1 inch in diameter
• "Flooding" (changing pad/tampon more than hourly)
• Low ferritin
• Personal or family history of bleeding disorders 3

Management Options

First-Line Treatment

• Levonorgestrel-releasing intrauterine system (LNG-IUS) - most effective medical treatment with 71-95% reduction in menstrual blood loss 1
  • Mirena (20 μg/day) is more effective than Kyleena (14 μg/day) for bleeding control 1

Other Medical Options (in order of effectiveness)

1. Combined hormonal contraceptives - effective for reducing menstrual blood loss; can be used in extended or continuous regimens 1
2. Tranexamic acid - provides 26-60% reduction in menstrual blood loss; take only during menstruation; contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1
3. Oral progestins - most effective when given for 21 days per month; option when estrogen is contraindicated 1
4. NSAIDs - modest reduction in menstrual blood loss; recommended for short-term treatment (5-7 days) during menstruation 1, 4

Treatment Selection Algorithm

1. For women desiring contraception: LNG-IUS or combined hormonal contraceptives 1
2. For women not needing contraception: Cyclic progestins 1
3. For perimenopausal women: Cyclic progestin or cyclic estrogen with progestin 1
4. For women with bleeding disorders or on anticoagulation: Progestin-only methods or tranexamic acid 5

When to Consider Surgical Management

• After failed medical management (3-6 month adequate trial)
• Options include:
  • Endometrial ablation - for women with completed childbearing
  • Hysterectomy - definitive treatment for refractory cases 1

Common Pitfalls to Avoid

1. Overlooking bleeding disorders - Heavy menstrual bleeding with flooding or prolonged menses should prompt evaluation for coagulation disorders 3
2. Inadequate trial of medical therapy - Allow 3-6 months before considering treatment failure 1
3. Missing structural causes - Ensure proper imaging is performed before attributing bleeding to hormonal causes
4. Ignoring patient preferences - Treatment selection should consider the patient's desire for fertility and contraception 5

By following this structured approach to diagnosis and management, most patients with heavy menstrual bleeding can achieve significant improvement with medical therapy, potentially avoiding surgical intervention.