What is the initial workup and treatment for a patient presenting with menorrhagia (heavy menstrual bleeding)?

Initial Workup and Treatment for Menorrhagia (Heavy Menstrual Bleeding)

Transvaginal ultrasound combined with a thorough history and laboratory testing is the most appropriate initial workup for patients presenting with menorrhagia, followed by targeted treatment based on the identified cause. 1

Initial Diagnostic Workup

History and Physical Examination

• Focus on bleeding characteristics (duration, frequency, volume), associated symptoms, and risk factors for structural or systemic causes 2
• Complete physical examination including pelvic examination to identify obvious anatomical causes 1

Laboratory Testing

• Complete blood count (CBC) - to assess for anemia and thrombocytopenia 2, 3
• Pregnancy test - to rule out pregnancy-related bleeding 3
• Thyroid function tests - hypothyroidism can cause menorrhagia 2, 3
• Coagulation studies (PT, aPTT, bleeding time) - to identify bleeding disorders 2, 4
• Consider additional tests based on clinical suspicion:
  • Liver and renal function tests 2
  • Hormone levels (FSH, LH, estradiol, prolactin) if endocrine disorder suspected 2, 3

Imaging

• Transvaginal ultrasound (TVUS) combined with transabdominal ultrasound with Doppler is the most appropriate initial imaging study 1
• If TVUS cannot adequately visualize the entire uterus or endometrium (due to patient factors, uterine position, or pathology):
  • Sonohysterography if polyp is suspected 1
  • MRI of pelvis without and with contrast if comprehensive evaluation needed 1

Tissue Sampling

• Endometrial biopsy/sampling should be performed to rule out endometrial hyperplasia or cancer, particularly in women with risk factors or those over 40 5, 6
• Consider hysteroscopy for direct visualization and targeted biopsy if structural abnormalities are suspected 6

Common Causes of Menorrhagia

Structural Causes

• Uterine fibroids (leiomyomas) - most common in women under 40 6
• Endometrial polyps - more common in women over 40 6
• Adenomyosis 5, 6
• Endometrial hyperplasia or cancer 5, 6

Systemic/Medical Causes

• Coagulation disorders (e.g., von Willebrand disease) 2, 4
• Endocrine disorders (thyroid dysfunction, PCOS) 2, 3
• Medications (anticoagulants, hormonal treatments) 2
• Liver or renal disease 2

Dysfunctional Uterine Bleeding

• Diagnosis of exclusion when no structural or systemic cause is identified 4
• Often related to hormonal imbalances or anovulation 3

Treatment Approach

Medical Treatments

First-Line Options

• Hormonal treatments:

  • Levonorgestrel intrauterine system (LNG-IUS) - reduces bleeding by 70-90%, comparable to surgical options 5, 6
  • Combined oral contraceptives - regulate cycles and reduce bleeding 3, 6

• Non-hormonal options:

  • Tranexamic acid - reduces bleeding by 40-60% during menstruation 5, 6
  • NSAIDs (e.g., mefenamic acid, ibuprofen) - reduce bleeding by 20-40% 3, 6

Second-Line Options

• Progestins (oral) - less effective for women who ovulate normally 6
• GnRH agonists - for short-term use due to side effects 2, 3

Surgical Treatments

• Consider when medical management fails or is contraindicated 6
• Options include:
  • Hysteroscopic procedures (polypectomy, myomectomy for submucous fibroids) 5
  • Endometrial ablation - destroys the endometrial lining 5, 6
  • Hysterectomy - definitive treatment but reserved for when other options fail 5, 6

Special Considerations

• In women with severe thrombocytopenia, progestin-only contraceptives may be useful in treating menorrhagia, but DMPA should be used with caution due to unpredictable bleeding patterns 1
• Emergency gynecology consultation is warranted for patients with active heavy bleeding causing significant anemia or hemodynamic instability 1
• For patients with menorrhagia requiring blood typing and cross-matching, consider this as part of the initial workup if anemia is severe 1

Treatment Algorithm

1. Assess severity and impact on quality of life
2. Rule out pregnancy and malignancy
3. Identify structural causes with imaging
4. Treat based on etiology:
   • For structural causes: Target the specific abnormality
   • For systemic causes: Treat the underlying condition
   • For dysfunctional bleeding: Start with hormonal or non-hormonal medical options
5. If initial treatment fails after 3 months, consider alternative medical therapy or surgical options