What are the diagnostic steps and treatment options for abnormal heavy menstrual bleeding?

Diagnostic Approach to Abnormal Heavy Menstrual Bleeding

Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study for identifying structural causes of abnormal uterine bleeding, and should be performed after confirming hemodynamic stability and ruling out pregnancy. 1, 2

Immediate Assessment

• Check hemodynamic stability first – measure orthostatic blood pressure and pulse, particularly if bleeding saturates a large pad or tampon hourly for at least 4 hours 2, 3
• Pregnancy test (β-hCG) is mandatory in all reproductive-age women before proceeding with further workup 2, 4
• Complete blood count to assess for anemia and platelet abnormalities 5, 3
• Serum ferritin to evaluate iron deficiency from chronic blood loss 3

Structural Causes (PALM)

The PALM-COEIN classification divides causes into structural (PALM) and non-structural (COEIN) etiologies 1, 2:

Polyps

• Endometrial polyps are particularly common in women over 40 years of age 2, 6
• Diagnosed via transvaginal ultrasound, though sonohysterography or hysteroscopy provides superior detection 1, 6

Adenomyosis

• Frequent cause in premenopausal women that appears on imaging studies 1, 2
• Identified on transvaginal ultrasound or MRI when ultrasound is inconclusive 1

Leiomyoma (Fibroids)

• Most common structural cause in women under 40 years of age with heavy menstrual bleeding 2, 6
• Submucosal fibroids specifically cause abnormal bleeding patterns 1, 4

Malignancy and Hyperplasia

• Endometrial cancer is the most serious etiology and primary concern in postmenopausal women with bleeding 1, 2
• Endometrial biopsy is indicated for women ≥35 years with recurrent anovulation, women <35 years with endometrial cancer risk factors, or excessive bleeding unresponsive to medical therapy 4

Non-Structural Causes (COEIN)

Coagulopathy

• Von Willebrand disease is the most common inherited bleeding disorder causing menorrhagia 4, 3
• Screen with TSH, prolactin levels, and consider hematology referral if bleeding disorder suspected 2, 3
• Approximately 70% of women on anticoagulation experience heavy menstrual bleeding 2

Ovulatory Dysfunction

• Chronic anovulation leads to irregular bleeding and prolonged unopposed estrogen stimulation 4
• Causes include polycystic ovary syndrome, uncontrolled diabetes, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics 4

Endometrial

• Primary endometrial disorders involve molecular deficiencies in regulation of endometrial hemostasis 1, 2

Iatrogenic

• Exogenous gonadal steroids and intrauterine devices commonly cause bleeding 1, 2
• Unscheduled spotting or heavy bleeding is common during first 3-6 months of copper IUD use 1

Not Yet Classified

• Bleeding disorder of unknown cause (BDUC) represents up to 60-70% of patients investigated for mild-moderate bleeding disorders with normal standard hemostatic tests 1

Imaging Algorithm

First-line: Combined transabdominal and transvaginal ultrasound with Doppler 1, 2

Second-line (if ultrasound incomplete): Saline infusion sonohysterography or hysteroscopy for better visualization of endometrial cavity and polyps 1, 4, 5

MRI is not recommended as first-line but may be used when ultrasound cannot adequately visualize the uterus due to patient body habitus, uterine position, or presence of large fibroids 1, 5

Common Pitfalls

• Transvaginal ultrasound has limitations – uterine position, body habitus, and presence of adenomyosis or leiomyomas can prevent complete visualization 1
• Patient's subjective assessment of blood loss does not reflect true amount – objective measurement tools are more reliable 6
• Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to MI and thrombosis risk 2
• Reassess antiplatelet therapy indication in patients with abnormal uterine bleeding and consider discontinuation if appropriate 2