What is the initial management approach for a 46-year-old female (F) with menorrhagia and a prolonged menstrual period lasting 3 weeks?

Initial Work-Up for Menorrhagia with 3-Week Prolonged Bleeding in a 46-Year-Old Woman

The initial work-up must exclude pregnancy, structural lesions (fibroids, polyps, endometrial pathology), infection, and bleeding disorders before initiating treatment, with pelvic ultrasound and endometrial sampling being the cornerstone diagnostic tests. 1

Immediate Diagnostic Evaluation

Essential Laboratory Tests

• Complete blood count (CBC) to assess for anemia and thrombocytopenia, as prolonged bleeding commonly causes iron deficiency 2, 3
• Pregnancy test (β-hCG) to rule out pregnancy complications, including incomplete abortion or gestational trophoblastic disease 4, 1
• Thyroid-stimulating hormone (TSH) to exclude hypothyroidism as an endocrine cause 2, 3

Critical Imaging and Tissue Diagnosis

• Pelvic ultrasound (transvaginal preferred) to evaluate for structural abnormalities including fibroids, polyps, adenomyosis, and endometrial thickness 4, 5
• Endometrial biopsy is essential in this 46-year-old woman to exclude endometrial hyperplasia or malignancy, particularly given her age and prolonged bleeding pattern 4, 1
• Consider hysteroscopy if initial imaging is inconclusive or if intrauterine pathology is suspected, as it provides direct visualization and allows for targeted biopsy 5, 6

Additional Screening When Indicated

• Screen for sexually transmitted infections (cervical cultures/NAAT) if risk factors present or cervicitis suspected on examination 1, 4
• Coagulation studies (PT, PTT, von Willebrand factor) only if personal or family history suggests bleeding disorder or if bleeding began at menarche 2, 3

Physical Examination Priorities

Key Examination Components

• Abdominal examination to assess for masses or organomegaly 4
• Speculum examination to visualize cervix, exclude cervical lesions, polyps, or active bleeding source 4
• Bimanual pelvic examination to characterize uterine size, shape, mobility, and identify adnexal masses 4

Common Pitfalls to Avoid

Do not initiate hormonal treatment before excluding malignancy in this perimenopausal woman - endometrial sampling is mandatory before starting therapy in women over 45 years with abnormal bleeding 1. The risk of endometrial pathology increases significantly in this age group.

Do not assume dysfunctional uterine bleeding without imaging - approximately 50% of menorrhagia cases have identifiable structural pathology (fibroids, polyps, adenomyosis) that requires specific management 6, 3.

Do not overlook systemic causes - while less common, thyroid dysfunction, liver disease, and coagulopathies can present as menorrhagia and require different management approaches 2, 5.

Initial Management While Awaiting Results

Acute Bleeding Control

• NSAIDs (e.g., ibuprofen 600-800mg TID) for 5-7 days can reduce menstrual blood flow by 25-35% acutely while diagnostic work-up proceeds 1, 7, 6
• Tranexamic acid (antifibrinolytic) can reduce blood loss by 50% and is particularly useful if NSAIDs are contraindicated 6, 8

Definitive Treatment Planning

Once structural and malignant causes are excluded, treatment options include:

• Combined oral contraceptives (30-35 μg ethinyl estradiol) as first-line medical management 9, 1
• Levonorgestrel IUD is highly effective for menorrhagia treatment and may be particularly appropriate given her age 4, 6
• Surgical options (endometrial ablation, hysterectomy) if medical management fails or structural lesions require intervention 4

The specific treatment choice depends on the underlying diagnosis, desire for future fertility (likely not relevant at 46), contraceptive needs, and patient preference after shared decision-making 4, 1.