What is the initial management for a patient with menorrhagia (heavy menstrual bleeding) and large clots?

Initial Laboratory Evaluation for Heavy Menstrual Bleeding with Large Clots

For a patient presenting with heavy menstrual bleeding and quarter-sized clots, obtain the following essential labs immediately: pregnancy test (β-hCG), complete blood count (CBC) to assess for anemia, thyroid-stimulating hormone (TSH), and consider coagulation studies if there is personal or family history of bleeding disorders. 1

Mandatory First-Line Testing

• Pregnancy test (β-hCG) is mandatory in all women of reproductive age with abnormal uterine bleeding, regardless of contraceptive use or reported sexual activity 1
• Complete blood count (CBC) to evaluate hemoglobin levels and assess severity of anemia from chronic blood loss 1
• TSH and prolactin levels are necessary to rule out ovulatory dysfunction as a cause of heavy bleeding 1

Assessment of Hemodynamic Stability

• Evaluate for signs of hemodynamic instability including tachycardia or hypotension, which indicate significant blood loss requiring urgent intervention 1, 2
• Bleeding that saturates a large pad or tampon hourly for at least 4 consecutive hours represents severe bleeding requiring urgent evaluation 1, 2

Additional Testing Based on Clinical Context

Coagulation Studies (When Indicated)

• Refer to hematology for coagulation workup if the patient has personal or family history of bleeding disorders (epistaxis, dental bleeding, easy bruising) or if bleeding is refractory to initial treatment 1
• This evaluation should include screening for von Willebrand disease and other hereditary bleeding disorders 1

Imaging Studies

• Transvaginal and transabdominal ultrasound with Doppler is the first-line imaging study to identify structural causes including polyps, adenomyosis, leiomyomas (fibroids), and endometrial hyperplasia or malignancy 1
• Ultrasound should be performed after initial laboratory assessment to guide further management 3

Endometrial Sampling

• Endometrial biopsy should be performed if there are features raising concern for other causes of heavy menstrual bleeding, particularly in women over 45 years or those with risk factors for endometrial hyperplasia or cancer 1
• Urgent referral is required if endometrial biopsy shows hyperplasia or malignancy 1

Special Populations Requiring Additional Evaluation

• Patients on anticoagulation therapy should have their medication regimen reviewed, as anticoagulants (particularly factor Xa inhibitors) can worsen menstrual bleeding 2
• Women with suspected bleeding disorders based on bleeding assessment tools (ISTH BAT score) may require second-line coagulation testing beyond initial screening 3

Immediate Medical Management While Awaiting Results

• Tranexamic acid is the most effective first-line treatment for acute bleeding, reducing menstrual blood loss by 40-60%, but is contraindicated in patients with history of thromboembolism or active cardiovascular disease 1, 4, 5
• NSAIDs (except aspirin) can reduce blood loss by 20-60% when used for 5-7 days during the bleeding episode if tranexamic acid is contraindicated 1, 2
• Aspirin should be avoided as it can paradoxically increase bleeding 1

Criteria for Urgent Gynecology Referral

• Failure of medical treatment after 3 months 1
• Endometrial thickness ≥4 mm in postmenopausal women 1
• Persistent hemodynamic instability despite initial management 1
• Endometrial biopsy showing hyperplasia or malignancy 1