What is the evaluation and management approach for a female patient of reproductive age presenting with menorrhagia?

Evaluation and Management of Menorrhagia in Reproductive-Age Women

Immediate Initial Assessment

Screen for iron deficiency anemia immediately, as menorrhagia is the most common cause of iron deficiency in women of reproductive age, affecting 20-25% of this population. 1, 2 Obtain complete blood count with hemoglobin, MCV, and ferritin levels. 3

Critical History Elements

• Quantify bleeding: Patient history alone is unreliable for assessing blood loss 3, but pictorial blood loss assessment charts have 80% sensitivity and specificity for detecting menorrhagia 3
• Age stratification matters: Women >45 years require more extensive evaluation due to increased risk of pathology 3
• Rule out pregnancy first with beta-hCG testing 3
• Screen for bleeding disorders, particularly in adolescents and young women 1

Essential Laboratory Testing

• Pregnancy test (beta-hCG) 3
• Complete blood count with platelets 3
• Thyroid-stimulating hormone and prolactin levels 3
• Ferritin <15 mg/dL confirms iron deficiency 3

Diagnostic Imaging Algorithm

Transvaginal ultrasound is the first-line imaging modality to evaluate for structural causes (polyps, adenomyosis, leiomyomas). 3

When to Advance Imaging:

• If ultrasound cannot completely visualize the endometrium (due to body habitus, uterine position, or presence of fibroids/adenomyosis), proceed to MRI with diffusion-weighted imaging 3
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for detecting intracavitary pathology 3
• Hysteroscopy is indicated when medical treatment fails or focal lesions are suspected but not adequately visualized 3

Age-Specific Endometrial Sampling Guidelines:

• Women >45 years: Endometrial biopsy is recommended regardless of ultrasound findings 3
• Women <45 years: Endometrial biopsy only if upper GI symptoms present, or check anti-endomysial antibodies (with IgA levels) to exclude celiac disease 3

First-Line Medical Management

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment, reducing menstrual blood loss by up to 96% after 12 months, with approximately 50% of users achieving amenorrhea or oligomenorrhea after 2 years. 2, 4, 5

Treatment Algorithm by Clinical Context:

When Contraception is Desired or Acceptable:

1. LNG-IUS (first choice) 2
2. Combined oral contraceptives as alternative, which regularize cycles and significantly reduce bleeding 3, 1, 2

When Contraception is Not Desired or Hormonal Therapy is Contraindicated:

1. Tranexamic acid 1.5-2g three times daily during menstruation reduces blood loss by 34-59% over 2-3 cycles 1, 2, 4, 5
2. NSAIDs: Mefenamic acid 500mg three times daily or ibuprofen 400mg every 4-6 hours during bleeding episodes 1, 6, 4, 5

Critical Prescribing Caveat:

Avoid oral progestins for more than 6 months due to meningioma risk, though they may be useful short-term in severe thrombocytopenia. 1, 2

Anemia Management Protocol

All patients with iron deficiency require ferrous sulfate 200mg three times daily to correct anemia and replenish body stores. 3, 1, 2

• Continue iron supplementation for three months after hemoglobin normalization to replenish stores 3, 1, 2
• Ascorbic acid enhances iron absorption and should be considered when response is poor 3
• Hemoglobin should rise by 2 g/dL after 3-4 weeks; failure suggests poor compliance, continued blood loss, or malabsorption 3

Follow-Up and Monitoring

Re-evaluate at 3-6 months after initiating treatment to assess efficacy. 3, 2

• Monitor hemoglobin and MCV every 3 months for 1 year, then annually 3, 1, 2
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained with iron supplementation 3

Surgical Options When Medical Management Fails

If medical treatment fails, is contraindicated, or not tolerated, or if concomitant significant intracavitary lesions exist, surgical options include: 3

1. Endometrial ablation for women who have completed childbearing, with satisfaction rates exceeding 95% 2
2. Uterine artery embolization (UAE) has 81-100% clinical success rates, with 83% symptom improvement at 3 months 3, 2
3. Hysterectomy remains definitive treatment 3

Pre-Procedural Workup for UAE:

• Cross-sectional imaging (preferably MRI) or ultrasound to confirm diagnosis 3
• Pap smear and endometrial biopsy if menometrorrhagia present 3
• Exclude viable pregnancy and active pelvic inflammatory disease 3

Common Pitfalls to Avoid

• Don't rely on patient history alone to quantify blood loss—use pictorial charts or objective measures 3
• Don't skip endometrial sampling in women >45 years, even with normal ultrasound 3
• Don't prescribe cyclic progestogens for ovulatory menorrhagia—they are ineffective 4
• Don't continue oral progestins beyond 6 months due to meningioma risk 1, 2
• Don't perform dilation and curettage as first-line diagnostic tool—endometrial biopsy is safer, less invasive, and lower cost 3