Initial Evaluation and Treatment of Menorrhagia
Begin with transvaginal ultrasound combined with transabdominal ultrasound with Doppler as your initial imaging study, alongside a complete blood count to assess for anemia, and treat based on the underlying cause identified. 1
Initial Diagnostic Workup
History and Physical Examination
- Perform a complete pelvic examination to identify anatomical causes such as fibroids, polyps, or cervical lesions 1
- Quantify bleeding severity—objectively defined as >80 mL per cycle, though patient perception varies significantly 2, 3
- Assess for systemic symptoms: fatigue, syncope, or signs of anemia 4
- Screen for bleeding disorders (especially von Willebrand disease), thyroid dysfunction, liver disease, and medication use (antipsychotics, antiepileptics) 5
Laboratory Testing
- Complete blood count to detect and quantify anemia 1, 4
- Thyroid stimulating hormone (TSH) to exclude thyroid dysfunction 5, 4
- Pregnancy test to rule out pregnancy-related bleeding 4
- Consider coagulation studies if bleeding disorder suspected (personal or family history of easy bruising, epistaxis) 5
Imaging
- Transvaginal ultrasound (TVUS) with transabdominal ultrasound and Doppler is the most appropriate initial imaging 6, 1
- If TVUS inadequately visualizes the uterus or endometrium, proceed to sonohysterography (if polyp suspected) or MRI pelvis without and with contrast 6, 1
- Women ≥45 years or those <45 years with risk factors for endometrial cancer (obesity, chronic anovulation, diabetes) require endometrial sampling 5
Critical caveat: Unexplained vaginal bleeding suspicious for malignancy must be evaluated before initiating treatment, though imaging/evaluation can proceed without removing existing contraceptive devices 6
Initial Treatment Approach
Medical Management (First-Line)
For ovulatory menorrhagia (regular cycles with heavy bleeding):
Levonorgestrel intrauterine system (LNG-IUD): Most effective medical option, comparable to surgical ablation, reduces bleeding by 71-96% 6, 1
Tranexamic acid: 1.5-2g three times daily during menstruation, reduces blood loss by 34-59% 7, 3, 8
- FDA-approved for ovulatory bleeding but expensive 5
NSAIDs: Mefenamic acid 500mg three times daily or ibuprofen during bleeding episodes (5-7 days), reduces blood loss by 20-60% 7, 3, 8
Combined oral contraceptives: Effective for cycle regulation and bleeding reduction 6, 7, 8
For anovulatory bleeding (irregular cycles):
- Combined oral contraceptives or cyclic progestins to regulate cycles 5
- Note: Cyclic progestins are ineffective for ovulatory menorrhagia 8
Iron Supplementation
- Ferrous sulfate 200mg three times daily for all patients with anemia 6, 7
- Continue for 3 months after hemoglobin normalization to replenish iron stores 6, 7
- Ascorbic acid enhances absorption when response is poor 6
Special Populations
Women with severe thrombocytopenia:
- LNG-IUD is particularly useful despite bleeding risk 6
- Progestin-only contraceptives may be beneficial, but avoid DMPA due to unpredictable bleeding 1
Active menstruation during acute stroke evaluation:
- IV alteplase is probably indicated in menstruating women without menorrhagia history 6
- May be considered even with menorrhagia history if benefits outweigh bleeding risks 6
- Emergency gynecology consultation needed if active heavy bleeding causes significant anemia or hemodynamic instability 1
Follow-Up and Escalation
- Monitor hemoglobin and MCV every 3 months for 1 year, then annually 6, 7
- If medical treatment fails after 3 months, consider alternative medical therapy or surgical options 1
- Surgical options include: polypectomy, fibroidectomy, uterine artery embolization, endometrial ablation, or hysterectomy (most definitive) 5
Important pitfall: Women <45 years without upper GI symptoms or risk factors for endometrial cancer do not routinely need endometrial sampling—reserve for those with treatment failure or specific risk factors 6