What is the systematic approach to evaluating and managing menstrual disorders in reproductive‑age women, including history, physical exam, investigations, and first‑ and second‑line treatments?

Systematic Approach to Menstrual Disorders in Reproductive-Age Women

Begin evaluation with a detailed menstrual history focusing on cycle length, duration of bleeding, presence of clots ≥1 inch, flooding (changing pad/tampon more than hourly), and associated symptoms including dysmenorrhea, pelvic pain, dyspareunia, galactorrhea, and hirsutism, as these specific features guide diagnosis and predict underlying pathology. 1, 2

History Taking: Essential Components

Menstrual Pattern Assessment

• Document age at menarche, current cycle length (normal 21-35 days), duration of bleeding (normal ≤7 days), and any recent changes in pattern 3, 1
• Quantify bleeding severity by asking about clots ≥1 inch diameter, flooding requiring pad/tampon changes more frequently than hourly, and interference with daily activities—these predict heavy menstrual bleeding (HMB) defined as >80 mL per cycle 4, 5
• Screen for bleeding disorders by asking about personal history of easy bruising, prolonged bleeding after dental procedures or surgery, and family history of bleeding disorders, as up to 20% of women with HMB have an underlying inherited bleeding disorder 4, 5

Reproductive and Medical History

• Obtain gravidity, parity, pregnancy outcomes, complications, contraceptive use, and fertility desires to guide treatment selection 3
• Review past surgeries (especially pelvic), hospitalizations, current medications (particularly anticoagulants and hormonal contraceptives), allergies, and medical conditions including thyroid disorders, diabetes, endocrine disorders, and obesity 3, 1
• Assess for symptoms suggesting specific etiologies: thyroid disease (fatigue, weight changes, temperature intolerance), PCOS (hirsutism, acne, weight gain), hyperprolactinemia (galactorrhea, headaches, visual changes), and endometriosis (dysmenorrhea, dyspareunia, dyschezia) 3, 1, 2

Sexual and Social History

• Document sexual activity, STI history, pelvic inflammatory disease, and screen for intimate partner violence, as these affect both diagnosis and treatment planning 3
• Assess lifestyle factors including smoking, alcohol use, recreational drugs, caffeine intake >5 cups/day, extreme weight (BMI <18.5 or ≥30), and occupational exposures, as these impact fertility and treatment options 3

Physical Examination: Targeted Assessment

General and Endocrine Examination

• Measure height, weight, and calculate BMI, as obesity (BMI ≥30) and underweight (BMI <18.5) are associated with menstrual irregularity and infertility 3
• Examine thyroid for enlargement, nodules, or tenderness, as thyroid disorders cause menstrual irregularity and occur in 43% of women with hyperprolactinemia 3, 1
• Perform clinical breast examination and assess for galactorrhea by gentle compression of nipples 3
• Evaluate for signs of androgen excess including hirsutism (modified Ferriman-Gallwey score), acne, and male-pattern hair loss 3, 1

Pelvic Examination

• Inspect external genitalia for abnormalities, assess vaginal and cervical anatomy for abnormalities, secretions, or discharge 3
• Perform bimanual examination to assess uterine size, shape, position, mobility, and identify any enlargement, masses, or tenderness 3
• Palpate adnexa for masses or tenderness and assess cul-de-sac for masses, tenderness, or nodularity suggesting endometriosis 3

Laboratory Investigations: First-Line Testing

Essential Hormonal Evaluation

• Measure FSH and LH between cycle days 3-6 using three samples taken 20 minutes apart for accuracy, with LH/FSH ratio >2 suggesting PCOS 1, 2
• Obtain estradiol during early follicular phase to establish baseline ovarian function, with low levels suggesting ovarian insufficiency 1, 2
• Check prolactin as morning resting sample (repeat if elevated), as hyperprolactinemia accounts for 20% of secondary amenorrhea and causes both fatigue and menstrual irregularity 1, 2
• Measure TSH and free T4 as critical first-line test, since hypothyroidism causes both menstrual irregularity and fatigue 1, 2
• Obtain mid-luteal progesterone (cycle day 21 in 28-day cycle) to confirm ovulation 1

Androgen and Metabolic Assessment

• Measure total and free testosterone if hirsutism, acne, or PCOS suspected clinically 1, 2
• Check DHEA-S (primarily adrenal origin), as markedly elevated levels suggest non-classical congenital adrenal hyperplasia or adrenal pathology 1, 2
• Perform fasting glucose and 2-hour oral glucose tolerance test if PCOS suspected or BMI elevated, as insulin resistance commonly accompanies hyperandrogenism 1

Additional Laboratory Tests

• Obtain CBC to assess for anemia (ferritin <15 ng/mL highly predictive of HMB), as low ferritin combined with flooding and large clots predicts significant blood loss 4, 5
• Perform pregnancy test (urine or serum β-hCG) to exclude pregnancy as the most common cause of menstrual irregularity in reproductive-age women 6, 2
• Consider coagulation studies (PT, aPTT, von Willebrand panel) if HMB with flooding, prolonged menses, or personal/family bleeding history, as 20% of HMB cases have underlying bleeding disorder 4, 5

Imaging Studies

Pelvic Ultrasound

• Perform transvaginal ultrasound between cycle days 3-9 if initial labs suggest PCOS, to exclude ovarian pathology, or if menstrual pattern has changed substantially or anemia present 1, 7
• Use sonohysterography or hysteroscopy for more reliable diagnosis of endometrial polyps and fibroids, as vaginal sonography alone is insufficient for these diagnoses 7
• Consider anti-Müllerian hormone (AMH) for ovarian reserve assessment, though interpret cautiously in women <25 years due to significant fluctuations 1

First-Line Medical Treatments

Hormonal Therapies

• Prescribe levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line for HMB, with efficacy comparable to endometrial ablation or hysterectomy, reducing menstrual blood loss by up to 90% 7, 8, 4
• Use combined oral contraceptives (estrogen-progestin) for HMB and cycle regulation, reducing blood loss by 40-50%, but avoid in women with positive antiphospholipid antibodies or very active SLE 3, 8, 9
• Consider progestin-only pills as safe alternative in all women with RMD, though higher breakthrough bleeding rates and must be taken same time daily for efficacy 3
• Avoid cyclic progestogens for HMB in ovulating women, as they do not significantly reduce menstrual bleeding 7

Non-Hormonal Therapies

• Prescribe tranexamic acid 1-1.5g three times daily during menses as highly effective non-hormonal option, reducing menstrual blood loss by 40-60% 7, 8, 4
• Use NSAIDs (mefenamic acid 500mg three times daily or ibuprofen 400-600mg three times daily) during menses, reducing blood loss by 20-30% 7, 8, 4
• Administer DDAVP (desmopressin) for HMB associated with certain inherited bleeding disorders (von Willebrand disease, platelet function disorders) 4, 5

Second-Line Treatments

Advanced Medical Options

• Consider ulipristal acetate as approved preoperative treatment for uterine fibroids, demonstrating efficacy in reducing menstrual blood loss 4
• Use factor concentrate administration during menses for HMB associated with severe inherited bleeding disorders when other therapies fail 4
• Combine haemostatic therapies (tranexamic acid or DDAVP) with hormonal treatments for enhanced efficacy 4

Surgical Interventions

• Perform endometrial ablation as minor outpatient procedure with low operative morbidity when medical therapies fail and fertility not desired 7, 4
• Reserve hysterectomy as definitive treatment when medical therapies have failed and endometrial ablation is not suitable or has failed 7, 4
• Consider hysteroscopic polypectomy or myomectomy for structural lesions (polyps, fibroids) causing HMB 7, 9

Critical Pitfalls to Avoid

• Never assume amenorrhea on hormonal contraception is benign without investigating systemic symptoms like hot flashes at age <40, as this is particularly concerning for premature ovarian insufficiency 2
• Do not evaluate cycles >35 days apart as "normal variation"—this represents oligomenorrhea requiring investigation 6
• Avoid continuing exogenous testosterone or other hormonal therapies without investigating their impact on menstrual function 6
• Do not assume subjective assessment of menstrual blood loss reflects true amount—use objective criteria (clots ≥1 inch, flooding, ferritin) for assessment 7, 4
• Never initiate surgical interventions before adequate trial of medical therapies, as drug treatment should be used and evaluated first 7, 9

Referral Indications

• Refer to endocrinology or gynecology if persistent abnormal hormone levels despite initial management, prolactin >4,000 mU/L (or >100 ng/mL), or pituitary abnormality on MRI 1
• Refer to hematology if HMB with flooding and/or prolonged menses accompanied by personal or family bleeding history 5
• Refer to reproductive endocrinology for infertility evaluation after 12 months unprotected intercourse (or 6 months if age >35, oligomenorrhea, known uterine/tubal disease, or subfertile partner) 3