From the Guidelines
The recommended workup for menorrhagia should begin with a thorough history and physical examination, followed by laboratory tests and imaging studies to evaluate for structural and nonstructural causes, as outlined in the PALM-COEIN classification system 1. The initial evaluation should include a complete blood count, pregnancy test, thyroid function tests, coagulation studies, and iron studies to assess for anemia.
- Transvaginal ultrasound is the first-line imaging study to evaluate the uterus and endometrium for structural abnormalities such as fibroids, polyps, or endometrial hyperplasia.
- If ultrasound findings are concerning or inconclusive, endometrial biopsy should be performed, particularly in women over 45 or those with risk factors for endometrial cancer.
- Saline infusion sonohysterography or hysteroscopy may be needed to better visualize intrauterine lesions. Additional testing may include cervical cytology, sexually transmitted infection screening, and hormonal assessments if indicated by clinical presentation. This comprehensive approach is necessary because menorrhagia can result from various causes including structural abnormalities, hormonal imbalances, coagulation disorders, or systemic conditions, and identifying the underlying cause is essential for appropriate management, as supported by the American College of Radiology 1. In adolescents with menorrhagia, coagulation disorders should be particularly considered, while perimenopausal women require careful evaluation for endometrial pathology. The use of medical treatments such as progestin-only contraception, combined hormonal contraception, or tranexamic acid may be considered based on the underlying cause of menorrhagia, with the goal of reducing bleeding symptoms and improving quality of life 1.
From the Research
Recommended Workup for Menorrhagia
The recommended workup for menorrhagia includes:
- Routine tests such as hematocrit or hemoglobin to detect and evaluate anemia 2
- Thyroid stimulating hormone (TSH) level to evaluate thyroid function as a possible cause 2
- Pregnancy test to rule out an incomplete, spontaneous abortion as a cause 2
- Pap test to screen for dysplasia that can suggest a gynecologic cancer cause 2
- Additional screening for endocrine disorders that may be causing menorrhagia, including tests of thyroid, liver, and kidney function, and tests of follicle stimulating hormone (FSH), prolactin, and cortisol levels 2
- Pelvic examination and vaginal sonography if the menstrual pattern has changed substantially or if anaemia is present 3
- Vaginal sonography combined with an endometrial biopsy to diagnose endometrial hyperplasia or carcinoma 3
- Sonohysterography or hysteroscopy to diagnose endometrial polyps and fibroids 3
Diagnostic Approach
A differential diagnosis approach can guide the types of historical data obtained from the patient, focus the physical examination, and alert the practitioner to the most appropriate laboratory and radiologic evaluation 4. This approach includes considering pregnancy-related causes, hormonal problems, iatrogenic etiologies, mechanical intrauterine disorders, infections of the lower genital tract, and gynecologic cancers (PHIMIC) 4.
Treatment Options
Treatment options for menorrhagia include:
- Medical treatment with prostaglandin inhibitors, specifically nonsteroidal antiinflammatory drugs (NSAIDs), and hormonal therapy with estrogen, progesterone, gonadotropin-releasing hormone agonists, or oral contraceptives 2
- Surgical treatment, including hysteroscopic endometrial ablation, laser electrodiathermy, and "roller ball," or surgical resection 2
- Hysterectomy as the treatment of last resort 2
- Non-steroidal anti-inflammatory drugs and tranexamic acid to reduce menstrual blood loss by 20-60% 3
- Hormonal intrauterine system (IUS) as an effective treatment option, comparable to endometrial ablation or hysterectomy 3