Red flag symptoms - Menorrhagia

Consider the age of the patient when establishing the diagnosis.

Endometriosis can be a cause of menorrhagia (Photograph: SPL)
Endometriosis can be a cause of menorrhagia (Photograph: SPL)

Heavy menstrual bleeding is a common presentation in general practice and constitutes approximately 20 per cent of outpatient gynaecology referrals.

Dysfunctional uterine bleeding

The vast majority of cases of heavy menstrual bleeding may be attributed to dysfunctional uterine bleeding but it is imperative to remember that this is a diagnosis of exclusion.

Dysfunctional uterine bleeding may be defined as abnormal bleeding in the absence of genital tract pathology, pregnancy, systemic disease or hormone treatment.

History
First, explore what the patient means by 'heavy periods' and assess the extent of blood loss by enquiring about whether she is passing clots, how frequently she is changing pads or tampons, flooding and the impact on her quality of life.

Second, a pattern of bleeding needs to be established. This is important in women in their 40s as the risk of endometrial cancer starts to rise. A history of erratic or intermenstrual bleeding, postcoital bleeding and/or dyspareunia raises suspicion.

Note any risk factors for endometrial hyperplasia and cancer, which include: nulliparity, polycystic ovarian syndrome, obesity, family history and exposure to unopposed estrogen. It is also essential to check the woman's cervical smear history and ask about contraception. If the patient has an acute episode of heavy vaginal bleeding, do not forget to consider pregnancy.

Menorrhagia is the most common cause of iron deficiency anaemia in pre-menopausal women, so enquire about symptoms of anaemia, such as lethargy. PID can cause irregular heavy menstrual bleeding. Consider this diagnosis in those at risk and in the presence of fever, lower abdominal pain, vaginal discharge and dyspareunia.

Examination and investigations
The first-line investigation recommended by NICE is an FBC. Routine female hormone testing, TFTs and serum ferritin are no longer recommended.

Having taken a thorough history, if no structural or histological abnormality is suspected, NICE guidance states that pharmaceutical treatment could be started at this stage, but if there are any clinical concerns a physical examination should be undertaken before starting medication.

Examine the patient to check for fibroids, adnexal tenderness or masses and cervical excitation. If indicated, a smear, high vaginal swab and chlamydia screen should be undertaken.

Pelvic ultrasound scanning is indicated if the uterus is palpable abdominally or a pelvic mass is identified, or if there is failure of initial pharmaceutical therapy. Where cancer or endometrial hyperplasia are suspected urgent gynaecology referral is required.

  • Dr Porter is a salaried GP in Rochford, Essex.

Resource
NICE. Heavy Menstrual Bleeding CG44. NICE, London, 2007.

Possible causes
  • Uterine fibroids.
  • Hormonal treatment.
  • Endometrial polyps, hyperplasia or malignancy.
  • Intrauterine contraceptive device.
  • PID.
  • Endometriosis.
  • Blood clotting disorders (rare).
  • Hypothyroidism (rare).
  • Dysfunctional uterine bleeding.

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