Menorrhagia

Probability diagnosis

Dysfunctional uterine bleeding (DUB)

    esp. ovulatory

    anovulatory

Fibroids

Cervical or endometrial polyps

Complications of hormone therapy

Adenomyosis/endometriosis

Serious disorders not to be missed

Disorders of pregnancy:

• ectopic pregnancy

• abortion or miscarriage

Neoplasia/cancer:

• cervical cancer

• endometrial cancer

• oestrogen-producing ovarian tumour (cancer)

• leukaemia

• benign tumours (polyps, etc.)

Endometrial hyperplasia Infection:

• PID

• tuberculosis endometritis

Pitfalls (often missed)

Genital tract trauma

IUCD

Adenomyosis/endometriosis

Pelvic congestion syndrome

SLE

Rarities:

• endocrine disorders (e.g. thyroid, adrenal, hyperprolactinaemia)

• bleeding disorder

• liver disease

Masquerades checklist

Depression (association)

Diabetes

Drugs (OCP, HRT)

Anaemia (association)

Thyroid disorder (hypothyroidism), other endocrine

Is the patient trying to tell me something?

Consider exaggerated perception. Note association with anxiety and depression.

Key history

This should be detailed to determine the exact amount of bleeding (e.g. number of tampons and pads used and the degree of saturation). Follow a menstrual calendar over 3+ months. Take a drug history, especially smoking. Questions need to be directed to rule out pregnancy or pregnancy complications, trauma of genital tract, medical disorders (e.g. bleeding disorder, endocrine disorders, cancer of the genital tract and complications of the OCP).

Key examination

General physical to rule out anaemia, evidence of a bleeding disorder and any stigmata of relevant medical or endocrine disease. Specific examinations include:

• speculum examination

• Pap smear

• bimanual pelvic examination.

Key investigations

Careful selection is based on history, patient’s age, abnormal pelvic examination findings and suspicion of disease.

   Consider:

• FBE

• iron studies

• pregnancy testing

• TFTs

• coagulation screen

• SLE antibodies

• ultrasound

• hormones: LH and FSH (?ovulation).

Hysteroscopy and D&C remain the gold standard for abnormal uterine bleeding.

Diagnostic tips

• Self-reporting of heaviness of bleeding is unreliable.

• Acute ‘flooding’ most often occurs in pubertal girls prior to regular ovulation.

• Ovulatory DUB is the most common single cause.

• Peak incidence of ovulatory DUB is late 30s and 40s (35–45 years)

• Peak for anovulatory DUB is 12–16 years and 45–55 years (i.e. puberty and menopause).