Obstetrics & Gynaecology
Question 89 of 180
A 19 year old woman presents to ED complaining of very heavy menstrual flow. She has been having heavy painful periods for the last year. She has no other past medical history. Which of the following investigations is most useful in the initial management of this patient?
Answer:
- Arrange a full blood count in all women — to rule out iron deficiency anaemia.
- For women with suspected submucosal fibroids, polyps, or endometrial pathology — offer a hysteroscopy or ultrasound to assess for a cause of menorrhagia
- Arrange other investigations as suggested by history and clinical findings, for example:
- A vaginal or cervical swab — if an infection is suspected.
- Thyroid function tests — if there are features of hypothyroidism.
- Tests for coagulation disorders (for example von Willebrand disease) — in women who have had heavy menstrual bleeding since menarche, and a personal or a family history of a coagulation disorder
Menorrhagia
Obstetrics & Gynaecology
Last Updated: 17th March 2021
Menorrhagia is excessive (heavy) menstrual blood loss that occurs regularly (every 24 to 35 days) which interferes with a woman's physical, emotional, social, and material quality of life. Excessive menstrual blood loss is classified as 80 mL or more and/or a duration of more than 7 days. Excessive menstrual bleeding is also defined as the need to change menstrual products every one to two hours, passage of clots greater than 2.5 cm, and/or 'very heavy' periods as reported by the woman.
Causes
In almost 50% of women with menorrhagia, no cause is identified — this is classified as dysfunctional uterine bleeding. In other women, the aetiology can be classified by the cause.
- Uterine and ovarian pathologies
- Uterine fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease and pelvic infection
- Endometrial polyps
- Endometrial hyperplasia or carcinoma
- Polycystic ovary syndrome
- Systemic diseases and disorders
- Coagulation disorders (for example von Willebrand disease)
- Hypothyroidism
- Diabetes mellitus
- Hyperprolactinaemia
- Liver or renal disease
- Iatrogenic causes
- Anticoagulant treatment
- Chemotherapy
- Herbal supplements (for example ginseng, ginkgo, and soya)
- Intrauterine contraceptive device
Investigations
- Arrange a full blood count in all women — to rule out iron deficiency anaemia
- For women with suspected submucosal fibroids, polyps, or endometrial pathology — offer a hysteroscopy or ultrasound to assess for a cause of menorrhagia
- Arrange other investigations as suggested by history and clinical findings, for example:
- A vaginal or cervical swab — if an infection is suspected.
- Thyroid function tests — if there are features of hypothyroidism.
- Tests for coagulation disorders (for example von Willebrand disease) — in women who have had heavy menstrual bleeding since menarche, and a personal or a family history of a coagulation disorder
Management
- For women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:
- Consider a levonorgestrel intrauterine system (LNG-IUS) as the first-line treatment.
- If an LNG-IUS is declined or unsuitable, consider the following pharmacological treatments:
- Non-hormonal: tranexamic acid or a non steroidal anti-inflammatory drug (NSAID).
- Hormonal: combined hormonal contraception (CHC) or a cyclical oral progestogen (such as oral norethisterone).
- If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to a specialist for:
- Investigations to diagnose the cause of menorrhagia, if needed, taking into account any investigations the woman has already had, and
- Alternative treatment choices, including pharmacological options not already tried and surgical options (second-generation endometrial ablation and hysterectomy).
- For women with fibroids of 3 cm or more in diameter:
- Consider specialist referral for additional investigations and consideration of treatment options.
- If pharmacological treatment is needed while the woman is awaiting treatment or referral appointment, offer tranexamic acid and/or an NSAID.
- Taking into account the size, location, and number of fibroids; the severity of the symptoms; the presence of any comorbidities; and the preference of the woman, secondary care treatment options for women with fibroids of 3 cm or more in diameter include:
- Pharmacological treatment — hormonal (LNG-IUS, CHC, or cyclical oral progestogens) or non-hormonal (NSAIDs or tranexamic acid).
- Uterine artery embolisation.
- Surgery — myomectomy, hysterectomy, or second-generation endometrial ablation (considered for women with menorrhagia and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers' instructions).
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
