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Menorrhagia (heavy menstrual bleeding) - Management
What investigations should I carry out?

  • Menstrual blood loss does not have to be measured accurately, and objective measurement is impractical.
  • Take a full blood count in all women to rule out iron deficiency anaemia.
    • Iron deficiency anaemia is a strong indicator of excessive menstrual bleeding (see the CKS topic on Anaemia - iron deficiency).
  • Other blood tests and endocrine investigations are not routinely indicated.
    • Thyroid function tests should only be carried out if the woman has other symptoms or signs suggestive of thyroid disease (for more information on hypothyroidism, see the CKS topic on Hypothyroidism).
    • Tests for bleeding disorders (e.g. von Willebrand disease) should be performed if there are suggestive features in the history or on examination. Investigations should be arranged in conjunction with the local haematology department, as many of the tests are not routine. Women who may require screening include:
      • Those who have had heavy menstrual bleeding since menarche, or a history of excessive bleeding after tooth extraction, operations, or childbirth.
      • Those with a family history of a coagulation disorder.
  • Consider opportunistic cervical screening, if appropriate, in line with national recommendations.
  • Consider arranging for a trans-vaginal pelvic ultrasound to identify structural abnormalities if the woman has symptoms suggesting an underlying cause for heavy menstrual bleeding, or if she:
    • Has a uterus that is palpable abdominally.
    • Has a pelvic mass of uncertain origin on vaginal examination (although also consider urgent referral).
    • Has had treatment that has proved ineffective.
  • Urgent referral to a specialist (rather than referral for ultrasound) should always be considered if a suspicious mass is detected.
  • Investigations that may be used in secondary care include hysteroscopy and tissue biopsy for endometrial cancer; for further information, see Management in secondary care.

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