• Menorrhagia is diagnosed when both the woman and clinician agree menstrual bleeding is heavy after a history has been taken.
• It is not necessary to measure blood loss to diagnose menorrhagia.

These recommendations are consistent with clinical guidelines on Heavy menstrual bleeding, published by the National Institute for Health and Clinical Excellence [National Collaborating Centre for Women's and Children's Health, 2007].

The history should set out to define the nature of the bleeding; identify potential underlying causes; and to address the woman's ideas, concerns, expectations, and needs.

• Ask the woman her age at menarche and for details about her menstrual cycle — length of cycle, the number of days of menstruation, how long she considers her periods to be heavy, what were her periods like previously, and impact on quality of life.
• Enquire about symptoms that suggest an underlying pathology, particularly 'red flag' symptoms (e.g. persistent intermenstrual or postcoital bleeding).
• Consider the possibility of an underlying systemic disease, such as hypothyroidism or a coagulation disorder (e.g. von Willebrand disease).
• Take a family history, and in particular ask about endometriosis and coagulation disorders that may have a hereditary component.
• Check the woman's smear status.
• Ask about current contraceptive use, contraceptive plans, and future plans for a family.
• It is important to ascertain the woman's need for contraception, as this may impact on the choice of treatment. For more information, see Advice and counselling.

• Underlying pathologies that might be found in women with heavy menstrual bleeding include pelvic inflammatory disease, endometriosis, and endometrial carcinoma. For further information, see Causes of menorrhagia.
• Symptoms that may indicate an underlying pathology include:
• Persistent postcoital bleeding.
• Persistent intermenstrual bleeding.
• Dyspareunia.
• Dysmenorrhoea.
• Pelvic pain and/or pressure symptoms.
• Vaginal discharge.

These recommendations are consistent with clinical guidelines on Heavy menstrual bleeding, published by the National Institute for Health and Clinical Excellence [National Collaborating Centre for Women's and Children's Health, 2007].

• Consider abdominal and pelvic examination in the following women:
• Women with symptoms suggestive of underlying abnormalities, before further investigations are arranged.
• Those in whom initial treatment has proved ineffective.
• Those for whom the levonorgestrel-releasing intrauterine system is being considered.
• A pelvic examination should include:
• Vulval examination for evidence of external bleeding and signs of infection (e.g. vaginal discharge).
• Speculum examination of vagina and cervix. High vaginal, endocervical, and chlamydia swabs should be obtained if infection is suspected.
• Bimanual palpation to identify uterine or adnexal enlargement or tenderness.
• In addition to abdominal and pelvic examination, look for systemic signs of underlying disease:
• Endocrine disease: hirsutism, striae, thyroid enlargement or nodularity, or changes in skin pigmentation.
• Coagulation disorders: bruises or petechiae.
• Women who refuse an examination should be referred directly for investigations as appropriate.
• Women who have fibroids that are palpable abdominally should be offered immediate referral or sent for an ultrasound.

These recommendations are consistent with clinical guidelines on Heavy menstrual bleeding, published by the National Institute for Health and Clinical Excellence [National Collaborating Centre for Women's and Children's Health, 2007], and are based on consensus opinion rather than primary evidence.

• 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.

These recommendations are consistent with clinical guidelines on Heavy menstrual bleeding, published by the National Institute for Health and Clinical Excellence [National Collaborating Centre for Women's and Children's Health, 2007].

• Although there is evidence from diagnostic studies to support objective measurements to determine menstrual blood loss, this is generally felt to be impractical in most clinical situations and is unlikely to guide clinical management.
• Direct objective measurement of menstrual blood loss includes the alkaline haematin technique.
• The pictorial blood loss assessment chart is an indirect measure.
• Results from epidemiological studies have found that:
• Thyroid disease is not associated with menstrual disorders and therefore should not be routinely tested for.
• Coagulation disorders, such as von Willebrand disease, are an identifiable risk factor in women who have experienced heavy bleeding since the menarche.