Heavy menstrual bleeding is prolonged (>7 days) or excessive (>10 mL) uterine bleeding occurring at regular intervals over several menstrual cycles.
It is menstrual blood loss that is excessive and interferes with patient's physical, emotional, social and quality of life.
It is also referred to as menorrhagia or hypermenorrhea.
It is a common problem in women of reproductive age that usually causes anemia.
Uterine fibroids and polyps are the most common pathology identified.


  • Main goal is to confirm HMB, rule out endometrial hyperplasia or cancer, and to identify other pathology


  • Should be able to identify nature of bleeding, presence of any underlying pathology and other features (including family history of pathology) that may determine future action or treatment
    • Important to inquire about the frequency, duration, amount of bleeding and timing of changes in menstrual patterns
    • Features suggestive of excessive blood flow:
      • Changes sanitary pads every <3 hours or at night
      • Consumes >20 pads or tampons/cycle
      • Passes >1-inch blood clot
      • Bleeds >7 days
      • With or without iron-deficiency anemia (IDA)
    • Intermenstrual and postcoital bleeding may be suggestive of an anatomical cause
  • Menstrual blood loss as a problem should be asked to the patient since direct (alkaline hematin) or indirect (pictorial blood loss assessment chart) measurement is not routinely recommended
  • Coagulation disorder may be suggested by the following:  
    • Heavy menstrual bleeding since menarche
    • History of easy bruising (bruises >5 cm) or bleeding from mucosal surfaces (epistaxis once a month)
    • Personal or family history of coagulopathy
    • History of postpartum hemorrhage
    • Bleeding from surgery
  • Pressure symptoms, eg urinary and bowel symptoms, may indicate a fibroid

Physical Examination

  • Done through observation, abdominal palpation, visualization of the cervix and bimanual (internal) exam
  • To identify any underlying pathology, indication for further investigation and possible treatment options
    • Size of the uterus and location of fibroids, if present, should be assessed
  • Examine for the presence of anemia, coagulopathy or thyroid disease

Laboratory Tests

  • Not always recommended but may be useful in excluding other diagnosis
  • Complete blood count (CBC) should be carried out in all women with heavy menstrual bleeding (HMB) to assess presence of anemia and, parallel with HMB treatment, to monitor response
  • Coagulation studies should be done in patients with history suggestive of coagulation disorder
    • Usually includes assessment of quantity and activity of von Willebrand’s factor (VWF) and factor VIII since von Willebrand’s disease is seen in majority of cases
  • Ferritin level is the most accurate test for determining iron deficiency anemia (IDA) but is not routinely requested; normal level does not rule out HMB
  • Hormonal examination (eg LH and FSH) should not be routinely performed in women with HMB; thyroid function test is recommended only in patients with signs and symptoms suggestive of thyroid disease
    • Hypothyroidism can cause menstrual irregularities and HMB

Endometrial Biopsy

  • Should be done to exclude endometrial cancer or atypical hyperplasia with 91% sensitivity
  • Recommended in women ≥45 years old with continuous intermenstrual bleeding or with treatment failure, in younger obese patients with prolonged periods of anovulation or unopposed estrogen stimulation, in women with ≥12-mm transvaginal endometrial thickness, or in younger women with endometrial cancer risk factors


  • Carried out in patients with abdominally palpable uterus, pelvic mass of unknown origin seen on vaginal exam, or failed medical treatment
  • Ultrasound (US) is the primary diagnostic imaging used for identifying structural abnormalities that is 60% sensitive and 93% specific
    • Useful if physical exam findings are abnormal or doubtful due to the women’s habitus, or if reassurance and no treatment is needed
    • Can detect small ovarian cysts, leiomyoma, endometrial hyperplasia or carcinoma
    • Transvaginal US depicts endometrium better than transabdominal US
      • Transvaginal US is the 1st-line imaging procedure for abnormal uterine bleeding
  • Hysteroscopy is used when US results show intrauterine abnormalities or are inconclusive, or when initial treatment has failed
    • Detects intrauterine lesion definitively with 86% sensitivity and 99% specificity
  • Saline infusion sonohysteroscopy/sonohysterography/infusion sonography detects fibroids with sensitivity of 87% and specificity of 92%, and polyps with sensitivity of 86% and specificity of 81%
    • Should not be used as an initial diagnostic tool
  • Magnetic resonance imaging (MRI) is used if menstrual bleeding is secondary to leiomyomas and myomectomy is contemplated, US is uncertain in differentiating adenomyosis from leiomyomas, or when malignancy and adnexal pathology is suspected
    • Should not be used as an initial diagnostic tool
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