History and examination for heavy menstrual bleeding

A thorough history is essential when investigating heavy menstrual bleeding, to establish:

• age
• last normal menstrual period, contraceptive usage and likelihood of pregnancy or miscarriage
• parity and desire for future fertility
• frequency and pattern of menstrual bleeding (regular or irregular)
• volume of bleeding; tools are available for assessment of blood loss (eg the Pictorial Blood Assessment Chart) but validity is not well established. See also the Royal Women’s Hospital website for indicators of heavy bleeding
• impact of bleeding on quality of life
• experience of pelvic pain or pressure (possible symptoms of endometriosis or fibroids)
• gynaecological history—including cervical screening status
• symptoms, signs or past history of comorbidities (eg diabetes, obesity, thyroid disease, polycystic ovary syndrome, bleeding disorders)
• current medications and use of over-the-counter supplements
• personal and family history of endometriosis, endometrial cancer or bowel cancer¹
• symptoms of iron deficiency (with or without anaemia).

Postcoital bleeding and intermenstrual bleeding have different causes and need separate investigation.

Perform a pelvic and abdominal examination to assess for masses (such as fibroids), uterine size and signs suggestive of endometriosis. See Examination of the vulva and vagina for advice on reducing distress related to examination.