Investigations for heavy menstrual bleeding

Approach to investigating and treating heavy menstrual bleeding outlines an approach to investigations for heavy menstrual bleeding. Consider a pregnancy test. Request a full blood examination, with a serum ferritin concentration (to exclude iron deficiency) in all individuals with heavy menstrual bleeding. Additional blood tests that may be indicated based on clinical assessment, include a:
  • coagulation profile and von Willebrand disease screening tests, especially in adolescents with irregular bleeding and a family history of clotting disorders
  • serum thyroid stimulating hormone (TSH) concentration.
Note: Assess all individuals with heavy menstrual bleeding for iron-deficiency anaemia.

Sex-hormone testing is not routinely required in individuals with cyclical menstrual bleeding as they will have normal ovarian and pituitary function.

Note: Do not measure sex hormones (eg serum estradiol, follicle stimulating hormone, luteinising hormone) in individuals with cyclical menstrual bleeding.

Perform a cervical screening test, if due, according to the National Cervical Screening Program guidance.

An ultrasound may be required to assess uterine pathology, including endometrial thickness (which may help evaluate the risk of endometrial hyperplasia and malignancy). The clinical relevance of endometrial thickness can be difficult to interpret; it varies with menopausal status and with the phase of the menstrual cycle. Indicate menopausal status (pre, peri, post) on the ultrasound request form, and request that the report include endometrial thickness.

Ultrasound should be performed on days 5 to 10 of the menstrual cycle if possible. A transvaginal scan gives better detail, but a transabdominal scan is an alternative if transvaginal ultrasound is not available or is declined.

Arrange an ultrasound if initial assessment identifies or suggests:

An ultrasound is also recommended if symptoms have not responded to 6 months of medical therapy (or 3 months of medical therapy if concurrent dysmenorrhoea is present).

Specialist investigations include:

  • saline-infused sonography
  • hysteroscopy
  • endometrial biopsy.

Biopsy is performed to exclude endometrial hyperplasia or malignancy. This may be considered if:

  • bleeding does not respond to medical therapy
  • other clinical risk factors for endometrial cancer are present (see Indications for specialist referral)
  • endometrium is thickened over 12 mm for premenopausal individuals and over 5 mm for perimenopausal individuals.

Endometrial cancer is not excluded by a normal cervical screening test.