International Women's Health Update

Clinical Assessment

Many women with a history of abnormal uterine bleeding do not have menorrhagia or excessive menstrual bleeding. Your doctor should carefully take a history to distinguish mid-cycle bleeding, proliferative phase spotting, secretory phase spotting or pre-menstrual phase spotting from excessive uterine bleeding.

A positive family history, or personal history, suggestive of bleeding disorders, may appear for the first time even in older women. Many patients with heavy periods have chronic tiredness due to anaemia and this can easily be confused with hypothyroidism.

General examination should focus upon the signs of anaemia, the bleeding diseases and the signs of hypothyroidism.

Gynaecological examination should include cervical cytology and inspection of the cervix for cervical or uterine polyps prolapsing through the cervix. Gynaecological examination should also particularly assess for uterine fibroids which are present in one woman in three in the 30-50 year age range and which are a major cause of heavy periods.

If a patient is losing more than 80 mL of measured menstrual blood loss each month, the full blood examination will show a low hemoglobin concentration and evidence of a microcytic hypochromic anaemia. If there is clinical suspicion, measurement of serum thyroid stimulating hormone (TSH) is the investigation to exclude hypothyroidism while measurement of serum ferritin is appropriate for measuring iron stores in the patient.

Vaginal ultrasound of the uterus is appropriate in a patient with a history and examination findings consistent with heavy periods. This should be undertaken by someone experienced in these techniques, as it should provide much more gynaecological information than is often provided by abdominal ultrasound examinations, which are not really appropriate for this gynaecological problem. In our practice, for women 40 years and younger, satisfactory vaginal ultrasound clearly demonstrating endometrium and a uterine contour, would be sufficient in the first instance. Endometrial sampling would not be required in these younger patients. Arbitrarily, for our patients over 40 years of age, endometrial sampling is undertaken as an out-patient procedure.

At our hospital, endometrial sampling after vaginal ultrasound is preferred to cervical dilatation and uterine curettage ("D&C") under anesthesia. Please understand that a "D&C" has never been demonstrated to be of benefit for dysfunctional uterine bleeding and that the placebo response to any surgery, including the "D&C", is powerful, understandable, but not effective gynaecological treatment.