Diagnostic Approach to Menorrhagia

Initial Evaluation

The initial work-up for menorrhagia must exclude pregnancy, structural lesions, infection, and bleeding disorders before initiating treatment, with pelvic ultrasound and endometrial sampling being the cornerstone diagnostic tests, as recommended by the American College of Radiology and supported by clinical guidelines 1.
A pregnancy test (β-hCG) is essential to rule out pregnancy complications, including incomplete abortion or gestational trophoblastic disease, according to the American College of Radiology 2, 1.

Pelvic ultrasound (transvaginal preferred) is used to evaluate for structural abnormalities, including fibroids, polyps, adenomyosis, and endometrial thickness, as recommended by the American College of Radiology 2, 1.
Endometrial biopsy is essential in women over 45 years old to exclude endometrial hyperplasia or malignancy, particularly given the age and prolonged bleeding pattern, as supported by the American College of Radiology and clinical guidelines 2, 1.

Screening for sexually transmitted infections (cervical cultures/NAAT) is recommended if risk factors are present or cervicitis is suspected on examination, according to the Centers for Disease Control and Prevention 3, 1.

Abdominal examination is necessary to assess for masses or organomegaly, as recommended by the American College of Radiology 2.
Speculum examination is used to visualize the cervix, exclude cervical lesions, polyps, or active bleeding source, according to the American College of Radiology 2.
Bimanual pelvic examination is essential to characterize uterine size, shape, mobility, and identify adnexal masses, as recommended by the American College of Radiology 2.

Combined oral contraceptives (30-35 μg ethinyl estradiol) are recommended as first-line medical management for menorrhagia, as supported by clinical guidelines 5, 1.
Levonorgestrel IUD is highly effective for menorrhagia treatment and may be particularly appropriate for women over 45 years old, according to the Centers for Disease Control and Prevention 6.
Surgical options (endometrial ablation, hysterectomy) may be considered if medical management fails or structural lesions require intervention, as recommended by the American College of Radiology 2, 7.