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Patients with symptoms of heavy menstrual bleeding have a detailed history taken, gynecological exam, complete blood count test, and pregnancy test (if pregnancy is possible) during their initial assessment.
Taking a detailed history and performing a physical exam will help to establish the cause of the heavy menstrual bleeding, direct further investigations, and guide management options. The comprehensive initial assessment can be performed over several visits. It is not recommended that patients routinely be asked to measure their blood loss. Heavy menstrual bleeding should be considered a problem if the patient believes it interferes with their life and normal functioning.
The following laboratory tests should not routinely be part of the initial assessment:
Thyroid testing — This should be done only when the history or physical examination suggests thyroid disease
Hormone testing and ferritin testing — Iron supplementation for anemia can be started without ordering a serum ferritin. Ferritin should not be ordered during an initial assessment unless iron deficiency without anemia is suspected; see Statement 14 for indications for ordering a serum ferritin test
Testing for coagulation disorders — This should only be considered in patients who have a history of heavy menstrual bleeding since menarche, a history of abnormal bleeding from other sites, or a family history of abnormal bleeding, and who screen positive using a structured bleeding assessment tool
At your initial assessment, your family doctor or nurse practitioner should ask you about your bleeding and how it affects your life, do a pelvic exam, and ask you to get blood and urine tests.
Ensure you perform a detailed history, gynecological exam, complete blood count, and pregnancy test (if pregnancy is possible) during the initial assessment. Heavy menstrual bleeding should be considered a problem if your patient feels their bleeding is too heavy and interferes with their life and normal functioning.
Ensure systems, processes, and resources are in place to assist clinicians with the comprehensive initial assessment of patients with heavy menstrual bleeding.
Percentage of patients with heavy menstrual bleeding who had a comprehensive initial assessment for heavy menstrual bleeding, including a detailed history, complete blood count, gynecological exam, and pregnancy test (if pregnancy is possible)
Denominator: number of patients with heavy menstrual bleeding
Numerator: number of patients with heavy menstrual bleeding who have the required comprehensive initial assessment within 3 months of their first visit, including:
Detailed history
Complete blood count
Gynecological exam
Pregnancy test (if pregnancy is possible)
Data source: local data collection
Note: The indicator can be calculated as an overall percentage and by each listed component.
The history should address the following:
Details about the bleeding
Symptoms of anemia and iron deficiency (e.g., restless leg syndrome, hair loss, fatigue)
Sexual and reproductive history
Desire for future fertility
Impact on quality of life, including social and sexual functioning
Symptoms suggestive of systemic causes of bleeding such as hypothyroidism or coagulation disorders
Associated symptoms such as vaginal discharge or odour, pelvic pain or pressure
Co-morbid conditions such as hormonally dependent tumours, thromboembolic disease, or cardiovascular problems that could influence treatment options
A list of medications including over-the-counter and natural or herbal remedies
Personal history of, or risk factors for, endometrial or colon cancer (see Statement 4 for risk factors for endometrial cancer)
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