Special Report

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Diagnosis of heavy menstrual bleeding

Heavy menstrual bleeding (HMB) is an important health problem. This paper gives Malou C Herman*,1, Ben W
an overview of the diagnosis of HMB. For each woman, a thorough history should be Mol2 & Marlies Y Bongers3
taken as one should ascertain whether there are underlying factors that could cause
1
Department of Obstetrics & Gynecology,
Maastricht University Medical Centre,
complaints of HMB. Objectively knowing whether or not the blood loss is excessive
The Netherlands
could also be very beneficial. The pictorial blood assessment chart score can help 2
The Robinson Institute, School of
with diagnosis. Physical examination starts with standard gynecological examination. Paediatrics & Reproductive Health,
Imaging tests are widely used in the work-up for women with HMB. The first step in University of Adelaide, Australia
imaging tests should be the transvaginal ultrasound. Other diagnostic tests should
3
Department of Obstetrics & Gynecology,
Máxima Medical Centre, Veldhoven,
only be performed when indicated.
The Netherlands
*Author for correspondence:
Keywords:  abnormal uterine bleeding • adenomyosis • diagnosis • fibroid • heavy menstrual malouherman@ hotmail.com
bleeding • hysteroscopy • intracavitary pathology • menorraghia • pictorial blood assessment
score • polyp

Heavy menstrual bleeding (HMB) is an
important health problem that affects many
premenopausal women. It is defined as men-
struation at regular intervals but with exces-
sive flow and duration. Clinically, it is defined
as blood loss of more than 80 ml per cycle [1] .
It can be embarrassing, annoying and incon-
venient and the bleeding can interfere with
daily activities.
HMB can be caused by abnormal blood
clotting, disruption of normal hormonal reg-
ulation or uterine pathology (e.g., fibroids,
polyps, adenomyosis). It is important to
diagnose the underlying cause in order to
determine the best treatment option.
History
Many women who seek treatment for HMB
complain about their physical, social and emo-
tional well-being. For each woman, a thorough
history should be taken to establish the true
nature of her symptoms. Asking about dura-
tion, intensity and regularity of the menstrual
blood loss (MBL) will identify the bleeding
problem and suggest whether or not it is a
structural or histological abnormality. Blood
clots and menstruation of more than 7 days
are independent predictors for HMB [2] . Nev-
ertheless, the clinician must take into account
the fact that there is a wide variation in men-
strual cycles between women. This variation
should be discussed with the patient and can
sometimes be reassuring for women. Patient-
focused discussions on HMB have revealed
that women feel that it is important that the
clinician takes the time to assess the impact of
HMB on daily living [3] .
One should also ascertain whether there
are underlying factors that could cause
women to present with complaints of HMB.
The amount of suffering that women expe-
rience from abnormal menstrual bleeding
is not only dependent on the severity of the
bleeding abnormality itself, but also on the
way they cope with it. Women in a vulner-
able position are more likely to have coping
difficulties than women in a stable position.
For example, a history of sexual assault is
twice as common among women with symp-
toms of dysmenorrhea, HMB and sexual dys-
function as compared with women without
part of
such complaints, in other words, 30% among

10.2217/whe.15.90 © 2016 Future Medicine Ltd Womens Health (2016) 12(1), 15–20 ISSN 1745-5057 15
Special Report  Herman, Mol & Bongers
women with gynecologic complaints versus 15% in
an unselected population. As this is likely to be the
result of differences in coping, it is to be expected that
women with a history of sexual assault will be less sat-
isfied with a particular treatment effect, as their com-
plaints were at least partially explained by their capac-
ity to cope with the problem. When there is a history of
sexual assault, it should be included in the evaluation
and management of HMB, as these women may bene-
fit from psychological help in addition to gynecological
assessment and therapy [4,5] .
Although a large amount of blood loss is the main
reason to consult a general practitioner or gynecologist,
women’s perception of the severity of bleeding does not
often correlate with the objective amount of blood loss.
Only 40–50% of women with complaints of HMB
exceed 80 ml blood loss [6,7] . Knowing whether or not
the woman is suffering from HMB can be very ben-
eficial for both patient and clinician; evaluating the
actual amount of blood loss means that many women
could be reassured that their blood loss is not excessive.
Nevertheless, any complaints about blood loss should
be fully examined. Women who experience blood loss
of less than 80 ml can then be counseled differently
from women who do have HMB. Therefore, evaluat-
ing the blood loss is the first step toward diagnosing
HMB.
A few methods have been developed for measuring
MBL. The gold standard for the measurement of MBL
is alkaline hematin extraction [1,6] . This is a very time-
consuming and stressful method, as women need to
collect all of their menstruation blood including all
used towels or tampons. This method is not practi-
cal for daily use and is only used in research. Another
simplified method is counting numbers of used towels
or tampons, but Fraser et al. did not find a correla-
tion between the numbers and the volume of blood
loss. Therefore, this method is not used anymore [6] .
Higham et al. developed a subjective method to deter-
mine whether or not women meet the diagnosis of
HMB: the pictorial blood assessment chart (PBAC).
The self assessed PBAC consists of diagrams repre-
senting different soiled towels and tampons. Women
are instructed to count their number of used towels
or tampons each day and then divide them by level of
soiling. The chart is scored using the scoring system
devised by Higham et al. This measurement method
has a specificity and sensitivity of 80–90% [8,9] . Other
studies have confirmed the accuracy of the PBAC com-
pared with the alkaline hematin extraction method for
the diagnosis of HMB. A PBAC score of 150 points
most accurately correlates with MBL of 80 ml. [2,9] .
Although the PBAC score is not a quantitative mea-
surement, it can reliably predict HMB. A menstrua-
16 Womens Health (2016) 12(1)
tion scorecard for one menstrual period is sufficient for
diagnosis, probably because of the constancy of indi-
vidual MBL [1,9] . In conclusion, the PBAC is a useful
measure for accurately diagnosing HMB.
In addition to assessing the menstruation cycle and
amount of blood loss, a personal or family history of
bleeding disorders must also be assessed. For exam-
ple, disorders of hemostasis should be suspected in a
woman with a history of bleeding associated with sur-
gery, dental extraction, childbirth, bruising or HMB
since menarche (see also laboratory testing).
Physical examination
Gynecological examination
Standard gynecological examination includes specu-
lum examination and vaginal examination (bimanual
examination). The speculum examination is particu-
larly important for women with dysfunctional blood
loss, such as irregular bleeding or intermenstrual
bleeding because during the speculum examination
the cervix can be clearly examined. An ectropion,
cervical polyp, myoma nascens (intrauterine fibroid
visualized extruding through the cervical canal) or
malignancy can be diagnosed and, if necessary, the
patient can receive additional treatment or additional
diagnostic testing. During a gynecological examina-
tion, a cervical smear and triple swabs can be obtained.
Although a standard speculum examination for HMB
is not supported by the literature, a speculum examina-
tion should always be a fixed item in the gynecological
examination.
The vaginal examination gives information about
the vagina, cervix and uterus. It determines the size,
shape and mobility of these structures and may sug-
gest the presence of fibroids, adenomyosis or possible
malignancy (e.g., tumor growth in the parametria).
The vaginal examination is also the most appropriate
examination for choosing the type of surgical approach
for a hysterectomy if required; vaginal, abdominal or
laparoscopic.
Laboratory testing
Laboratory testing is selective and depends upon infor-
mation obtained from the patient’s history and physical
examination.
Hemoglobin & ferritin
Women with menorrhagia can lose a great deal of
blood each month and may become anemic. Deter-
mination of hemoglobin concentration (Hb) is an
important factor in the assessment of iron supple-
mentation, yet a hemoglobin threshold should not be
used for diagnosis of HMB, as the absence of anemia
does not exclude the diagnosis of HMB. Janssen et al.
future science group

describes that 20% of women with HMB had a nor-
mal hemoglobin. However, anemia makes the clini-
cal impression of excessive blood loss plausible. Three
quarters of women suffering from anemia had MBL
exceeding 80 ml/day [9] . Although the gold standard
measure for iron stores in the body is serum ferri-
tin, this may only be important if anemia also exists
(Hb <7.5 mmol/l) [10,11] .
Coagulation factors
Testing for coagulation abnormalities may only be con-
sidered if HMB is objectified and other causes, such as
intracavitary pathology, are excluded. Hemostasis dis-
orders should be suspected in women with a history
of bleeding associated with surgery, dental extraction,
childbirth, bruising or HMB since menarche. The
prevalence of von Willebrand disease as an underly-
ing coagulation disorder in patients with HMB varies
from 10 to 20% [12,13] . A 61% of women with HMB
since menarche have von Willebrand disease or factor
XI deficiency versus 7% of women who develop HMB
at a later age [14,15] . The frequency of other potential
bleeding disorders is less certain and requires further
investigation. Testing for coagulation disorders should
be considered in women who have a personal history
that suggests a coagulation disorder. Nevertheless,
standard screening for coagulation is not necessary, as
it is expensive and often has no implications for the
choice of treatment [16] .
Endocrine examination
Endocrine examination is not indicated in HMB [16] .
Endometrium from women with HMB is indistin-
guishable in terms of sex steroid immunoreactivity
compared with women without HMB, and there are
no differences in plasma gonadotropin or sex steroid
levels between women with or without HMB [17] .
Thyroid function has never shown a clear relationship
with HMB and should therefore not be checked [18] . In
cases with obvious symptoms of hypothyroidism, it is
of course useful to check thyroid function.
Imaging tests
In daily practice, imaging tests are widely used in
the work-up for women with HMB. The diagnosis of
HMB is mostly a combination of one of the following
imaging tests: transvaginal ultrasonography (TVS);
saline infusion sonography (SIS); hysteroscopy; and
MRI.
Anatomical abnormalities of uterine muscle and
cavity, such as polyps, fibroids or adenomyosis, can
be visualized by using these techniques. The aim is to
make a distinction between these abnormalities so an
appropriate treatment can be offered.
future science group
Diagnosis of heavy menstrual bleeding  Special Report
Transvaginal ultrasonography
A transvaginal ultrasound should be the first diagnos-
tic test for identifying structural abnormalities [16] .
Subserosal and intramural fibroids can be visualized
with ultrasound, and endometrial thickness can be
assessed. However, ultrasound cannot reliably distin-
guish between polyps, submucous fibroids and adeno-
myosis. So if structural abnormalities are suspected,
further diagnostic tests such as SIS or hysteroscopy, are
required [19,20] .
Saline infusion sonography & gel infusion
sonography
SIS or gel infusion sonography (GIS) are used to visu-
alize intracavitary abnormalities and should only be
used if TVS is inconclusive or if structural abnor-
malities are suspected. SIS and GIS are techniques in
which a catheter is placed into the endometrial cavity
and sterile saline or gel is instilled while a transvagi-
nal ultrasound examination is performed. The saline
or gel distends the uterine cavity to aid detection of
intracavitary abnormalities. This procedure is only
used as a diagnostic tool, it is not a therapeutic pro-
cedure. No differences in sensitivity and specificity
are found between SIS or GIS, although the image
quality of SIS is slightly better [21,22] . De Kroon et al.
show in a meta-analyses that the overall sensitivity
and specificity of SIS for intracavitary lesions is 0.95
(95% CI: 0.93–0.97) and 0.88, respectively, (95% CI:
0.85–0.92). The likelihood ratios were respectively
8.23 (95% CI: 6.2–11) and 0.06 (95% CI: 0.04–0.09).
So a normal SIS or GIS excludes intracavitary pathol-
ogy  [23] . In conclusion, an SIS/GIS should be used
when TVS is inconclusive. It is a reliable diagnostic
procedure for excluding intracavitary abnormalities in
women with HMB.
Hysteroscopy
Hysteroscopy provides direct visualization of the uter-
ine cavity by endoscopy with access through the cervix.
Intracavitary abnormalities, such as polyps or fibroids,
can be directly visualized. If required, a target biopsy
or removal of the pathology can be performed during
the same procedure. Hysteroscopy is a highly sensi-
tive and specific test, both around 93–98% (Grimbizi,
Soguktas).
Three studies compare TVS, SIS and hysteroscopy
for detecting intracavitary pathology. The sensitivity of
TVS varies from 0.69 to 0.89, and for SIS and hysteros-
copy 0.94 and 0.84–0.98, respectively. The specificity
was 0.56–0.71 for transvaginal ultrasound, 0.60–0.91
for SIS and 0.88–0.93 for hysteroscopy [24–26] .
Van Dongen et al. compared pain scores for SIS
and office hysteroscopy. Both methods were well tol-
www.futuremedicine.com 17
Special Report  Herman, Mol & Bongers
erated by women, but SIS induced significantly less
discomfort than outpatient hysteroscopy [27] .
In conclusion, the sensitivities of TVSU, SIS and
hysteroscopy are all high, but TVSU and SIS are
better tolerated by patients. Based upon these data,
hysteroscopy should only be performed if structural
abnormalities are suspected after TVS and SIS.
Outpatient versus day case hysteroscopy
Trials which compare outpatient hysteroscopy with
day case hysteroscopy in terms of patient satisfaction
and acceptability show no difference in satisfaction
(84 vs 77%) and acceptability (89%). Patients recover
significantly more quickly from outpatient hysteros-
copy than from day case hysteroscopy and pain scores
after the procedure are equivocal [28,29] . Therefore,
diagnostic hysteroscopy should be performed in an
outpatient setting.
MRI
MRI is used to visualize internal structures of the body
in detail. For the diagnosis of HMB there are only a
few indications for using MRI, such as adenomyosis or
for assessment of the suitability of fibroids for uterine
artery embolization.
If the clinician suspects that a woman has adeno-
myosis, MRI can be used in the workup for HMB as
detecting and diagnosing adenomyosis is often diffi-
cult and can be missed in daily practice. TVSU and
MRI can both be used as diagnostic tools for detect-
ing adenomyosis, and both have a similar diagnostic
accuracy  [30] . However, the accuracy of MRI seems to
be higher than the TVU. Only an experienced sonog-
Physical
examination
Laboratory testing MRI
HMB Trans vaginal Fibroids or
ultrasound adenomyosis
(no intracavitary pathology)
Pre-menopausal
women with History
No intracavitairy
complaints of +
pathology
HMB PBAC
Intracavitairy
No HMB pathology suspected
Figure 1. Flowchart for the investigation of heavy menstrual bleeding.
GIS: Gel infusion sonography; HMB: Heavy menstrual bleeding; PBAC: Pictorial blood assessment chart; SIS: Saline infusion
sonography. 
18 Womens Health (2016) 12(1)
rapher has the expertise to get the accuracy of 70%
required to detect adenomyosis. On the other hand,
MRI is less dependent on expertise, as a relatively inex-
perienced radiologist can get an accuracy of around
80%. The combination of both tests results in the best
accuracy, approximately 90% [31,32] .
MRI is also used for the visualization of fibroids,
but this is not supported by literature and the workup
for fibroids should start with TVS. Regardless of the
indication, we have to keep in mind that imaging with
MRI only has value if the result will affect the choice
of treatment.
Pathology
Endometrial sampling
There is lack of consensus for endometrial sampling
of premenopausal women presenting with HMB. The
NICE guideline recommends endometrial sampling in
women of 45 years and over or if treatment is ineffec-
tive [16] . One retrospective trial investigated the cut-off
age for endometrial sampling of premenopausal women
presenting with abnormal uterine bleeding (AUB) and
found a higher prevalence of atypical hyperplasia and
carcinoma in women over 45 years of age. They did
not, however, find a significant difference in simple
and complex hyperplasia. Nevertheless, this study was
not specified for HMB and was independent of the
findings from examination [33] .
Consider performing endometrial sampling in
women greater than 45 years. Obviously, sampling is
indicated if TVS or hysteroscopy show abnormalities
of the endometrium which make histologic pathology
likely.
No pathology
SIS/GIS Diagnostic
Inconclusive hysteroscopy
Intracavitary
pathology
future science group
 Diagnosis of heavy menstrual bleeding  Special Report

Investigation of HMB
A flowchart outlining a suggested algorithm for inves-
tigating women with HMB is shown in Figure 1. Con-
sidering the variety of underlying causes for HMB and
the increased uptake of concomitant ‘see & treat’ ser-
vices, further research is needed to better define what
the optimal testing strategies in HMB are.
Conclusion & future perspective
This chapter gives an overview of the diagnosis of
HMB. Many women who seek treatment for HMB
complain about both their physical, social and emo-
tional well-being. Objectively knowing whether or not
the blood loss is excessive could be very beneficial for
both patient and clinician. This determination will
clarify the patient’s complaint, and it will also influence
the choice and expectations of treatment. The PBAC
score can help with diagnosis as it predicts HMB reli-
ably. The clinician must also take into account the fact
that there is a wide variation in menstrual cycles and
amount of blood loss between women. This variation
should be discussed with the patient as this informa-
tion can sometimes be reassuring for her. For each
woman a thorough history should be taken to establish
the true nature of her symptoms. One should ascertain
whether there are underlying factors that could cause
these women to present with complaints of HMB.
Physical examination starts with standard gyneco-
logical examination. In daily practice, imaging tests
are widely used in the work-up for women with HMB.
The diagnosis of HMB is mostly a combination of one
of the following imaging tests: TVS; SIS; hysteros-
copy; and magnetic resonance imaging (MRI). The
first step in imaging tests should be the transvaginal
ultrasound. If this is inconclusive or if intracavitary
abnormalities are suspected then the physician can
perform an SIS or gel infusion sonography (GIS) to
visualize the uterine cavity. Laboratory tests, endome-
trial sampling, hysteroscopy and MRI should only be
performed when indicated.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involve-
ment with any organization or entity with a financial inter-
est in or financial conflict with the subject matter or mate-
rials discussed in the manuscript. This includes employment,
consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this
manuscript.

Executive summary
• Many women who seek treatment for heavy menstrual bleeding (HMB) complain about both their physical,
social and emotional well-being.
• There is a wide variation in menstrual cycles between women, so diagnosing whether the patient really suffers
from HMB can be beneficial for both physician and patient. The pictorial blood assessment chart can help with
diagnosis as it reliably predicts HMB.
• Bleeding disorders could be an underlying cause of HMB, therefore the physician has to pay attention to this
while assessing the patient’s history. However, there is no need to screen all women with HMB for coagulation
disorders.
• The first step in imaging tests is the transvaginal ultrasound. If this is inconclusive or if intracavitary
abnormalities are suspected then the physician can perform an saline infusion sonography.
• Saline infusion sonography/gel infusion sonography are reliable diagnostic procedures for excluding
intracavitary abnormalities in women with HMB.
• Laboratory tests, endometrial sampling and MRI should only be performed when indicated.

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