Menorrhagia/dysmenorrhoea
O&G
Introduction
Author: Idayat Oluwale
When taking a history for menorrhagia (excessive menstrual bleeding), focus on onset, duration, pattern, and severity of bleeding. Ask about cycle regularity, clot size, need for pad/tampon changes, and impact on daily life. Assess for associated symptoms (e.g., pain, intermenstrual or postcoital bleeding) and systemic signs (e.g., fatigue, pallor suggesting anemia). Inquire about potential causes, including gynecological (fibroids, polyps, endometriosis), hormonal (PCOS, thyroid dysfunction), or hematological disorders. A thorough medical, surgical, and medication history (especially anticoagulants) is essential.
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WIPER
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB or Hospital number
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Presenting Complaint
Main symptom: Heavy/Painful periods
History of Presenting complaint:
Use the acronym SOCRATES where applicable
Site- Where do you experience pain? – Abdomen, Pelvic area, etc
Onset- When did this start? Has it happened before?
Character- Amount of blood, Are there any clots, Colour/ Can you describe the pain? Eg: sharp, dull, cramp-like, etc
Radiation- Do you feel the pain anywhere else?
Associated features – Fatigue, Pain eg dyspareunia, Menstrual irregularities eg IMB, Post-coital bleeding
Timing – Continuous bleeding or at specific times eg: inter-menstrual bleeding, post-coital bleeding
Exacerbating & relieving factors-
Severity – Amount of blood eg: bleeding through clothes, using how many pads/ tampons and needing to change how often
Don’t neglect asking in-depth questions about associated features, eg: regarding the fatigue, how long have you been feeling that way? You can again use SOCRATES if applicable. This may help separate acute issues from non-acute ones
Systems review:
A systems review may help identify risk factors which will help to narrow down differentials
For gynae histories use the acronym MOSC
Menstruation: Regular/Irregular, Age at Menarche, Date of LMP
Obstetrics: Gravida and Parida, Methods of delivery, Any previous complications,
Sexual activity: Is the patient sexually active, One or more sexual partners, Using any contraception, Previous STI screening
Cervical smear: If of age then has the patient had smear tests?, Any previous abnormal results?
Always do a constitutional systems review asking about: Unintentional weight loss, SOB, fevers, fatigue, loss of appetite, pain
Elicit ideas, concerns and expectations using the acronym ICE
Ideas- Do you have any ideas what might be causing this?
Concerns- Is there anything you’re worried about?
Expectations- What are you most hoping for from me today?
Summarise everything the patient has told you to ensure you have correct information or incase anything was missed
Past Medical History
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB or Hospital number
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Medications
Ask about allergies and OTC, herbal or prescribed medications
For vaginal bleeding specify blood thinners and certain contraceptives eg: IUDs even if the patient says they aren’t on any current regular medications
Family History
Are there any medical conditions that run in the family
Specify family history of bleeding, clots, breast or ovarian cancer
Social History
Social history refers to a patient’s sexual activity, smoking, alcohol and drug use, as well as housing, dietary, and occupational status
Tailor these towards whichever history you are undertaking. For gynae histories important factors include: smoking (how many a day and for how long), sexual activity (may have been asked during systems review)
Differential Diagnosis
Separate differentials into most likely, less likely and can’t miss. Each section will differ based on results from the history and examination
Examples of differentials for vaginal bleeding include: Endometreosis, Leiomyoma, STIs, Anticoagulation, Cervical cancer, Ectopic pregnancy, etc
Management
Remember: Bedside --> Laboratory --> Imaging
Bedside examination includes:
Bimanual +/- speculum examination
Laboratory investigations include bloods such as:
Group and save/crossmatch depending on amount of bleeding
FBC to check for anaemia
Pregnancy test/ beta HcG
Imaging includes:
Ultrasound eg: TVUS, Abdominal
Hysteroscopy +/- biopsy
Summarise and present findings from history, exam and lab results
Management plan
Tailor the management based on diagnoses
Discuss with all relevant persons ie: the patient and colleagues