MENORRHAGIA (Part Two)

DIAGNOSIS:

1. Detailed Anamnesis:
• Exclusion of pregnancy
• The amount and quality of vaginal hemorrhage: The patient should be carefully asked about the frequency of changing tampons or pads and the presence or absence of clots (coagulated blood).
• Age of the patient: Girls from menarche until the end of adolescence often have anovulatory cycles due to the immaturity of the hypothalamus-pituitary-ovary axis. Women aged 30-50 are more often suspected of organic or anatomical causes of menorrhagia. Postmenopausal women are suspected of endometrial cancer. Endometrial hyperplasia is suspected in women over 70, obese, nulliparous, or with diabetes.
• Pelvic pain: detailed information about the time of onset of pain and duration.
• Menstrual history: whether menorrhagia has been established since menarche or has been established at another age and time.
• Sexual activity: Sexually transmitted infections such as chlamydia or gonorrhea cause vaginal hemorrhage. Chlamydia causes postpartum endometritis, which is accompanied by hemorrhage.
• Use of contraceptives: IUD and oral contraceptives
• Presence of hirsutism: Polycystic ovary syndrome
• Galactorrhea (production of milk from the mammary glands not in lactation conditions): prolactin-producing pituitary tumor.
• Chronic diseases: Liver, kidney, diabetes, etc.
• Thyroid diseases: hypo or hyperthyroidism.
• Bleeding disorders or coagulation disorders.
• Medications currently used: anticoagulants or progestin.
• Surgical interventions.
2. Objective Examination: Inspection of the patient for:
• Signs of anemia
• Obesity – adipose tissue is the site where estrogen conversion occurs; the more obese the patient, the higher the risk of endometrial cancer.
• Hirsutism – a sign of polycystic ovary syndrome and anovulatory cycles.
• Ecchymosis – a sign of trauma or coagulation disorders
• Purpura – a sign of coagulation disorders.
• Acne – a sign of polycystic ovary syndrome.
• Visual fields
• Gingivorrhagia
• Evaluation of the thyroid gland
• Galactorrhea
• Hepato-splenomegaly
3. Pelvic Examination
• Vulva – presence of external lesions
• Vaginal secretions amount, color, consistency, smell.
• Inspection of the cervical neck for macroscopically visible lesions, mobility, position.
• Shape, size, consistency, and mobility of the uterus.
• Adnexa and parameters – masses, mobility, tender or not on bimanual palpation.
4. Laboratory Tests
• Complete Blood Count
• Ferritinemia, Sideremia
• Coagulation factors
• Beta- human chorionic gonadotropin.
• Hormones TSH, ft3, ft4 for thyroid gland function, and Prolactin.
• Transaminases and bilirubin.
• Creatinine, azotemia, uricemia.
• Hormones LH, FSH and androgens to assess polycystic ovary syndrome.
• Test for adrenal gland function – 17 – alpha hydroxyprogesterone (17-OHP).
• Pap-Test
• Vaginal secretion cultures
5. Imaging Examinations
• Abdominal Ultrasound
• Hysterosalpingography
6. Procedures
   • Diagnostic and interventional hysteroscopy.
   • Endometrial biopsy through dilation-curettage. If after the result it is seen that there are few cells, the diagnosis of endometrial atrophy is made, which is treated with estrogen replacement. Non-atypical endometrial hyperplasia requires treatment with progesterone. Atypical endometrial hyperplasia, especially the adenomatous type, is assessed as an intraepithelial malignant lesion and hysterectomy (removal of the uterus) is usually advised. In the case of endometrial carcinoma, it should be examined and treated based on the cancer staging by the oncogynecologist.