Best Practice & Research Clinical Obstetrics and Gynaecology

Vol. 21, No. 6, pp. 891–903, 2007

doi:10.1016/j.bpobgyn.2007.03.013
available online at http://www.sciencedirect.com

Diagnosis of abnormal uterine bleeding

Shruti Mohan * MRCOG, MBChB

Specialist Registrar

Louise M. Page MBBS, BSc

Specialist Registrar
St Mary’s Hospital, Paddington, London W2 1NY, UK

Jenny M. Higham MD, FRCOG

Head of Undergraduate Medicine
Faculty of Medicine, Imperial College London, South Kensington Campus, Sir Alexander Fleming Building,
London SW7 2AZ, UK

Abnormal uterine bleeding is an extremely common indication for referral to a gynaecologist.

This chapter examines the modes of presentation and the causes of such symptoms, which range
from physiological variations to more sinister underlying pathology. A thorough understanding of
these causes is required to direct investigation in an appropriate manner. The full range of pos-
sible investigations is discussed with emphasis on how to choose the most appropriate tests for
a particular patient. This is fundamental to ensure that tests are pertinent and streamlined, and
to prevent unnecessary anxiety and delay. Once the underlying causes have been clarified, a suit-
able management plan can be made.

Key words: menorrhagia; postcoital bleeding; intermenstrual bleeding; postmenopausal

bleeding; dysfunctional uterine bleeding; endometrial neoplasm; cervix; leiomyoma/fibroid;
polyp; hysteroscopy; ultrasonography; endometrial biopsy.

The vast majority of women will, at some time in their life, experience a degree of
menstrual cycle disturbance. A significant proportion of these women will seek med-
ical attention, and these symptoms therefore place a large burden on healthcare
services. Menorrhagia alone accounts for 12% of all gynaecology clinic referrals.1
In many cases, the symptoms will be relatively minor and related to self-limiting
alterations in normal physiology. However, many women experience debilitating

* Corresponding author. Tel.: 0207 8861959; Fax: 02078861569.

E-mail address: shrutimohan1@hotmail.co.uk (S. Mohan).
1521-6934/$ - see front matter ª 2007 Elsevier Ltd. All rights reserved.
892 S. Mohan et al

symptoms, and for some women, abnormal uterine bleeding will be a sign of significant
or sinister underlying pathology. In order to manage women with abnormal uterine
bleeding in a safe and efficient manner, methods are required to quantify and investi-
gate these symptoms. These investigations should be pertinent and streamlined to
prevent unnecessary anxiety and delay. Once the underlying causes have been clarified,
further action can be tailored to the individual, whether that takes the form of simple
reassurance or appropriate treatment.

DEFINITION OF ABNORMAL UTERINE BLEEDING

Abnormal uterine bleeding is a broad term encompassing a range of presentations.

Those most commonly prompting referral to a gynaecologist are as follows.

Menorrhagia

Menorrhagia may be defined in two ways. The Royal College of Obstetricians and
Gynaecologists has defined it as ‘heavy cyclical bleeding over several consecutive
cycles’.2 However, this is a subjective definition and women’s own retrospective
account of bleeding heaviness has been shown to have little consistency with measured
blood loss.3 The generally accepted objective definition of menorrhagia is of menstrual
blood loss greater than 80 mL per cycle. This definition is based upon population stud-
ies which demonstrated that approximately 10% of women experienced this level of
bleeding and that it carries an association with iron deficiency.4 Methods for the
objective measurement of menstrual blood loss are considered later in this chapter.

Postcoital bleeding

Postcoital bleeding (PCB) is genital tract bleeding after intercourse. It may be a mani-
festation of cervical dysplasia, polyps, ectropion or genital tract infection, and there-
fore warrants thorough investigation. In a recent case series of 142 women with
PCB, 19% were found to have cervical intra-epithelial neoplasia (10% high grade), of
whom 74% had a recent negative smear test.5 This suggests that all women with
this presentation should be referred for colposcopy.

Intermenstrual bleeding

Intermenstrual bleeding (IMB) is bleeding arising from the genital tract, not during
menstruation or following intercourse in a woman having periods.

Postmenopausal bleeding

Postmenopausal bleeding (PMB) is defined as genital tract bleeding occurring more

than 12 months after the last menstrual period.

The term ‘menorrhagia’ generally supposes bleeding from the uterus. PCB, IMB and
PMB describe presentations and do not refer to a specific site of bleeding. The whole
genital tract, the gastrointestinal tract and the urinary tract must be considered as
possible sources of bleeding.
 Diagnosis of abnormal uterine bleeding 893

The choice of appropriate investigations for abnormal uterine bleeding will depend
upon the particular combination of the above symptoms, as well as the presence or
otherwise of associated risk factors for malignancy, such as age (Table 1).

QUANTIFICATION OF MENSTRUAL BLOOD LOSS

As discussed above, women’s own descriptions of levels of bleeding often have a poor
correlation with objective measurements. Many methods have been described for
quantifying blood loss, such as collection of menstrual blood in a menses cup or the
alkaline haematin method, which involves chemical extraction of haem from sanitary
pads.
In clinical practice, these techniques have little relevance, as the focus must be on
improving quality of life for any woman who feels that she has a problem with
heavy bleeding.6 However, pictorial blood loss assessment charts (Figure 1) have
been shown to be simple and quick to use, and can be particularly useful in the
monitoring of therapy.7

CAUSES OF ABNORMAL UTERINE BLEEDING

An understanding of the causes of these symptoms is required in order to direct

history, examination and investigation in a rational manner. In practice, the non-uterine
causes of abnormal bleeding will also need to be excluded in women with the presen-
tations discussed above. Table 2 outlines the non-uterine causes of abnormal genital
tract bleeding.
The causes of abnormal uterine bleeding can be classified as follows:

Pregnancy related

Pregnancy must be excluded in any woman of reproductive age presenting with abnor-
mal uterine bleeding. This may be by urine pregnancy test or serum b-human chorionic
gonadotrophin measurement.

Physiological

Menstrual cycle disturbance is common at the extremes of reproductive life. In addi-

tion, IMB is sometimes caused by a decrease in oestrogen levels following the follicular
phase peak, allowing shedding of the endometrium.

Table 1. Risk factors for endometrial carcinoma.

Raised body mass index Inactive lifestyle
Diabetes mellitus Poor diet e high fat/low complex carbohydrate
Early menarche Tamoxifen use
Late menopause Unopposed oestrogens
Prolonged irregular Personal or family history of breast cancer/bowel cancer/
bleeding endometrial cancer
Nulliparity Age >40 years
894 S. Mohan et al

Name: E.G.N
Day start=5.NOV 89

Score=283
Towel 1 2 3 4 5 6 7 8

II I I I I

IIII III II

II II

Clots/ 50P 1P
Flooding x1 x3

Tampon 1 2 3 4 5 6 7 8

I II I

II III II

IIII IIII
I

Clots/
Flooding

Figure 1. Assessment of menstrual blood loss using the pictorial blood loss assessment chart.

Benign endometrial or cervical pathology

Fibroids
Uterine leiomyomas (fibroids) are benign smooth muscle tumours of the myometrium
and are present in one in five women of reproductive age.8 The majority of these
women will be asymptomatic, but a significant proportion (between 20% and 50% in
different series) will experience menstrual disturbance, pressure symptoms, or fertil-
ity- and pregnancy-related problems. Certainly the most commonly attributed symp-
tom is menorrhagia9, although much of the evidence for this relates to the reduction in
blood loss following myomectomy.10 There is no clear evidence that size or location of
fibroids affects symptoms, although it is often felt that submucous fibroids distorting
the uterine cavity are more likely to cause abnormal bleeding. The malignant potential
 Diagnosis of abnormal uterine bleeding 895

Table 2. Non-uterine causes of genital tract bleeding.

Atrophic vaginitis
Vulval causes
Vulval intra-epithelial neoplasia
Vulval carcinoma
Skin conditions
Vaginal lesions
Trauma
Foreign body

of fibroids is debatable, but is extremely low. Therefore, this should not be used as
a clinical justification for their removal in an asymptomatic woman.

Endometrial polyps
A significant cause of menorrhagia or IMB, particularly in the later reproductive years,
is the formation of endometrial polyps. These are the result of focal overgrowth of
endometrial glands and stroma, and may also cause PMB. The risk of malignancy is
approximately 1%11, although this is predominantly in the postmenopausal group.

Endocervical polyps
Endocervical polyps consist of connective tissue stroma and cervical glands covered
with columnar epithelium, which may undergo squamous metaplasia. There is a very
low risk of malignancy (approximately one in 6000). They are often asymptomatic
but can be a cause of abnormal bleeding, classically PCB.
On speculum examination, these polyps are usually identified protruding through
the cervix and can commonly be avulsed in the outpatient clinic. However, the endo-
metrium must be assessed if abnormal bleeding does not resolve after removal of the
polyp.

Cervical ectropion
When endocervical columnar epithelial cells are everted on to the ectocervix, they
appear as an ‘erosion’. This is thought to be induced by exposure to higher levels
of oestrogens and is therefore more common at puberty and during pregnancy. It is
also seen more frequently in women taking the combined oral contraceptive pill12,
although this association is less strong with modern low-dose pills.
An ectropion is a common incidental finding and, when asymptomatic, does not re-
quire treatment. It may, however, lead to increased vaginal discharge, PCB or predispose
to cervicitis. Cervical dysplasia and infection should be excluded before any destructive
treatment, such as cryotherapy, is performed.

Malignant endometrial or cervical pathology

The possibility of cancer of the cervix or endometrium must be considered in any

patient with abnormal bleeding. The need to exclude these conditions formally will
depend upon the particular risk factors and presentation.
896 S. Mohan et al

Endometrial carcinoma and endometrial hyperplasia

The most significant risk factor for endometrial cancer is increasing age and it must be
excluded in any woman presenting with PMB. However, 20–25% of cases occur in pre-
menopausal women13 who may present with menorrhagia.
Other risk factors include obesity, nulliparity and polycystic ovarian syndrome14 (see
Table 1). These share a common pathway of excessive endometrial oestrogenic stimu-
lation, and therefore tamoxifen therapy also predisposes to endometrial malignancy.
This same aetiology is also implicated in the development of endometrial hyperplasia.
Endometrial hyperplasia is excessive proliferation of the endometrial glands and, to
a lesser extent, the endometrial stroma. It may present with menorrhagia, IMB or PCB
and is classified as simple, complex or atypical. Simple and complex hyperplasias carry
a 1–3% risk of malignant transformation. The risk of endometrial carcinoma with a
diagnosis of atypical hyperplasia has been reported to be between 23%15 and, more
recently, 43%.16

Cervical cancer and cervical intra-epithelial neoplasia

In the UK, the death rate from cervical cancer has halved since the introduction of
nationwide screening.17 Worldwide, however, it remains the most common gynaeco-
logical malignancy, and even in the developed world, it must not be forgotten as an
important cause of abnormal bleeding. The age distribution of these tumours shows
a bimodal peak of incidence at 35–39 years and 60–64 years.18 The vast majority
(85–95%) are squamous cell carcinomas, but the prevalence of adenocarcinomas is ris-
ing and these often present in women under 35 years of age.19
Although premalignant changes in the cervix are common and generally asymptom-
atic, cervical intra-epithelial neoplasia may also provoke symptoms such as PCB or IMB.5

Systemic causes

Exogenous hormones
The use of any form of hormonal contraceptive can lead to a disturbance of the nor-
mal menstrual cycle, particularly around the time of their commencement. The com-
bined oral contraceptive pill may cause IMB, and progestogen-only contraceptives are
associated with irregular bleeding. Similarly, hormone-replacement therapy in post- or
perimenopausal women can lead to abnormal bleeding. Despite these associations, it is
important to exclude other pathology in a woman in whom these symptoms do not
settle swiftly.

Medical conditions
Numerous medical conditions have been postulated to influence the menstrual cycle,
often without firm evidence. In particular, a wide variety of disorders have been sug-
gested as causes of menorrhagia, a summary of which is given in Table 3. A few of these
conditions are considered further here.

Thyroid disease. There is evidence that hypothyroidism is associated with menorrha-

gia20, and that return to the euthyroid state with thyroxine treatment reduces objec-
tively measured losses significantly.21 Conversely, there are data supporting the link
between hyperthyroidism and oligo- or amenorrhoea.
 Diagnosis of abnormal uterine bleeding 897

Table 3. Medical diseases thought to be associated with menorrhagia.

Endocrine disease Thyroid dysfunction
Pituitary/adrenal gland abnormalities
Haematological disease Coagulation disorders
Platelet abnormalities
Sickle cell disease
Auto-immune disease Systemic lupus erythematosus
Hepatic, renal and cardiac disease Liver disease
Renal disease
Cardiac disease
Metabolic disease Gaucher’s disease

Haematological conditions. That coagulation disorders can lead to abnormal menstrua-

tion seems irrefutable22, and thrombocytopaenia has also been implicated. In addition,
iatrogenic anticoagulation has been shown to increase menstrual blood loss.23
Although only a small proportion of menstrual disturbances can be attributed to
such conditions, these patients pose a particular challenge as diagnosis can easily be
missed and they may not be amenable to conventional treatments.

Pelvic infection

Infection of the upper or lower genital tract can lead to abnormal bleeding. Cervicitis, which
may be caused by chlamydia or gonorrhoea infection for example, is a common cause of
IMB and PCB. Women with pelvic inflammatory disease, endometritis or salpingitis may
present with non-scheduled bleeding, with or without associated symptoms such as fever
and pain. Infection screening must therefore be considered, particularly in young women.

Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) can be defined as ‘excessive uterine bleeding

(excessively heavy, prolonged or frequent), which is not due to demonstrable pelvic
disease, complications of pregnancy or systemic disease’.24 It is therefore a diagnosis
of exclusion and includes both ovulatory and anovulatory bleeding. The majority of
cases of DUB are secondary to hormonal dysfunction, and occur in perimenopausal
women or after the menarche.25 In adolescence, this is usually of hypothalamic-pitui-
tary origin, whilst in the perimenopause, it is related to unstable and reducing ovarian
function. A wealth of observational data4,26 supports the idea of increasing variability
of the menstrual pattern as women approach the menopause. This may make the
detection of underlying pathology particularly challenging in this age group.

HISTORY

The taking of a good history is essential to any therapeutic encounter. The history
should focus on the likely causes of abnormal menstrual bleeding (see Table 4) as
well as aiming to establish the amount and frequency of the bleeding.
898 S. Mohan et al

Table 4. Causes of abnormal uterine bleeding.

Pelvic Uterine fibroids
Adenomyosis
Endometrial polyps
Pelvic infection
Endometrial hyperplasia
Endometrial adenocarcinoma
Presence of copper-containing intra-uterine contraceptive device
Uterine vascular malformations
Myometrial hypertrophy
Systemic Coagulation disorders, i.e. thrombocytopenia, von Willebrand disease
Hypothyroidism
Systemic lupus erythematosus
Chronic liver failure
Functional Dysfunctional uterine bleeding

Features within the history that are identified risk factors for endometrial carcinoma
should be looked for specifically, as the identification of endometrial carcinoma or hyper-
plasia is clearly of importance (see Table 2) A relevant family history should be established.
Enquiries should be made about IMB and PCB. Pregnancy must always be excluded.
A contraceptive history should be taken, as recent-onset menorrhagia may be
explained by, for example, the cessation of the combined oral contraceptive pill follow-
ing male or female sterilization, or by the recent insertion of a copper-containing intra-
uterine device. The wish for preservation, or otherwise, of fertility should be noted, as
this will have much importance when planning management options.
The date and result of the last cervical smear should be noted, and any previous
cervical smear abnormalities, colposcopy attendances or cervical surgery reviewed.
The presence of pelvic pain and/or pressure effects should be investigated, as these
may indicate the presence of uterine pathology or other disorders.27 Questions should
be directed specifically to ensure that the bleeding is from the genital tract, and is not
being confused with urological or gastrointestinal bleeding which require different in-
vestigations and appropriate referral.
In order to provide a holistic approach, the clinician should explore the woman’s
perspective of her symptoms. By exploring the woman’s ideas, concerns and expecta-
tions regarding her bleeding and potential treatments, the requirements of therapy,
education and reassurance may be determined.6

EXAMINATION

General examination should include assessment for anaemia, thyroid disease and clot-
ting disorders.
Abdominal palpation may detect a grossly enlarged fibroid uterus, which should
trigger referral from primary to secondary care.6 Inspection of the vulva and vagina
is essential in order to exclude any gross pathology.
Speculum examination of the cervix is vital to exclude a cervical polyp or macro-
scopic cervical tumour. A cervical smear should be taken if due or clinically indicated.
If there is a suggestion of invasive tumour, urgent colposcopic assessment should be
sought. Vaginal and cervical swabs should be taken for microbiology where appropriate.
 Diagnosis of abnormal uterine bleeding 899

Bimanual pelvic examination will allow for the assessment of uterine size and
mobility, pelvic tenderness and adnexal masses.

INVESTIGATIONS

The need to exclude local pelvic pathology and systemic disease is the driving force
behind investigations for uterine bleeding. However, the vast majority of women inves-
tigated for menorrhagia have ‘normal’ endometrium, and would therefore be consid-
ered to have a functional disorder, DUB.27 Therefore, those women most likely to
have abnormal endometrium should be identified through history and examination
findings to limit unnecessary investigations, which have economic implications and
may, to varying degrees, be difficult for women to tolerate.
The latest guidance from the National Collaborating Centre for Women’s and
Children’s Health states that if the history obtained suggests menorrhagia without
structural or histological abnormality, pharmaceutical treatment (with the exclusion
of the levonorgestrel-releasing intra-uterine system) can be commenced without
carrying out a physical examination or other investigations at the initial consultation
in primary care.6
If, however, the history suggests menorrhagia with structural or histological abnor-
mality, with symptoms such as IMB or PCB, pelvic pain and/or pressure symptoms,
a physical examination and/or other investigations should be performed.6

Blood tests

A full blood count should be obtained from all women with menorrhagia who require
investigation in order to recognize iron deficiency and anaemia. Iron supplements
should be prescribed as needed.2 A serum ferritin level may be useful if there is any
doubt about iron deficiency28, but should not be a routine investigation.6 The full
blood count will also provide information about the platelet count and thereby identify
those women with thrombocytopenia.28
Systemic diseases are rare causes of menorrhagia and investigations to treat them
should not be routine.28 Thyroid function tests are only indicated in women where the
history or examination findings are suggestive of thyroid disease.6 The same is true for
bleeding disorders.2 A coagulation screen may be indicated where there is a history of
easy bruising or dental bleeding.28 Testing for coagulation disorders (e.g. von Wille-
brand disease) should be considered in women who have had menorrhagia since men-
arche and have a personal or family history suggesting a coagulation disorder.6

Assessment of the uterine cavity

In women at high risk for endometrial carcinoma (see Table 1) or those for whom
symptoms do not resolve following first-line medical therapy, the endometrium should
be assessed for both structural and histological abnormalities. Imaging should be un-
dertaken if the uterus is palpable abdominally or when vaginal examination reveals
a pelvic mass of uncertain origin.6
The assessment may be by:

 ultrasound;
 endometrial biopsy;
900 S. Mohan et al

 dilation and curettage (no longer conducted alone);

 hysteroscopy; or
 magnetic resonance imaging.

These modalities may be used in isolation or in combination.

Ultrasonography
Ultrasound is the first-line diagnostic tool for identifying structural abnormalities.6
Ultrasonography using transabdominal or transvaginal probes can be used to assess
the size, number and location of fibroids and to measure endometrial thickness; a
useful indicator to determine the need for further endometrial assessment.13
The introduction of transvaginal ultrasound has allowed higher frequency probes to
be employed, resulting in high-quality image resolution and improved predictive
ability.29
It is possible to obtain more information about the endometrium by the use of
saline instillation at the time of ultrasonography. This allows distension of the endome-
trial cavity to allow improved imaging of the cavity. Ultrasonic detection of submucous
fibroids is improved substantially with saline infusion sonography.29
Transvaginal ultrasound is less limited by patient obesity than the transabdominal
route, and is a quick, simple and reproducible procedure. The failure rate of transva-
ginal ultrasound is negligible.29
Endometrial thickness of 5 mm or less over the whole cavity is said to exclude
endometrial carcinoma; this is mainly of value in postmenopausal women. Where
the endometrial thickness is found to be greater than 5 mm on transvaginal
ultrasound, endometrial sampling should be performed in the postmenopausal
setting.30
Endometrial thickness measurement using ultrasound is of minimal use in premen-
opausal women because specific cut-off levels or morphological features do not define
accurately the presence or absence of endometrial hyperplasia or cancer.29 However,
the Royal College of Obstetricians and Gynaecologists’ Guideline Development Group
concluded that 10–12 mm represented a reasonable cut-off to decide if further
investigations are indicated when using transvaginal ultrasound in premenopausal
women.2,27

Endometrial sampling
An endometrial biopsy should be performed for all women with ultrasonic abnormal-
ities and should be considered for all women with persistent menorrhagia.2 An endo-
metrial biopsy is important even if a hysteroscopy is normal.2,27
Outpatient endometrial biopsy has high accuracy in diagnosing endometrial cancer
and hyperplasia, and should be employed when serious endometrial disease is sus-
pected in both pre- and postmenopausal women.29
Following acceptability trials in the 1980s, the Pipelle endometrial sampler has been
adopted as the preferred device.2,27
The main concern of ‘blind’ sampling of the endometrium is that serious pathology
may be missed. The incidence of false-negative results is now known to be so high that
serious consideration needs to be given to discarding this investigation in favour of the
more precise modern methods of imaging and tissue collection.28
 Diagnosis of abnormal uterine bleeding 901

Dilation and curettage

Dilation and curettage is now largely of historical interest. Available evidence suggests
that dilation and curettage no longer has a place in either the treatment or investiga-
tion of abnormal uterine bleeding.27

Hysteroscopy
Modern hysteroscopes combine miniaturization with excellent image resolution and
visualization29; therefore, hysteroscopy can be performed in the outpatient setting
without the need for a general anaesthetic. Outpatient hysteroscopy is generally
very well tolerated by and acceptable to women.
Instrumentation and distension of the uterine cavity, whether using saline infusion
sonography or outpatient hysteroscopy, is comparatively more painful than transvagi-
nal ultrasound, but both procedures appear to be equally well tolerated.29 The use of
saline as opposed to carbon dioxide for uterine distension and attention to pain con-
trol help to minimize discomfort during hysteroscopy.29
Hysteroscopy can fail due to the inability to pass the scope along the endocervical
canal or due to patient discomfort. Once the hysteroscope is within the uterine cavity,
the view obtained can be limited by bleeding or intra-uterine debris.29
Hysteroscopy should be used as a diagnostic tool only when ultrasound results are
inconclusive, e.g. to determine the exact location of a fibroid or the exact nature of an
abnormality.6 Hysteroscopy is better at identifying polyps than ultrasound.6 Hystero-
scopy allows direct visualization of the endometrial cavity and, importantly, directed
endometrial sampling of any suspicious areas.
Hysteroscopy can also be therapeutic, allowing the removal of endometrial polyps,
submucous fibroids or the endometrium.

Magnetic resonance imaging

Evidence shows that magnetic resonance imaging has no advantage over ultrasound as
a first-line investigation for menorrhagia, but may be reserved for problem solving
where ultrasound provides indeterminate results.6

SUMMARY

Abnormal uterine bleeding is common and encompasses the presentations of menor-

rhagia, PCB, IMB and PMB. The causes are varied and include complications of preg-
nancy, benign and malignant lesions, systemic causes and DUB. Although a large
proportion of these women will require nothing more than reassurance, these symp-
toms must be taken seriously as they may have a major impact on a woman’s quality of
life, and to ensure that the minority of women with significant underlying pathology
are identified.
Investigations should be chosen carefully to distinguish between these diagnoses
in as safe and efficient a manner as possible. Where appropriate, structural and his-
tological abnormalities should be identified so that therapies can be directed
accordingly.
To maximize the success of the therapeutic encounter, the woman’s ideas, con-
cerns, expectations and needs must be explored and used to guide investigations
and treatment. Good counselling and adequate explanation of all procedures and
results is paramount for successful management of abnormal uterine bleeding.
902 S. Mohan et al

Practice points

 anaemia needs to be assessed and treated in women with abnormal uterine bleeding
 women with abnormal uterine bleeding and risk factors for endometrial carci-
noma should be investigated thoroughly to exclude endometrial hyperplasia
and carcinoma
 where a woman has a abdominally-palpable uterus, a pelvic mass on vaginal ex-
amination or where pharmacological treatments have failed, imaging should be
employed to investigate structural abnormalities
 if on reviewing the history from a woman with abnormal uterine bleeding,
there are no features suggestive of serious pathology, pharmacological treat-
ments may be commenced without the need for examination or investigation
 any abnormal uterine bleeding that does not improve with simple pharmaco-
logical measures needs investigation
 thyroid function and clotting tests should only be performed if the history or
examination findings are suggestive of systemic abnormalities

Research agenda

 investigation of the impact of abnormal menstrual bleeding on quality-of-life

parameters of affected women
 development of increasingly accurate non-invasive investigative techniques in
order to minimize morbidity from invasive procedures

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