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Screening for Heavy Menstrual Bleeding

The following are two clinical tools that help assess for excessive bleeding. They are general bleeding assessments and are not for vaginal blood loss alone. There are many validated Bleeding Assessment Tools (BATs)!

Patient Self-Administered Bleeding Assessment Tool (Self-BAT): 
Online version: https://bleedingscore.certe.nl/ 
Printable version: https://www.path.queensu.ca/labs/james/docs/self-bat_questionnaire_and_key.pdf 

Expert (e.g. MD, RN) Administered International Society on Thrombosis and Haemostasis (ISTH) BAT
Online version: https://practical-haemostasis.com/Clinical%20Prediction%20Scores/Formulae%20code%20and%20formulae/Formulae/Bleeding-Risk-Assessment-Score/ISTH_BAT_score.html 

HMB Module Screening Diagram.png

This is from Elbaz and Sholzberg’s An illustrated review of bleeding assessment tools and common coagulation tests. 

The following is a chart that patients can use to track menstrual bleeding and help identify HMB: Menstrual Chart and Scoring System: 
Printable version: https://www1.wfh.org/docs/en/Resources/Assessment_Tools_PBAC.pdf

Consider involving a hematologist in the patient’s care if they have been having HMB since the onset of menarche. They may be living with an undiagnosed bleeding disorder.

A gynecological assessment is recommended to rule out anatomical and/or hormonal disorders that may be contributing to heavy menstrual bleeding. 

Evaluation and Workup of Heavy Menstrual Bleeding

History:​

  • Menstrual history (GTPAL, age of menarche, regularity of cycles, cycle length, cycle duration, number of heavy days, intermenstrual/postcoital bleeding)

  • Medical history, including GTPAL status

  • Bleeding history (e.g. using a Bleeding Assessment Tool)

  • Medications, including use of hormonal contraceptives, anticoagulants, and antiplatelet agents

  • Recent trauma 

  • Bleeding Assessment Tools (BATs) as described above should be incorporated into the history-taking of any patient with HMB

Vital Signs: Blood pressure, Heart Rate

Speculum and Pelvic Examinations:​

  • Depending on the age of the patient and the clinician’s judgment

  • Depending on the age of the patient and their previous history

    • Papanicolau test or HPV DNA test (age > 25 y)

    • Endometrial biopsy (age > 40 y or unopposed estrogen)

Pelvic Ultrasound:

  • Indicated for most individuals 

  • With (sonohysterogram) intrauterine saline instillation for increased sensitivity and to assess for intracavitary pathology - depending on clinical judgment (based on diagnostic suspicion and the age of the patient) 

Laboratory Tests:

  • Immediate: CBC, Ferritin

  • If periods are irregular: Pregnancy test (beta-hCG), TSH, Prolactin, FSH, estradiol

  • If signs of androgen excess: Total/free testosterone, DHEAS, androstenedione, 17-hydroxyprogesterone

  • If on warfarin: PT/INR

  • If on a direct oral anticoagulant (DOAC): Creatinine

  • If BAT is positive: refer to hematology 

Screening for bleeding disorders

We often think of INR and APTT as initial tests to evaluate for a bleeding disorder. These are not screening tests!

What to do instead? Talk to the patient! A Bleeding Assessment Tool (BAT) is the best way to screen for bleeding disorders. 

INR and APTT have sensitivities and specificities of 1-2% for inherited bleeding disorders! The most accurate tool to evaluate for bleeding disorders is a validated bleeding assessment tool (BAT).

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