Excessive menstrual loss: menorrhagia

Menorrhagia can be due to uterine or systemic disorders.

Some differential diagnoses and typical outline evidence

Fibroids	Suggested by: (sometimes) urinary frequency, constipation, recurrent abortion, infertility.
	Confirmed by: pelvic examination, ultrasound or CT.
	Management: OHCS pp276–7.
Endometrial carcinoma	Suggested by: abnormal uterine bleeding, blood-stained vaginal discharge, postmenopausal bleeding.
	Confirmed by: pelvic ultrasound, tissue sampling of endometrium, hysteroscopy.
	Management: OHCS pp278–9.
Pelvic endometriosis	Suggested by: dysmenorrhoea, dyspareunia, infertility, pelvic mass.
	Confirmed by: laparoscopy.
	Management: OHCS p288.
Chronic pelvic inflammatory disease	Suggested by: lower abdominal pain, fever, vaginal discharge, dysuria, ↑ ESR and ↑ CRP, leucocytosis.
	Confirmed by: high vaginal swab, pelvic ultrasound, ± laparoscopy.
	Management: OHCS p286.
Intrauterine contraceptive device	Suggested by: history of its insertion ± painful periods.
	Confirmed by: symptoms subside after removal of IUCD.
Primary hypothyroidism	Suggested by: cold intolerance, tiredness, constipation, bradycardia.
	Confirmed by: ↑ TSH, ↓ FT4.
	Management: OHCM p306.
Bleeding diathesis	Suggested by: family history, tendency to bleed, easy bruising.
	Confirmed by: abnormal clotting screen.
	Management: OHCM pp644–9.