How to investigate Uterine Bleeding

Patient History:
Menstrual cycles: regularity, menarche, duration, abnormalities
- establish their idea of normal/abnormal, regular/irregular
- presence of clots, pain, swelling, discharge, postcoital bleeding, dyspareunia, clots, premenstrual cycles
- Family history of 1º relatives - cycles, menarche, regularities.
Use of contraception: type, duration of length, side-effects
Obstetric history: previous/current pregnancies; complications; ante/post-partum haemorrhage; miscarriages/abortions; previous infertility.
Pap-Smears: results/regularity
STD-checks.

Presenting Complaint:
- Pain, Hirsutism, virilism, male secondary characteristics, abdominal bloating, vaginal bleeding, discharge, weight changes, temperature intolerance, galactorrhoea, nausea, vomiting, constipation, signs of blood loss (shock, anaemia), psychological/mental changes

Medical History:
- Coagulation disorders, bleeding disorders, Endocrine disease (Thyroid), Previous cancers, Previous STDs (PID), IBD (Ulcerative Collitis), Liver/Renal disease

Surgical History:
- Hysteroscopy, laparoscopic salpingoscopy, salpingectomy, hysterectomy, caesarian birth.

Medications:
- anticoagulant medication; OCP (Oestrogen/Oestrogen+Progesterone); IUD; HRT (MP/Contraceptive based)

Family History
- Bleeding disorders
- Endocrine disorders
- Previous menstrual history of first degree relatives

Social History
- Smoking, alcohol, drug use; exercise; diet; occupation; relationships (how many partners/current/past)

Physical Examination
- General appearance: pallor (anaemia), signs of endocrine disease
- Thyroid inspection
- Abdominal examination: uterine, masses (faeces, fat, flatulance, fluid, foetus, tumor), pain, colour abnormalities

Vaginal Examination (only used on currently/previously sexually active individuals)
- Cervical swab (infection - cervicitis)
- Pap-smear
- Examination of vagina (masses, colour, abrasions, bleeding, rashes)

Haematology
- FBC, Iron Studies/Anaemic studies, Blood glucose - normocytic (blood loss anaemia);
- Coagulation studies (INR/PTT)
Biochemistry
- Serum ferritin
- LFT/RFT
Hormones
- Pituitary Hormones (TFTs, Prolactin, LH/P (Ovulation), FSH(PMP/MP), Oestrogen (PMP,MP), testosterone (PCOS)
- Serum b-hCG (pregnancy/ levels indicative of intra/extra-uterine pregnancy)

Pelvic US (if not virgin - Transvaginally and transabdominally)
- Visualisation of polyps, fibroids, uterine bleeding, adenomyosis
CT/MRI
Hysteroscope
- Saline-infusion sonohysteroscopy - use of saline infusion to fill uterine cavity and show any filling abnormalities
Endometrial Biopsy
- Dilatation and Curettage