3.  Ultrasound pelvis  Full blood count  Pap smear  Coagulation profile  Liver function tests  Serum Iron  Serum ferritin  Endometrial biopsy  CT pelvis and abdomen  Serum CA125  Renal function tests  Office hysteroscopy  TSH  Thyroid function tests  Serum FSH & LH  Serum beta HCG  Serum oestradiol  Serum prolactin  Serum Progesterone  D&C uterus  None of the above

4.  Ultrasound pelvis To evaluate the endometrium. If diffusely thickened it suggests that a Pipelle biopsy would be useful Exclude submucous fibroid(s) Other fibroids of less interest because the uterus is not enlarged Ovarian imaging useful

5.  Full blood count  Check HB  RBC’s may show signs of chronic blood loss  Platelet count  Excludes major blood dyscrasia

6.  Pap smear  This is not a test for cervical cancer. If that is suspected after visual inspection and palpation then biopsy is required  Should be done if not previously done or overdue

7.  Coagulation profile  A clotting disorder is very rarely the cause of this problem  This is not a first line test  Ask about “other bleeding and bruising”  Check family history  Warfarin but not aspirin or NSAID may be relevant

8.  Liver function tests  Renal function tests  This patient requires a blood test and adding these two to a FBC is sensible  Renal failure may present with menstrual disorder  Liver failure can cause a coagulopathy

9.  Serum Iron  Serum ferritin  Not first line tests but may be required if anaemia is a problem  Serum ferritin is favoured by NZ DOH as a criterion for the Mirena for which this patient may be a candidate

10.  Endometrial biopsy  If there is diffuse widening of the endometrial echo a simple Pipelle sampling will exclude cancer of the endometrium with >97% sensitivity  Some pathologists would prefer that you do this before administering progestins

11.  CT pelvis and abdomen  Not unless you (or the patient or the radiologist) are prepared to pay for it!

12.  Serum CA125  Not required  It would be indicated if the ultrasound disclosed a suspicious ovarian mass  But it is not recommended as a screening test for ovarian cancer  I sometimes use a menstrual phase CA125 for a patient with possible endometriosis  But only when laparoscopy is not readily available

13.  TSH  Thyroid function tests  Thyroid dysfunction may present as a menstrual problem  Look for other symptoms and signs  TSH is the best screening test

14.  Serum FSH & LH  Serum beta HCG  Serum oestradiol  Serum prolactin  Serum Progesterone  Although anovulation is the most likely diagnosis endocrine studies are rarely used or useful  Do not use a high FSH to label the patient as “postmenopausal”  Ask about hot flushes instead  Always exclude pregnancy

15.  D&C uterus  A 21 st century gynaecologist would favour ultrasound +/- saline ultrasonography or Pipelle sampling or office hysteroscopy

17.  Oral oestrogens  IV Oestrogen  Oral Progestin  IM Depot Provera  Oestrogen and Progestin by mouth  Tranexamic acid (Cyklokapron)  Mirena IUS  Danazol  D&C uterus

18.  Oestrogens by mouth  This patient may already be hyperoestrogenic  There is a risk of thromboembolism

19.  IV Oestrogens  IV Premarin said to be very effective  There is a risk of thromboembolism

20.  Oral Progestin  Creates a decidual-like endometrium  Use Norethisterone 5 -10 mg Q6H til bleeding stops then BD for 10 – 12 days  Has progestogenic and oestrogenic actions  There is a theoretical risk of thromboembolism  Warn the patient about withdrawal bleeding

21.  IM Depot Provera  Unpredictable in onset  Unpredictable in duration

22.  Oestrogen & Progestin by mouth  Using any form of oral contraceptive pill may be effective  However, BD or TDS dose required my be an unacceptable risk of thromboembolism

23.  Tranexamic acid (Cyclokapron)  Will reduce menstrual flow in 85% of women but it is not the drug of choice to stop bleeding here  There is no risk of thromboembolism when used according to directions i.e. 500 – 1000 mg TDS or QID

24.  Mirena IUS  A very good option  Circulating concentration of d-norgestrel equivalent to 2 tablets of Noriday per week  Troublesome irregular bleeding can occur for 6 – 16 weeks

25.  Danazol  Would probably work  Indicated in the management of menorrhagia  Expensive  Has more androgenic side- effects than progestins

26.  D&C uterus  Both diagnostic and therapeutic  Requires hospitalisation and usually GA  And the patient may have the same problem next cycle!