Heavy Menstrual Bleeding (menorrhagia)
Excessive menstrual blood loss (> 80 mL per cycle) or prolonged bleeding (> 7 days) that interferes with a woman's physical, social, or emotional quality of life.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Dysfunctional uterine bleeding / AUB-Endometrial (anovulatory) | Irregular heavy cycles, no structural cause, reproductive age | 「你經期準唔準時？有時會唔會遲好耐先嚟？」(Are your periods regular or do they sometimes come very late?) | ~25% |
| Uterine fibroids (AUB-Leiomyoma) [3] | Regular HMB ± pressure sx, asymmetric bulky uterus on exam | Bimanual: asymmetrical uterine enlargement [3] | ~25% | |
| Adenomyosis [3] | Regular HMB + progressive dysmenorrhoea, mid-30s–40s | 「經痛有冇一年比一年嚴重？」(Is your period pain getting worse year by year?) | ~10% | |
| Serious Not To Miss | Ectopic / miscarriage | Missed period → heavy PV bleeding, +ve pregnancy test | 「上一次經期幾時嚟？有冇機會懷孕？」 | ~2% |
| Endometrial cancer | IMB, risk factors (obesity, PCOS, tamoxifen, age ≥45), failed Tx | 「兩次經期之間有冇出血？你體重有冇過重？」 | ~2% | |
| Coagulopathy (vWD) [2] | HMB since menarche, mucocutaneous bleeding, FHx | 「你由第一次嚟M開始就好多？拔牙流血耐唔耐？」 | ~1% | |
| Cervical cancer | PCB, abnormal Pap, contact bleeding on speculum | 「同房之後有冇流血？」+ speculum: friable cervical lesion | < 1% | |
| Pitfalls | Endometrial polyp | IMB, often missed on exam; needs US/hysteroscopy | 「兩次經期之間有冇少少出血？」+ TVUS | ~10% |
| Copper IUCD [3] | Temporal relationship with IUCD insertion | 「你幾時裝咗避孕環？裝之後經期有冇變多？」 | ~5% | |
| Chronic PID / endometritis | Discharge, pelvic pain, fever | 「有冇分泌物多咗？有冇發燒或者肚痛？」 | ~2% | |
| Masquerades | IDA secondary to HMB [4] | The anaemia IS the masquerade – treat cause not just iron | Pallor, koilonychia, tachycardia | ~20% |
| Anticoagulant / NSAID use | Drug-induced; temporal correlation | 「你有冇食薄血藥或者止痛藥？」 | ~3% | |
| Hypothyroidism | Fatigue, weight gain, cold intolerance + HMB | 「有冇肥咗？怕唔怕凍？」 | ~2% | |
| Trying to Tell Me Something? | Fear of cancer / infertility anxiety / relationship stress / domestic violence | Explore with open questions | 「你最擔心啲咩？呢個情況有冇影響你同屋企人嘅關係？」 | ~15% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport | 「你好，我係X醫生，今日想了解下你嘅情況，方唔方便傾下？」(Hello, I'm Dr X, is it OK to chat about your concerns today?) | Greeting + permission → interpersonal marks |
| 0:30–2:00 | Chief complaint & HPI – characterise bleeding (duration, quantity, clots, flooding, cycle regularity, IMB/PCB) | 「你月經大概幾時開始多咗？每次嚟幾多日？要換幾多塊M巾？有冇出血塊？有冇半夜要起身換？」 | Establishes HMB & chronology; clots/flooding = clinically significant blood loss [1] |
| 2:00–2:45 | Red flags & associated symptoms – IMB, PCB, pain, discharge, anaemia sx, bleeding tendency | 「除咗經期之外有冇出血？同房之後有冇流血？有冇頭暈、心跳、氣喘？有冇容易瘀？」 | Rules out malignancy, coagulopathy, anaemia |
| 2:45–3:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得點解會咁樣？你最擔心啲乜嘢？你今日嚟睇醫生最希望得到啲乜嘢幫助？」 | Directly scores ICE marks on Case Report Form |
| 3:30–4:15 | PMH, Drug Hx, FHx, O&G Hx – fibroids, thyroid, bleeding disorders, anticoagulants, IUCD, obstetric history, Pap smear | 「你有冇其他病？食緊乜嘢藥？有冇用避孕環？屋企人有冇流血傾向？你做過子宮頸抹片檢查未？」 | Uncovers structural/iatrogenic causes; bleeding disorder FHx |
| 4:15–5:00 | Psychosocial & functional impact – ADL, work, sexual life, mood, relationships | 「月經多咗有冇影響你返工？瞓覺？心情？同另一半嘅關係？」 | Biopsychosocial problems; hidden agenda (e.g. relationship stress, fear of cancer) |
| 5:00–5:30 | Signpost & summarise | 「等我總結一下：你最主要嘅問題係…我理解你最擔心嘅係…我講得啱唔啱？」 | Shows active listening; checks understanding |
| 5:30–6:00 | Safety-net & close | 「我建議我哋做幾個檢查，包括驗血同超聲波。如果經期突然好大量，或者頭暈企唔穩，要即刻去急症。」 | Safe closing with red-flag safety net |
Uncovering the hidden agenda: The simulated patient may present with HMB but actually be worried about cancer, infertility, or relationship/sexual problems. Always ask 「你今日點解會嚟睇醫生？」 separately from the symptom – the trigger (e.g. friend diagnosed with cancer, flooding at work causing embarrassment) is often the real reason for consultation.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did the heavy periods start? | 「經期幾時開始變多？」 | Acute vs chronic; since menarche → coagulopathy | vWD if since menarche [2] |
| Quantity | How many pads/day? Clots? Flooding? Night changes? | 「一日用幾多塊M巾？有冇血塊？幾大塊？半夜要換嗎？」 | Clinical estimation of blood loss [1] | > 80 mL/cycle = HMB definition [1] |
| Cycle regularity | Are your periods regular? How many days apart? | 「你經期準唔準？隔幾多日嚟一次？嚟幾多日？」 | Regular HMB → structural; irregular → anovulation/endometrial | Fibroids vs anovulatory DUB |
| IMB / PCB | Any bleeding between periods or after sex? | 「兩次經期之間有冇出血？同房之後有冇流血？」 | IMB/PCB → surface lesion, cervical/endometrial pathology [1][3] | Cervical Ca, polyp, ectropion |
| Dysmenorrhoea | Any period pain? Getting worse? | 「有冇經痛？有冇越嚟越痛？」 | Progressive dysmenorrhoea → adenomyosis/endometriosis [3] | Adenomyosis |
| Anaemia symptoms | Dizziness, tiredness, SOB, palpitations? | 「有冇頭暈、成日好攰、氣喘、心跳快？」 | Assesses severity; IDA secondary to HMB [4] | IDA |
| Bleeding tendency | Easy bruising? Nosebleeds? Bleeding after dental work? | 「容唔容易瘀？流鼻血？拔牙之後有冇流血唔止？」 | Coagulopathy screening (esp if HMB since menarche) [1][2] | vWD, platelet disorder |
| Family history | Anyone in family with heavy periods or bleeding problems? | 「屋企人有冇經期特別多？或者容易流血唔止？」 | vWD is AD; clotting profile indicated if FHx+ [1] | vWD |
| Drug history | Any medications? Anticoagulants? Aspirin? | 「有冇食緊藥？薄血丸？止痛藥？」 | Iatrogenic HMB; NSAIDs → GI bleed masking anaemia | Drug-induced AUB |
| Contraception/IUCD | What contraception do you use? Copper IUCD? | 「你用邊種避孕方法？有冇裝避孕環？」 | Copper IUCD → foreign body reaction → HMB [3] | AUB-Iatrogenic |
| Pregnancy test | Could you be pregnant? LMP? | 「有冇機會懷孕？上次經期幾時？」 | Pregnancy test is first-line investigation [1] | Miscarriage, ectopic, GTD |
| Thyroid symptoms | Weight change? Heat/cold intolerance? | 「體重有冇變？怕唔怕凍/熱？」 | TFT only if symptomatic [1] | Hypothyroidism |
| Pap smear / O&G Hx | When was your last Pap smear? Pregnancies? | 「上次做子宮頸檢查幾時？有幾多次懷孕？」 | Cervical screening; obstetric context | Cervical pathology |
| Functional impact | How does this affect your daily life / work / mood? | 「呢個問題對你日常生活、返工、心情有咩影響？」 | Biopsychosocial scoring; HMB definition includes QoL impact [1] | Psychosocial problem |
| Reason for attendance | Why did you come today specifically? | 「你今日特別嚟睇醫生，係因為咩原因？」 | Hidden agenda / trigger | Fear of cancer, social embarrassment |
Case Report Form Answer Builder
- CC: Heavy menstrual bleeding for [X months/years]
- HPI points to capture:
- Duration and pattern (regular vs irregular cycles)
- Estimated volume: pads/day, clots (size), flooding, night changes
- Associated symptoms: dysmenorrhoea, IMB, PCB, anaemic symptoms
- Impact on QoL/ADL
- Red flags: since menarche → coagulopathy; IMB/PCB → malignancy
- Relevant PMH/DHx: IUCD, anticoagulants, thyroid disease
- Obstetric/gynae history: gravidity/parity, last Pap smear
- Examples: "Heavy periods affecting her daily life and work" / "Worried that heavy bleeding may indicate something serious (cancer)" / "Flooding episode at work causing embarrassment"
- Phrasing tip: Link the symptom to why today – often the functional/emotional trigger, not just the bleeding itself.
| Example Wording | |
|---|---|
| Ideas | "Patient thinks the heavy periods may be caused by fibroids / hormonal imbalance / something wrong with the womb" |
| Concerns | "Worried about cancer / anaemia / infertility / not being able to work" |
| Expectations | "Wants investigation (ultrasound) / medication to reduce bleeding / referral to gynaecologist" |
- In a young woman with regular HMB, no pelvic mass, no IMB/PCB: Dysfunctional uterine bleeding (AUB-Endometrial / anovulatory bleeding) or Uterine fibroid (if bulky uterus or pelvic mass)
- Minimum supporting evidence: Regular heavy cycles, no structural abnormality on examination, reproductive age, ± anaemia symptoms
- If there is progressive dysmenorrhoea + bulky tender uterus → adenomyosis [3]
| DDx | Key Discriminator |
|---|---|
| 1. Uterine fibroid | Irregular/asymmetric uterine enlargement, pressure symptoms |
| 2. Adenomyosis | Progressive dysmenorrhoea, symmetric tender bulky uterus, age 35–45 [3] |
| 3. Endometrial polyp | IMB, often no abnormal findings on exam; diagnosed on TVUS/hysteroscopy |
(If HMB since menarche: replace one DDx with von Willebrand disease) [2]
| Domain | Problem |
|---|---|
| Biological | Iron deficiency anaemia secondary to chronic HMB |
| Psychological | Anxiety about possible serious diagnosis (cancer); low mood from chronic symptoms |
| Social | Functional impairment at work/school (needing to miss days); impact on sexual/intimate relationships |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Dysfunctional uterine bleeding | Pallor (conjunctival/palmar) indicating IDA | Inspect conjunctivae, palmar creases | HMB causing chronic iron loss → anaemia; no structural sign expected on brief FM exam [4] |
| Uterine fibroid | Asymmetrically enlarged, irregular, firm, non-tender uterus on bimanual exam [3] | Bimanual pelvic examination | Irregular contour = fibroid vs smooth enlargement in adenomyosis |
| Adenomyosis | Symmetrically enlarged, boggy, tender uterus on bimanual exam [3] | Bimanual pelvic examination | Diffuse myometrial thickening; tenderness distinguishes from fibroid |
| Endometrial polyp | No reliable physical sign in brief FM station | TVUS or hysteroscopy needed | Polyp is usually not palpable; state investigation instead |
| Coagulopathy (vWD) | Ecchymoses / petechiae on skin | Inspect skin, esp limbs and trunk | Mucocutaneous bleeding pattern supports platelet/vWF disorder [2] |
| Endometrial cancer | Bulky uterus or no sign; friable tissue on speculum (if cervical involvement) | Speculum exam | Often no physical sign in early disease; requires endometrial biopsy |
Top Traps That Lose Marks
- Forgetting to ask about pregnancy – pregnancy test is the FIRST investigation in any woman of reproductive age with abnormal PV bleeding [1].
- Not asking about bleeding since menarche – this is the key trigger for ordering a clotting profile and thinking of vWD [1][2].
- Ordering TFT routinely – TFT is NOT routinely recommended; only if symptomatic [1].
- Confusing regular HMB with irregular bleeding – they have different differential diagnoses [3]. Regular = structural (fibroids, adenomyosis). Irregular = anovulatory, endometrial pathology.
- Ignoring ICE / psychosocial impact – HMB definition itself includes interference with QoL [1]. If you don't ask about functional impact, you miss marks AND the diagnostic definition.
- Not asking about IMB/PCB – misses cervical/endometrial malignancy red flags.
- Writing "menorrhagia" without specifying regularity – examiners want the FIGO AUB classification [1].
Must-Not-Miss Red Flags → Urgent Referral:
- PCB or persistent IMB → cervical/endometrial pathology → speculum + cervical smear + endometrial assessment
- Age ≥45 with irregular HMB or ≥40 with persistent IMB → endometrial aspirate indicated [3]
- HMB + haemodynamic instability → A&E
- Positive pregnancy test + heavy PV bleed → exclude ectopic; urgent O&G referral
Safety-Net Closing Line: 「如果經期突然好大量、或者頭暈企唔穩、或者驗孕陽性就要即刻去急症室。」
Key investigations to mention (not manage in detail): Pregnancy test, CBC (Hb + platelets), pelvic USS; cervical screening; endometrial aspirate if age ≥40 with IMB or ≥45 with HMB; clotting profile only if HMB since menarche or FHx [1][3]
High Yield Summary
What to ASK: Cycle regularity → quantity (pads/clots/flooding/night changes) → IMB/PCB → dysmenorrhoea → anaemia symptoms → bleeding tendency since menarche → contraception/IUCD → pregnancy possibility → thyroid symptoms → drug history → functional/psychosocial impact → ICE → hidden agenda.
What to WRITE: CC with duration → HPI covering volume, regularity, red flags, associated sx → RFC linked to trigger → ICE → Most likely Dx (DUB or fibroid depending on stem) → 3 DDx with discriminators → 3 biopsychosocial problems → Physical sign: pallor (if DUB) or asymmetric bulky uterus (if fibroid).
What NOT to MISS: Pregnancy test first; HMB since menarche = coagulopathy workup; TFT only if symptomatic; regular vs irregular HMB have different DDx; IMB/PCB = cancer red flag; QoL impact is part of the HMB definition.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: CFB (OG04) Menstrual Disorders.pdf (p14, p31, p7) [2] Senior notes: Maksim Medicine Notes.pdf (p164) — vWD and mucocutaneous bleeding; Ryan Ho Haemtology.pdf (p128) — vWD clinical features [3] Senior notes: Adrian Lui Gynecology Notes.pdf (p13, p20) — HMB differential, history, examination, investigations, management [4] Senior notes: Maksim Medicine Notes.pdf (p153) — IDA causes including menorrhagia; Block A - Pallor_ diagnosis of anaemia; nutritional anaemia; anaemia of systemic diseases.pdf (p3, p6) [5] Past papers: 2019 Fourth Summative SAQ.pdf (Q1) — HMB initial investigations and structural causes
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