A menstruating woman complains of greater than usual bleeding,
which is either off her usual schedule (metrorrhagia), lasts
longer than a typical period, or is heavier than usual
(menorrhagia) perhaps with crampy pains and passage of clots.
What to do: Obtain orthostatic pulse and blood pressure
measurements, a hematocrit, and pregnancy test (urine or serum
beta hCG). Try to quantify the amount of bleeding by number of
saturated pads used. If there is significant bleeding,
demonstrated by tachycardia, lightheadedness, orthostatic
pressure changes, a pulse increase of more than 20 per minute on
standing, or a hematocrit below 30%, start an intravenous line
of lactated Ringer's solution, and have blood ready to transfuse
on Obtain a menstrual, sexual, and reproductive history. Are her
periods usually irregular, occasionally this heavy? Does she
take oral contraceptive pills, and has she missed enough to
produce estrogen withdrawal bleeding? Is an IUD in place and
contributing to cramps, bleeding, and infection?