Historical feature | Potential significance |
Menstrual history | |
Age of menarche | Earlier age at menarche associated with shorter time to establish ovulatory cycles |
Menstrual pattern (eg, frequency, regularity, duration and volume of flow) | Allows classification into etiologic categories (eg, amenorrhea, irregular menses, excessive menstrual bleeding, intermenstrual bleeding)* |
Events that coincided with change in menstrual pattern (if there was a change) | May suggest an etiology (eg, hypothalamic dysfunction if coincided with weight loss, stress, or intensive exercise; breakthrough bleeding if coincided with initiation of hormonal contraception) |
When did abnormal bleeding start (eg, with the first period or sometime thereafter)? | May suggest an etiology (eg, heavy bleeding at onset of menarche may indicate bleeding disorder) |
Sexual/reproductive history | |
Use, type, and adherence to contraception | Estrogen-progestin contraceptives: May cause unscheduled bleeding, particularly with poor adherence Progestin-only contraceptive: May cause irregular bleeding Copper IUD: Increases menstrual flow Levonorgestrel IUD: May cause irregular spotting or bleeding soon after insertion |
Use of condoms; number of partners; new partners | Affects risk of STI |
History of STI or current symptoms of STI (eg, vaginal discharge, pelvic pain) | Bleeding may be related to STI |
History of sexual abuse¶, assault, or forced sexual activity | Bleeding may be extrauterine (vaginal, cervical) or related to STI |
Recent delivery or abortion | Endometritis |
Past medical history | |
Chronic medical illness | May affect coagulation (eg, liver disease, renal disease, systemic lupus erythematosus) or HPO axis (eg, diabetes mellitus) |
Medications, including over-the-counter medications and complementary/alternative agents; ask specifically about aspirin, aspirin-containing medications, and antidepressants | May affect coagulation (eg, aspirin, valproic acid) or HPO axis (eg, antidepressants, antipsychotics) |
Review of systems | |
Bleeding symptoms (bruising, epistaxis, bleeding gums, postoperative bleeding) | Bleeding disorder (eg, von Willebrand disease) |
Orthostatic symptoms | Hypovolemia, significant blood loss |
Weight change | Weight loss: Hypothalamic dysfunction or other endocrine disorder (eg, diabetes mellitus, hyperthyroidism), malnutrition Weight gain: PCOS, hypercortisolism, hypothyroidism |
Abdominal pain, fever, and/or vaginal discharge | Pelvic inflammatory disease, endometritis |
Dysmenorrhea, dyspareunia, infertility | Endometriosis and/or adenomyosis |
Galactorrhea; heat or cold intolerance, fatigue; visual changes, headaches; hirsutism/acne | Endocrine problem (hyperprolactinemia, thyroid dysfunction, pituitary dysfunction, PCOS) |
Changes in bowel or bladder function | Extrauterine bleeding (eg, hematuria), abdominal mass |
Joint hypermobility, joint dislocations, hyperextensible skin, abnormal scarring | Heritable collagen disorders (associated with bleeding abnormalities due to capillary fragility) |
Changes in hair, skin, or nails | Thyroid dysfunction |
Family history | |
Bleeding disorders | Patient may have the same disorder |
Menstrual disorders | Family members with heavy menstrual bleeding may have undiagnosed bleeding disorders |
Endocrine disorders (eg, thyroid disease, diabetes mellitus) | Family history of diabetes mellitus or lipid disorders may suggest PCOS |
Leukemia and other cancers | Some types of cancer run in families and may be associated with increased bleeding |
Social history | |
Social stressors, substance use, exercise patterns | May affect the HPO axis |
School absence, decreased participation in recreational activities (eg, sports, hobbies) | May provide information about effects on quality of life |
IUD: intrauterine device; STI: sexually transmitted infection; HPO: hypothalamic-pituitary-ovarian; PCOS: polycystic ovary syndrome.
* Refer to UpToDate content on evaluation of abnormal uterine bleeding in adolescents for details.
¶ Sexual abuse should be reported in accordance with local regulations. Refer to UpToDate content on management of sexual abuse in children and adolescents for details.