From the Guidelines
Hysteroscopy is indicated for this patient with prolonged, heavy menstrual bleeding lasting up to two weeks monthly for the past year, as it allows for direct visualization of the endometrial cavity to identify structural abnormalities that could be causing the bleeding, and can be both diagnostic and therapeutic if abnormalities are found. Before proceeding with hysteroscopy, a complete history, physical examination, and initial investigations including complete blood count, pregnancy test, and pelvic ultrasound should be performed, as recommended by the American College of Radiology 1.
The patient's symptoms of heavy and prolonged uterine bleeding, which can lead to anemia, are consistent with the symptoms associated with uterine fibroids, as described in the ACR Appropriateness Criteria® management of uterine fibroids: 2023 update 1. Hysteroscopy is superior to blind endometrial sampling alone as it allows targeted biopsies and can be both diagnostic and therapeutic if abnormalities such as polyps, fibroids, or endometrial hyperplasia are found.
Medical management options including hormonal treatments, such as progestin-only contraception and combined hormonal contraception, should be discussed with the patient as alternatives or adjuncts to the procedure, depending on the findings and the patient's reproductive goals, as recommended by the American College of Obstetricians and Gynecologists 1. The procedure is typically performed as an outpatient procedure under local or general anesthesia.
Key considerations in the management of this patient include:
- Identifying the underlying cause of the heavy menstrual bleeding, which may include structural abnormalities such as fibroids or polyps, or non-structural causes such as coagulopathy or ovulatory dysfunction 1
- Discussing the risks and benefits of hysteroscopy and medical management options with the patient, including the potential for targeted biopsies and therapeutic interventions during the procedure
- Considering the patient's reproductive goals and medical history when selecting a treatment approach.
From the Research
Indications for Hysterectomy and Hysteroscopy
- The patient's symptoms of heavy menstrual bleeding with clots, lasting up to 2 weeks, may be indicative of menorrhagia, which can be caused by various factors such as thyroid dysfunction, coagulation defects, endometrial polyps, and submucosal fibroids 2.
- According to the study by 3, half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids and endometrial polyps, which can be diagnosed more reliably by sonohysterography or hysteroscopy.
- Hysteroscopy is a diagnostic tool that can be used to evaluate the uterine cavity and identify any abnormalities, such as polyps or fibroids, that may be causing the heavy bleeding 3.
Diagnostic Evaluation
- The patient's symptoms and medical history should be evaluated to determine the underlying cause of the heavy menstrual bleeding 2.
- A pelvic examination and vaginal sonography should be performed to assess the uterus and rule out any structural abnormalities 3.
- If the patient's symptoms persist and the cause of the bleeding is not identified, further diagnostic testing, such as hysteroscopy, may be necessary to evaluate the uterine cavity and identify any abnormalities 3.
Treatment Options
- Medical management, such as tranexamic acid, nonsteroidal anti-inflammatory drugs, and hormonal intrauterine systems, may be effective in reducing menstrual blood loss and improving symptoms 2, 3, 4.
- If medical management is ineffective, surgical interventions, such as polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation, may be considered 2, 3.
- Hysterectomy is the most definitive treatment option for heavy menstrual bleeding, but it is typically reserved for cases where other treatments have failed or are not appropriate 5, 6.