What is the management plan for a patient with abnormal uterine bleeding (AUB), suspected adenomyosis, and a need to rule out malignancy, who is also obese and has a history of thyroidectomy?

Management Plan for AUB with Adenomyosis and Rule Out Malignancy in Post-Thyroidectomy Obese Patient

The management of abnormal uterine bleeding with suspected adenomyosis requires transvaginal ultrasound with Doppler as first-line imaging, followed by endometrial biopsy to rule out malignancy, and consideration of MRI with contrast if initial evaluation is inconclusive. 1, 2

Initial Diagnostic Evaluation

Imaging

• Transvaginal ultrasound (TVUS) with Doppler is the first-line imaging modality 1

  • Combined with transabdominal approach for complete assessment
  • Evaluates endometrial thickness and identifies structural abnormalities
  • Assesses for features of adenomyosis (heterogeneous myometrium, myometrial cysts)

• Sonohysterography if focal endometrial abnormality is detected on TVUS 1

  • Helps distinguish between focal (polyps, submucous fibroids) and diffuse pathology
  • Cannot reliably differentiate between benign and malignant endometrial lesions

• MRI with gadolinium and diffusion-weighted imaging if ultrasound is inconclusive 1, 2

  • Superior for diagnosing adenomyosis (sensitivity ~78%, specificity ~93%)
  • Can identify malignant uterine pathology with higher accuracy
  • Essential for ruling out leiomyosarcoma if rapid growth of fibroids is observed

Tissue Sampling

• Endometrial biopsy or curettage is mandatory 1
  • Critical to rule out endometrial hyperplasia or cancer
  • Particularly important given patient's obesity (risk factor for endometrial cancer)
  • Should be performed before any hormonal or interventional treatment

Treatment Options

Medical Management

1. First-line options:

   • Levonorgestrel-releasing intrauterine system (LNG-IUS) 3

     • Most effective long-term medical treatment for heavy menstrual bleeding
     • Provides local progestin effect with minimal systemic side effects

   • Combined hormonal contraceptives 2, 3

     • Effective for controlling abnormal bleeding
     • May help with adenomyosis-related pain

2. Alternative options:

   • Oral progestins such as norethindrone acetate 4

     • 5-10 mg daily for 5-10 days to produce secretory transformation
     • Can be increased to 15 mg daily for adenomyosis management
     • Particularly useful for patients with contraindications to estrogen

   • Selective progesterone receptor modulators (SPRMs) 1

     • Can reduce both bleeding and bulk symptoms
     • Especially useful in perimenopausal women to help transition to menopause
     • Requires monitoring for endometrial changes

   • Tranexamic acid for acute heavy bleeding episodes 3

   • NSAIDs for pain management and reduction of bleeding 3

Surgical Options (if medical management fails)

1. Endometrial ablation 3

   • Comparable efficacy to LNG-IUS
   • Lower risk than hysterectomy
   • Appropriate only if malignancy has been ruled out

2. Hysterectomy 3, 5

   • Definitive treatment for adenomyosis
   • Consider if:
     • Medical management fails
     • Patient has completed childbearing
     • Symptoms significantly impact quality of life

3. Uterine artery embolization (UAE) 1, 2

   • Option for patients with concurrent fibroids and adenomyosis
   • Less invasive than hysterectomy
   • May preserve fertility

Special Considerations for This Patient

• Obesity increases risk of endometrial cancer (RR 2.54) 2

  • More thorough evaluation for malignancy is warranted
  • Consider additional risk factors (diabetes, hypertension)

• Post-thyroidectomy status

  • Ensure thyroid replacement is optimized
  • Hypothyroidism can exacerbate menstrual irregularities

• Monitoring

  • If medical management is chosen, follow-up TVUS in 3-6 months
  • Any rapid increase in uterine/fibroid size requires immediate evaluation for malignancy 2

Pitfalls to Avoid

• Failure to rule out malignancy before initiating treatment

  • Endometrial biopsy is mandatory in this patient with obesity and AUB

• Inadequate imaging

  • Relying solely on TVUS when findings are inconclusive
  • MRI with contrast and diffusion-weighted imaging provides superior assessment of adenomyosis and can help exclude malignancy

• Overlooking thyroid status

  • Ensure adequate thyroid replacement therapy
  • Untreated hypothyroidism can contribute to abnormal bleeding

• Misdiagnosis of adenomyosis

  • Can be confused with leiomyomas on imaging
  • MRI is the most accurate non-invasive diagnostic tool 5, 6

• Delayed diagnosis of malignancy

  • Adenomyosis with extensive glandular proliferation can mimic malignancy on imaging 7
  • Tissue sampling is essential for definitive diagnosis