What is the workup for a pre-menopausal patient with spotting or irregular bleeding who has had a bilateral salpingectomy (fallopian tube removal)?

Workup for Spotting/Irregular Bleeding in Pre-Menopausal Patients with Bilateral Salpingectomy

For pre-menopausal patients with spotting or irregular bleeding who have had bilateral salpingectomy, the initial workup should include transvaginal ultrasound with Doppler, followed by endometrial biopsy if the endometrial thickness is ≥5mm or if bleeding persists despite normal imaging.

Initial Evaluation

History and Physical Examination

• Assess duration and pattern of bleeding
• Document associated symptoms (pelvic pain, dyspareunia)
• Review medication history (hormonal therapies, anticoagulants)
• Evaluate risk factors for endometrial pathology:
  • Obesity
  • Diabetes
  • Hypertension
  • Family history of gynecologic cancers
  • Lynch syndrome
• Complete pelvic examination to identify source of bleeding

First-Line Imaging

• Combined transabdominal and transvaginal ultrasound with Doppler 1
  • Evaluate endometrial thickness and morphology
  • Assess for structural abnormalities (polyps, fibroids, adenomyosis)
  • Evaluate ovarian morphology (if ovaries remain)

Laboratory Testing

• Complete blood count with differential and platelets
• Pregnancy test (despite salpingectomy, as pregnancy is still possible with IVF)
• Thyroid function tests
• Consider coagulation studies if heavy bleeding

Secondary Evaluation

When Initial Ultrasound is Inconclusive

• Sonohysterography if polyp is suspected 1
• MRI of pelvis without and with contrast if:
  • Uterus is incompletely visualized on ultrasound
  • Multiple fibroids are present
  • Adenomyosis is suspected 1

Tissue Sampling

• Endometrial biopsy is indicated when:
  • Endometrial thickness ≥5mm
  • Endometrial stripe cannot be adequately visualized
  • Persistent or recurrent bleeding despite normal imaging 2
  • Note: Office endometrial biopsies have a 10% false-negative rate 1

Advanced Evaluation

• Hysteroscopy with directed biopsy if:
  • Initial endometrial biopsy is negative but bleeding persists
  • Focal lesion is suspected 1
• Fractional dilation and curettage (D&C) under anesthesia if:
  • Office biopsy is negative in a symptomatic patient 1
  • Persistent unexplained bleeding

Special Considerations for Patients with Bilateral Salpingectomy

Impact on Ovarian Function

• Bilateral salpingectomy does not appear to cause early menopause or significant hormonal changes 3
• Unlike bilateral salpingo-oophorectomy, salpingectomy alone does not typically cause menopausal symptoms requiring hormone replacement therapy 3
• However, some studies have shown a slight increase in menopausal symptoms after bilateral salpingectomy compared to hysterectomy alone 4

Potential Causes of Bleeding After Salpingectomy

1. Structural abnormalities:

   • Endometrial polyps
   • Submucosal fibroids
   • Adenomyosis

2. Hormonal factors:

   • Anovulation
   • Polycystic ovary syndrome
   • Perimenopause

3. Endometrial pathology:

   • Endometrial hyperplasia
   • Endometrial cancer (evaluate especially if Lynch syndrome is present) 1

Management Based on Findings

If Structural Abnormality Identified

• Polyps: Hysteroscopic polypectomy
• Fibroids: Medical management or myomectomy based on symptoms
• Adenomyosis: Medical management (hormonal therapies)

If Endometrial Hyperplasia/Cancer

• Urgent referral to gynecologic oncology 2
• Consider genetic testing if Lynch syndrome is suspected 1

If Hormonal Etiology

• Levonorgestrel-releasing intrauterine device (most effective for heavy bleeding) 2
• Oral contraceptives
• Cyclic progestins
• Tranexamic acid (non-hormonal option)

Common Pitfalls to Avoid

• Failing to perform endometrial biopsy when ultrasound is inconclusive 2
• Attributing bleeding to normal hormonal fluctuations without proper evaluation
• Overlooking the possibility of endometrial cancer, especially in patients with Lynch syndrome 1
• Assuming bilateral salpingectomy causes significant hormonal changes (it typically does not) 3
• Delaying evaluation of persistent bleeding

Follow-up Recommendations

• If initial evaluation is negative but bleeding persists, repeat evaluation in 3 months
• For patients with identified and treated pathology, follow-up in 4-6 weeks to assess symptom resolution
• Consider annual surveillance with transvaginal ultrasound for patients with high-risk factors for endometrial cancer