Diagnostic Approach for Abnormal Uterine Bleeding with Pelvic Fullness
Ultrasound of the pelvis is the most appropriate next diagnostic step for this 36-year-old woman with heavy menses, urinary frequency, and pelvic fullness. 1
Clinical Presentation Analysis
This 36-year-old woman presents with:
- Heavy menses (saturating 5-6 pads during first two days)
- Urinary frequency
- Sensation of pelvic fullness for 2 months
- Enlarged, regularly shaped uterus on exam
- BMI of 43
- Hypertension (146/92)
- Recent discontinuation of oral contraceptives
These symptoms strongly suggest abnormal uterine bleeding (AUB) with possible structural causes, particularly given the enlarged uterus found on examination.
Diagnostic Algorithm
First-Line Imaging
- Pelvic ultrasound (combined transabdominal and transvaginal with Doppler) is the most appropriate initial imaging study for abnormal uterine bleeding 1
- Provides excellent visualization of uterine size, contour, and endometrial thickness
- Can identify structural causes such as leiomyomas (fibroids), adenomyosis, and endometrial polyps 1
- Allows assessment of adnexal structures to rule out ovarian pathology
- Non-invasive and does not expose the patient to radiation 1
Benefits of Ultrasound in This Case
- Can evaluate the enlarged uterus noted on physical examination 1
- Can assess for fibroids, which commonly cause heavy bleeding and pelvic pressure symptoms 2
- Can evaluate for adenomyosis, which may present with similar symptoms 1
- Can measure endometrial thickness to assess for endometrial hyperplasia or malignancy 1
- Can assess for urinary tract compression that may explain the urinary frequency 2
Why Other Options Are Less Appropriate
Endometrial biopsy: While important in the evaluation of AUB, this should typically follow imaging, especially in a patient with an enlarged uterus where structural causes are likely 1
Hysterosalpingography: Not indicated for initial evaluation of AUB; primarily used to assess tubal patency in infertility workups 3
Laparoscopy: Too invasive for initial diagnostic approach; should be reserved for cases where less invasive methods are inconclusive or treatment is planned 3
MRI of pelvis: While excellent for soft tissue characterization, MRI is more appropriate as a second-line imaging study after ultrasound, particularly if the ultrasound is inconclusive 1
Follow-up Considerations
If the initial ultrasound is inconclusive:
- Sonohysterography may be appropriate if a polyp is suspected 1
- MRI of the pelvis without and with contrast would be appropriate if the uterus is incompletely visualized 1
If fibroids are identified as the cause:
- The relationship between fibroid size/location and symptoms should be assessed 2
- Treatment options can be discussed based on imaging findings
Important Clinical Caveat
While the patient's BMI (43) and hypertension (146/92) are concerning and should be addressed, they do not change the initial diagnostic approach for her gynecologic symptoms. However, these factors may influence subsequent management decisions 3.
Remember that the size of the uterus or fibroids does not always correlate with symptom severity - some women with large fibroids may be asymptomatic while others with smaller fibroids may have significant symptoms 2.