What are the next steps in evaluation and management after experiencing abnormal bleeding and severe cramps following confirmed ovulation and negative pregnancy tests, with an endometrial thickness of 14mm and mild thickness in the left fallopian tube?

Management of Abnormal Uterine Bleeding After Confirmed Ovulation

Based on your clinical presentation with confirmed ovulation, abnormal bleeding pattern, and endometrial thickness of 14mm, you should undergo a transvaginal ultrasound with Doppler imaging to evaluate for structural causes of abnormal uterine bleeding, followed by endometrial sampling if no clear cause is identified. 1

Clinical Assessment of Your Presentation

• Your symptoms suggest abnormal uterine bleeding with an unusual pattern (light bleeding with severe cramping and clot passage) following a confirmed ovulatory cycle 1
• The endometrial thickness of 14mm is concerning, as normal post-ovulatory endometrium is typically thinner 1
• The negative pregnancy tests on days 16 and 22 effectively rule out pregnancy as the cause of your symptoms 2
• The mild thickening in the left fallopian tube (4.3mm vs 3.2mm on the right) from where you ovulated may represent normal physiological changes but warrants further evaluation 1

Recommended Diagnostic Approach

Immediate Next Steps:

• Combined transabdominal and transvaginal ultrasound with Doppler imaging is the most appropriate initial imaging study to fully evaluate the endometrium and any potential structural causes 1

• This imaging should specifically assess for:

  • Retained products of conception (despite negative pregnancy tests) 1
  • Structural causes using the PALM-COEIN classification: polyps, adenomyosis, leiomyomas (fibroids), malignancy/hyperplasia 1, 3
  • Complete evaluation of the fallopian tubes, particularly the thickened left tube 1

If Initial Ultrasound is Inconclusive:

• Sonohysterography (saline infusion sonography) should be performed if a polyp is suspected 1
• MRI of the pelvis without and with contrast if the uterus is incompletely visualized with ultrasound 1
• Endometrial sampling is indicated given your endometrial thickness of 14mm, which exceeds normal parameters 1, 3

Management Considerations

Medical Management Options:

• If ovulatory dysfunction is confirmed as the cause:
  • Progestin-only contraception or combined hormonal contraception can regulate bleeding 1
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce bleeding volume 4, 3

If Structural Causes Are Identified:

• Polyps: Polypectomy may be indicated 3
• Fibroids: Management depends on size and location (medical management, myomectomy, or uterine artery embolization) 3
• Endometrial hyperplasia: Treatment depends on histologic findings 4

Important Considerations and Pitfalls

• Do not ignore the endometrial thickness of 14mm - this finding requires further investigation as it could indicate hyperplasia or other pathology 1
• Beware of assuming normal menstruation - your described bleeding pattern (light flow with large clot and severe cramping) is not consistent with normal menstruation 3
• Monitor for signs of hemodynamic instability - though your current bleeding is light, watch for increased bleeding, dizziness, or tachycardia 3
• Don't assume ectopic pregnancy is ruled out - while unlikely with negative pregnancy tests, the fallopian tube asymmetry warrants careful evaluation 1

Follow-up Recommendations

• If bleeding persists or worsens, seek immediate medical attention 3
• After diagnostic evaluation is complete, follow-up should be based on findings:
  • For structural causes: specific treatment followed by monitoring
  • For non-structural causes: hormonal management with follow-up in 3 months 1, 3

The combination of confirmed ovulation, abnormal bleeding pattern, and thickened endometrium requires comprehensive evaluation to rule out significant pathology and guide appropriate management.