What imaging modalities are recommended for evaluating heavy menstrual bleeding?

Imaging for Heavy Menstrual Bleeding

Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study for evaluating heavy menstrual bleeding. 1, 2

Initial Imaging Approach

Start with combined transabdominal and transvaginal ultrasound (TAUS + TVUS) with Doppler imaging as your first-line diagnostic test. 1, 2, 3

• Transvaginal ultrasound provides superior resolution for evaluating the endometrium, with 90-99% sensitivity for detecting fibroids and 90% sensitivity/98% specificity for submucosal fibroids. 1, 3

• Transabdominal ultrasound is essential when the uterus is significantly enlarged, when large subserosal/pedunculated fibroids are present, or when TVUS has limited field-of-view. 1

• Doppler imaging is a standard component that helps differentiate vascular from nonvascular tissue and identifies peripheral vascular flow patterns characteristic of fibroids versus adenomyosis. 1

• This combined approach allows assessment of endometrial thickness, identification of structural causes (fibroids, polyps, adenomyosis), and characterization of fibroid location, size, and number. 2, 4

When Initial Ultrasound is Inconclusive

If the uterus is incompletely visualized or the initial ultrasound is inconclusive, proceed to MRI of the pelvis without and with IV contrast. 1, 2

• MRI is superior to ultrasound for visualizing the endometrium when ultrasound is limited and for diagnosing adenomyosis, which often coexists with fibroids. 1, 2

• MRI excels at identifying and mapping fibroids including their size, number, location, vascularity, and characterization as classic, degenerated, cellular, or atypical. 1

• Gadolinium-based IV contrast is preferred for identification of fibroid vascularity and other characteristics. 1

Special Circumstance: Suspected Polyp

If a polyp is suspected on the original ultrasound, perform sonohysterography instead of proceeding directly to MRI. 1, 2

• Sonohysterography has 94% sensitivity and 81% specificity for diagnosing submucosal fibroids and allows better visualization of intracavitary lesions. 1, 2

• This modality is highly sensitive for endometrial lesions and can distinguish between focal or diffuse pathology. 1

Ongoing Surveillance

For follow-up imaging when surveillance is appropriate, use transvaginal ultrasound with Doppler, transabdominal ultrasound, sonohysterography, or MRI with contrast. 1

• These modalities are complementary and can be used to assess for presence and growth of endometrial pathology over time. 1

Critical Pitfalls to Avoid

Never rely on imaging alone in perimenopausal women—endometrial biopsy is essential even with normal imaging due to significantly increased endometrial cancer risk in this age group. 2

• Endometrial cancer risk increases significantly in perimenopausal women, and bleeding should not be assumed to be due to perimenopause without thorough evaluation. 2

• Sonohysterography cannot distinguish between benign endometrial pathology and endometrial cancer with high certainty, so endometrial sampling or hysteroscopy is recommended when pathology is suspected. 1

• Do not miss coexisting adenomyosis, as it often coexists with fibroids and affects treatment success; MRI is more sensitive than ultrasound for this diagnosis. 2

• Submucosal fibroids are most likely to cause heavy bleeding, so accurate characterization of fibroid location is crucial for treatment planning. 2