What is the diagnosis for a patient with abnormal uterine bleeding, who underwent a transvaginal (t/v) ultrasound on 3/28/25, with findings of an anteflexed uterus, endometrium measuring 4.4 mm, and no adnexal masses or free pelvic fluid?

From the Guidelines

The transvaginal ultrasound performed on March 28,2025, for abnormal uterine bleeding shows normal findings, and given the results, further evaluation with additional testing such as hormone panels, endometrial biopsy, or monitoring over time may be necessary to determine the cause of the bleeding. Your uterus, endometrium, and ovaries all appear within normal size ranges with no concerning masses or abnormalities, as indicated by the ultrasound findings of a uterus measuring 6.2 x 2.9 x 4.0 cm, an endometrium measuring 4.4 mm, and ovaries with normal blood flow and no cystic or solid masses 1. The endometrial thickness of 4.4 mm is normal for a non-pregnant woman. Nabothian cysts were noted in the cervix, but these are common benign findings that typically require no treatment. Both ovaries showed normal blood flow and no concerning features. The pelvic pain you experienced during the exam is not uncommon due to the pressure from the ultrasound probe. Despite your symptoms of abnormal uterine bleeding, this ultrasound is considered unremarkable, meaning no structural cause for bleeding was identified. According to the American College of Radiology Appropriateness Criteria, if the initial ultrasound is inconclusive or if the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate 1. You should follow up with your doctor to discuss these results and determine next steps for managing your abnormal bleeding, as causes could include hormonal imbalances, polyps too small to visualize, or other factors not apparent on ultrasound. Key points to consider include:

• The normal size and appearance of the uterus and ovaries
• The absence of concerning masses or abnormalities
• The need for further evaluation to determine the cause of abnormal uterine bleeding
• The potential for additional testing such as hormone panels, endometrial biopsy, or monitoring over time
• The importance of follow-up with your doctor to discuss results and determine next steps.

From the Research

Ultrasound Findings

• The uterus is anteflexed and measures 6.2 x 2.9 x 4.0 cm, with an endometrium measuring 4.4 mm 2, 3.
• The cervix measures 3.37 cm, and Nabothian cysts are noted.
• The right ovary measures 3.2 x 2.1 x 1.7 cm, and the left ovary measures 2.5 x 1.7 x 1.6 cm, with no cystic or solid masses and blood flow demonstrated in both ovaries.
• No adnexal masses or free pelvic fluid are present.

Diagnosis and Evaluation

• The patient's symptoms of abnormal uterine bleeding and pelvic pain during the transvaginal exam are consistent with the need for a comprehensive evaluation, including a thorough history, physical and pelvic examinations, and adjunctive diagnostic tests 2, 4, 5.
• Transvaginal ultrasound is a useful diagnostic tool for evaluating abnormal uterine bleeding, and can help identify structural causes such as polyps, adenomyosis, leiomyomas, and malignancy 3.
• The PALM-COEIN classification system can be used to classify the etiology of abnormal uterine bleeding, and is facilitated by a complete patient history and appropriate imaging, histopathologic analysis, or laboratory evaluation 5.

Treatment Options

• Medical treatments for abnormal uterine bleeding include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid 4, 6.
• Surgical treatment options include endometrial ablation and hysterectomy 4.
• Oral hormonal therapies, such as combined oral contraceptives and progestin-only pills, can be effective in treating abnormal uterine bleeding, especially when levonorgestrel intrauterine devices are contraindicated or declined by the patient 6.