What is the best management approach for a 46-year-old woman with Abnormal Uterine Bleeding (AUB), mildly elevated prolactin level (Hyperprolactinemia), and diminished ovarian reserve (indicated by Anti-Müllerian Hormone (AMH) level of 2.415)?

Management of AUB in a 46-Year-Old with Mildly Elevated Prolactin and Low AMH

This 46-year-old perimenopausal woman requires immediate structural evaluation with transvaginal ultrasound, endometrial assessment given her age and bleeding pattern, and treatment of the hyperprolactinemia as a contributing cause of ovulatory dysfunction. 1

Initial Diagnostic Workup

Mandatory Immediate Assessments

• Pregnancy test (β-hCG) must be performed despite perimenopausal status 1
• Hemodynamic stability assessment—urgent evaluation needed if saturating a large pad hourly for ≥4 hours 1
• Complete blood count to assess for anemia, which affects 20% of women with AUB 2, 3
• Speculum examination to exclude cervical or vaginal bleeding sources 1
• Bimanual examination to assess uterine size, contour, and adnexal masses 1

Laboratory Evaluation Already Completed

• The prolactin level of 32 ng/mL represents mild hyperprolactinemia and confirms ovulatory dysfunction as a contributing mechanism 1, 2
• TSH should be checked if not already done, as thyroid dysfunction causes both anovulatory and ovulatory AUB 1, 2
• The AMH of 2.415 ng/mL indicates diminished ovarian reserve consistent with perimenopausal transition, which increases anovulation risk 4

Imaging Strategy

First-Line Imaging

• Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study 5, 1
• Transvaginal approach provides superior endometrial and myometrial assessment 1
• Transabdominal imaging assesses enlarged uterus or masses beyond transvaginal field of view 5
• Doppler evaluation identifies vascularity within endometrial polyps or cancer 5

Second-Line Imaging if Initial Ultrasound Unclear

• Saline infusion sonohysterography (SIS) should be performed if initial ultrasound shows focal endometrial abnormality or thickened endometrium 5, 1
• SIS distinguishes leiomyomas from endometrial polyps with 97% accuracy 5, 1
• SIS has 96-100% sensitivity and 94-100% negative predictive value for uterine pathology 1

Endometrial Sampling Indications

At age 46 with AUB, this patient requires endometrial biopsy given her perimenopausal status and risk stratification. 1, 6

Specific Indications Present

• Age ≥35 years with recurrent anovulation (confirmed by hyperprolactinemia) 2
• Perimenopausal status with AUB warrants endometrial assessment 1, 6
• Additional risk factors requiring biopsy include obesity, diabetes, hypertension, or unopposed estrogen exposure if present 1

Optimal Biopsy Technique

• Office hysteroscopy with directed biopsy is the gold standard approach, especially for high-risk perimenopausal women 6
• Blind endometrial biopsies should no longer be performed as sole diagnostic strategy in perimenopausal women 6
• Single-stop approach combining office hysteroscopy, directed biopsy of focal lesions, and vacuum sampling of normal-appearing endometrium provides most accurate diagnosis 6

Treatment of Hyperprolactinemia

The prolactin level of 32 ng/mL requires further evaluation and treatment as it contributes to ovulatory dysfunction causing AUB. 1, 2

• Investigate secondary causes: medication review (antipsychotics, antiepileptics), thyroid dysfunction, pituitary adenoma 2
• MRI of pituitary if prolactin remains elevated without medication cause
• Dopamine agonist therapy (cabergoline or bromocriptine) if prolactinoma or idiopathic hyperprolactinemia confirmed
• Correcting hyperprolactinemia may restore ovulatory cycles and reduce bleeding 2

Medical Management Options

First-Line Medical Therapy (After Excluding Malignancy)

Levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for idiopathic AUB in perimenopausal women. 2, 3, 7

Alternative Medical Options (Ranked by Efficacy)

1. Tranexamic acid—particularly useful if hormones contraindicated or immediate pregnancy desired 2, 3
2. Combined oral contraceptives—regulate menstrual cycles and treat anovulatory bleeding 2, 3, 7
3. Cyclic progestins (21 days per month)—effective for anovulatory bleeding 2, 3
4. NSAIDs—reduce menstrual blood loss by 20-50% 2, 3

Perimenopausal-Specific Consideration

• Pulsatile courses of selective progesterone receptor modulators (ulipristal acetate where available) can bridge perimenopausal women to menopause while avoiding surgery 5
• This approach particularly useful for women nearing menopause who wish to avoid hysterectomy 5

Surgical Management

Indications for Surgical Intervention

• Failed medical management after 3-6 months 1, 3
• Structural lesions identified (polyps, submucosal fibroids) requiring removal 1, 3
• Patient preference after counseling on options 3

Surgical Options (Ranked by Invasiveness)

1. Hysteroscopic polypectomy or myomectomy for focal lesions 5, 3
2. Second-generation endometrial ablation (thermal balloon, microwave, radiofrequency) for completed childbearing 3
3. Hysterectomy (vaginal or laparoscopic route preferred)—most definitive but reserved for failed conservative measures 2, 3

Critical Pitfalls to Avoid

• Do not skip pregnancy testing despite perimenopausal status and low AMH 1
• Do not perform blind endometrial biopsy alone in perimenopausal women—combine with imaging or hysteroscopy 6
• Do not attribute all bleeding to anovulation without excluding structural causes (polyps, adenomyosis, leiomyomas, malignancy) 4, 1
• Do not overlook hyperprolactinemia as a treatable cause requiring specific workup 1, 2
• Do not proceed to hysterectomy without attempting medical management or conservative surgical options first 3

Referral Criteria

Refer to gynecology if:

• Endometrial thickness ≥4 mm with persistent bleeding after initial management 1
• Failed medical management after 3-6 months 1
• Endometrial biopsy shows hyperplasia with atypia (refer to gynecologic oncologist) 2
• Complex structural abnormalities requiring surgical expertise 1