What is the best management approach for a woman with a history of light periods, now presenting with menorrhagia (heavy menstrual bleeding), passing large clots, and minimal abdominal cramping, who has a history of tubal ligation (tubal sterilization) and has been found to have a bulky heterogeneous uterus with an ill-defined endometrium on transvaginal ultrasound (TV USS)?

Management of Menorrhagia with Bulky Heterogeneous Uterus

This patient requires endometrial tissue sampling via office endometrial biopsy as the next critical step, followed by saline infusion sonohysterography to characterize the fundal lesion, with gynecology referral if medical management fails or tissue diagnosis reveals hyperplasia/malignancy. 1

Immediate Diagnostic Priorities

The ultrasound findings of a bulky heterogeneous uterus with an ill-defined fundal lesion (17 mm with peripheral vascularity) and poorly defined endometrium create diagnostic uncertainty that cannot be resolved by imaging alone. Transvaginal ultrasound is sensitive for detecting structural abnormalities but cannot determine the specific etiology of endometrial thickening or masses. 2

Critical Next Steps:

• Endometrial tissue sampling is mandatory because the ultrasound shows a focal abnormality in the fundal region with vascularity, and the endometrium is poorly defined despite being within normal thickness limits (10 mm). 1, 2

• The presence of a heterogeneous myometrium with a focal lesion does not exclude concurrent endometrial pathology—neither ultrasound nor MRI can definitively distinguish benign from malignant conditions; tissue diagnosis is mandatory. 2

• Office endometrial biopsy should be performed first, as it has high sensitivity for endometrial cancer and can be done immediately in the outpatient setting. 1

Saline Infusion Sonohysterography for Lesion Characterization

After tissue sampling is obtained or scheduled:

• Saline infusion sonohysterography (SIS) is recommended when initial transvaginal ultrasound demonstrates a focal endometrial abnormality, with 96-100% sensitivity and 97% accuracy in distinguishing leiomyomas from polyps. 1, 3

• SIS will help characterize whether the fundal lesion is a submucosal leiomyoma (the most likely diagnosis given the bulky uterus and focal lesion) versus an endometrial polyp or other pathology. 3

• Submucosal fibroids are the primary cause of heavy menstrual bleeding when a discrete lesion is identified within the uterine cavity, as they directly impinge on the endometrial surface and disrupt normal hemostatic mechanisms. 3

Common Diagnostic Pitfalls to Avoid

• The presence of fibroids on ultrasound does not exclude concurrent endometrial pathology—endometrial sampling must still be performed when any focal abnormality is present. 2

• Office endometrial biopsy has a 10% false-negative rate, so if the biopsy is negative but symptoms persist, advance to hysteroscopy with directed biopsy or fractional D&C under anesthesia. 1

• Do not assume the bleeding is solely from a fibroid without tissue diagnosis—endometrial biopsy may not be accurate for diagnosing malignancies of the uterine wall, such as mesenchymal tumors or endometrial stromal neoplasms. 1

Medical Management Options

Once structural pathology is characterized and malignancy excluded:

• Medical therapy should be attempted first unless the structural pathology clearly requires surgery, with first-line options including: 1, 3

  • Levonorgestrel-releasing intrauterine system (most effective, comparable to surgical ablation) 4, 5
  • Tranexamic acid (reduces menstrual blood loss by 20-60%) 4, 5
  • Combined oral contraceptives 6, 5
  • NSAIDs (can be combined with other therapies) 6, 5

• For acute heavy bleeding requiring immediate control, consider multidose combined oral contraceptive regimen, tranexamic acid, or parenteral estrogen depending on hemodynamic stability. 6

• Tranexamic acid dosing: 10 mg/kg actual body weight IV for acute management, or oral formulations for ongoing treatment. 7

Indications for Gynecology Referral

• Referral to gynecology is indicated when endometrial sampling shows hyperplasia or malignancy, failed medical management, or if surgical intervention is required for symptomatic submucosal fibroids. 1

• If the fundal lesion is confirmed as a submucosal leiomyoma causing refractory bleeding despite medical therapy, surgical options include hysteroscopic myomectomy, uterine artery embolization, or hysterectomy depending on fertility desires and lesion characteristics. 8

MRI Consideration

• MRI pelvis with gadolinium-based IV contrast should be considered if ultrasound findings remain indeterminate after SIS or if the uterus cannot be completely visualized, with sensitivity up to 79% for endometrial cancer and 100% for leiomyosarcomas. 1, 2

• MRI with diffusion-weighted imaging can help distinguish benign from malignant lesions when there is concern for uterine sarcoma or endometrial stromal neoplasm. 2