What is the best course of action for a 53-year-old female with a history of heavy and irregular menstrual periods, increased Body Mass Index (BMI), and recent episode of heavy bleeding with lower back pain, to investigate and manage her symptoms?

Management of Heavy Menstrual Bleeding in a 53-Year-Old Woman with Elevated BMI

The current plan is appropriate: proceed with pelvic ultrasound and complete blood work (including coagulation studies) first, then determine need for endometrial sampling based on ultrasound findings, with strong consideration for pipelle biopsy given this patient's age (53), elevated BMI, and risk factors for endometrial pathology.

Immediate Diagnostic Priorities

Blood Work Assessment

• Complete the ordered investigations immediately: FBC to assess for anemia, coagulation screen (INR, APTT, fibrinogen) to exclude bleeding disorders, TSH to rule out thyroid dysfunction, and HbA1c given the elevated BMI 1, 2, 3.
• Tumor markers (CA-125) are appropriate given age >40 and need to exclude ovarian pathology 2.
• Up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder, making coagulation studies essential 4.

Imaging Strategy

• Transvaginal ultrasound is the first-line imaging modality to evaluate for structural abnormalities including fibroids, polyps, endometrial thickening, and ovarian pathology 5, 2.
• Transvaginal ultrasound is more sensitive than transabdominal ultrasound for identifying structural abnormalities 5.
• Half of women presenting with heavy menstrual bleeding have uterine abnormalities, most commonly fibroids (under age 40) or endometrial polyps (over age 40) 6.

Endometrial Sampling Decision Algorithm

High-Risk Features Present - Proceed with Biopsy

This patient has multiple risk factors mandating endometrial assessment:

• Age 53 years (perimenopausal/menopausal transition) 2
• Elevated BMI (obesity increases endometrial cancer risk) 5, 2
• Lifelong irregular periods (chronic anovulation increases endometrial hyperplasia risk) 2
• Recent change in bleeding pattern (periods slowed then returned heavy) 2

Timing of Endometrial Biopsy

• If ultrasound shows endometrial thickening, polyps, or other concerning features: pipelle biopsy is mandatory to exclude endometrial hyperplasia or malignancy 2, 6.
• Even with normal ultrasound: given this patient's age and risk factors, endometrial sampling should be strongly considered 2.
• The plan to potentially perform this as a hospital-based procedure due to elevated BMI and anticipated technical difficulties is prudent 2.

Medical Management Options (After Excluding Pathology)

First-Line Medical Therapy

If structural pathology and malignancy are excluded:

• Levonorgestrel-releasing intrauterine device (LNG-IUD) reduces menstrual blood loss by 71-95% and is the most effective long-term medical treatment 2, 6.
• Combined oral contraceptives (30-35 μg ethinyl estradiol with levonorgestrel or norgestimate) are first-line alternatives, reducing menstrual blood loss by inducing regular shedding of thinner endometrium 1, 2.

Non-Hormonal Options

• Tranexamic acid reduces menstrual blood loss by 20-60% (approximately 80 mL/cycle or 50% reduction) and is appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired, though contraindicated with history of thrombosis 1, 2, 6, 4.
• NSAIDs (mefenamic acid, ibuprofen, indomethacin, or diclofenac) reduce menstrual blood loss by 20-50% when used for 5-7 days during menstruation 1, 7, 2, 6.

Critical Pitfalls to Avoid

Do Not Delay Endometrial Assessment

• Never initiate hormonal therapy before excluding endometrial pathology in a woman over 45 with risk factors 2.
• Vaginal sonography combined with endometrial biopsy is reliable for diagnosing endometrial hyperplasia or carcinoma 6.
• However, ultrasound alone is insufficient for diagnosing endometrial polyps and fibroids; these require sonohysterography or hysteroscopy for definitive diagnosis 6.

Assess Thrombotic Risk

• Before prescribing combined oral contraceptives, assess thrombotic risk factors as they increase venous thromboembolism risk three to fourfold 1.
• Tranexamic acid is contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1, 2.

Exclude Pregnancy and Infection

• Pregnancy testing is mandatory before initiating any treatment 2.
• The vaginal swabs taken were appropriate to exclude sexually transmitted infections, particularly given the milky discharge noted 1.

Follow-Up Strategy

After Initial Investigations

• Review blood work and ultrasound results promptly to determine next steps 2.
• If endometrial sampling is performed, ensure histopathology is reviewed before initiating any hormonal therapy 2, 6.

If Medical Therapy Initiated

• Counsel that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and is generally not harmful 1, 2.
• Re-evaluate for underlying gynecological problems if bleeding persists beyond 3-6 months 5, 1.
• No routine follow-up visit is required, but patients should return for side effects or concerns 1, 7.

Surgical Options if Medical Management Fails

• Endometrial ablation is effective for reducing bleeding when medical management fails after 3-6 months 2.
• Hysterectomy provides complete resolution but is reserved for failed medical and conservative surgical management 2.