What is the appropriate workup for a woman presenting with heavy menses, including the use of colposcopy and ultrasound (US)?

Workup for Heavy Menses: Imaging and Diagnostic Approach

Transvaginal ultrasound (TVUS) combined with transabdominal ultrasound is the initial imaging study of choice for evaluating heavy menstrual bleeding, while colposcopy has no role in this workup. 1, 2

Initial Diagnostic Evaluation

The workup for heavy menstrual bleeding should begin with specific laboratory tests and imaging to identify structural and non-structural causes:

Laboratory Assessment:

• Pregnancy test (mandatory in all reproductive-age women) 3
• Complete blood count with platelets to assess for anemia 2
• Thyroid-stimulating hormone and prolactin levels to identify endocrine causes 4, 2
• Coagulation studies if bleeding history suggests inherited bleeding disorder 5

Initial Imaging:

• Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study 1, 2
• This allows assessment of endometrial thickness and identification of structural causes including fibroids, polyps, and adenomyosis 2
• TVUS is superior to transabdominal ultrasound alone for visualizing the endometrium and detecting submucosal fibroids 4

Advanced Imaging When Initial Ultrasound is Inadequate

Saline Infusion Sonohysterography (SIS):

• Should be performed when a polyp is suspected on initial ultrasound 2
• Superior to TVUS for detecting submucosal fibroids (75% accuracy vs. standard ultrasound) 4
• Demonstrates 75% sensitivity and 93% specificity for detecting intrauterine adhesions 4
• Has high sensitivity and negative predictive value for assessing intracavitary pathology 3

MRI Pelvis:

• The next appropriate imaging study if initial ultrasound is inconclusive or the endometrium cannot be fully visualized 2
• Superior for diagnosing adenomyosis compared to ultrasound 2
• More sensitive than ultrasound for visualizing the endometrium when ultrasound is limited 2

Endometrial Sampling: Critical Component

Endometrial biopsy is essential in perimenopausal women with heavy menstrual bleeding to rule out endometrial cancer or hyperplasia, even when imaging appears normal. 2

• Required in patients with risk factors for endometrial cancer (obesity, diabetes, family history) 2
• Preferred over dilation and curettage due to lower invasiveness, safety, and cost 4
• Important caveat: Endometrial biopsy alone cannot rule out focal lesions like polyps, as sensitivity varies depending on lesion location 3

Hysteroscopy: When to Consider

Hysteroscopy should be performed when:

• Medical treatment fails and bleeding persists 4, 3
• Focal lesions are suspected but missed by endometrial sampling 4, 3
• Direct visualization of the endometrial cavity and endocervix is needed 4

Common Pitfalls to Avoid

Colposcopy has no role in the evaluation of heavy menstrual bleeding. Colposcopy is used to evaluate the cervix for dysplasia or cancer, not to assess the endometrium or uterine causes of bleeding.

Do not assume bleeding is simply due to perimenopause in perimenopausal women - endometrial cancer risk increases significantly in this age group, requiring thorough evaluation 2

Do not rely on endometrial biopsy alone to exclude focal lesions - saline infusion sonohysterography or hysteroscopy may be necessary 3

When TVUS cannot completely evaluate the endometrium, do not delay further investigation - proceed to MRI or endometrial sampling 1

Algorithmic Approach

1. Start with: Pregnancy test + CBC + TSH/prolactin + combined transabdominal/transvaginal ultrasound with Doppler 1, 2, 3

2. If polyp suspected: Add saline infusion sonohysterography 2

3. If ultrasound inconclusive: Proceed to MRI pelvis 2

4. If perimenopausal or risk factors present: Perform endometrial biopsy regardless of imaging findings 2

5. If medical treatment fails: Consider hysteroscopy for direct visualization 4, 3