Laboratory and Diagnostic Workup for Premenopausal Woman with Hair Loss, Flushing, and Abnormal Uterine Bleeding
Order a pregnancy test (β-hCG), thyroid-stimulating hormone (TSH), prolactin level, and complete blood count as your initial laboratory panel, followed by transvaginal ultrasound to evaluate for structural causes of bleeding. 1, 2
Essential Laboratory Tests
The combination of hair loss, flushing, and abnormal uterine bleeding suggests potential endocrine dysfunction, making hormonal evaluation critical alongside standard AUB workup:
Pregnancy test (β-hCG) is mandatory in all reproductive-age women with abnormal uterine bleeding, regardless of contraceptive use or perceived pregnancy risk 1, 2, 3
Thyroid-stimulating hormone (TSH) should be checked as part of the standard diagnostic workup, as thyroid dysfunction (particularly hypothyroidism) is a significant contributor to AUB and can present with hair loss 1, 2, 4
Prolactin level should be evaluated for hyperprolactinemia as a cause of ovulatory dysfunction, which can manifest with menstrual irregularities 1, 2
Complete blood count (CBC) with platelets is essential to assess for anemia from chronic blood loss and to screen for coagulopathy as an underlying cause 5, 3
First-Line Imaging Study
Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study for identifying structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1, 2, 5
Transvaginal ultrasound serves as the primary modality for evaluating the endometrium and myometrium with superior visualization 1, 2
Transabdominal imaging complements transvaginal approach when the uterus is significantly enlarged or field of view is limited 6, 1
Additional Considerations Based on Clinical Context
The triad of hair loss, flushing, and AUB raises specific diagnostic considerations:
Consider FSH level if perimenopausal transition is suspected (flushing suggests vasomotor symptoms), though this is not part of routine initial AUB workup in younger reproductive-age women 2
Evaluate for polycystic ovary syndrome (PCOS) if chronic anovulation is suspected, as this can cause both hair changes and irregular bleeding 7, 3
Hair loss combined with thyroid dysfunction is particularly common, making TSH testing even more critical in this presentation 4
When to Proceed with Endometrial Sampling
Endometrial biopsy should be performed if the patient has risk factors for endometrial cancer including obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, or failed medical management 1, 7
Age 35 years or older with recurrent anovulation warrants endometrial biopsy 7, 3
Younger patients with risk factors for endometrial cancer or excessive bleeding unresponsive to medical therapy should also undergo biopsy 7, 3
Advanced Imaging When Initial Workup is Inconclusive
Saline infusion sonohysterography (SIS) should be performed when initial ultrasound findings are unclear or suggest intracavitary lesions, with sensitivity of 96-100% for uterine and endometrial pathology 1, 2, 5
SIS can distinguish between leiomyomas and endometrial polyps with 97% accuracy 1
Common Pitfalls to Avoid
Do not skip pregnancy testing even in perimenopausal women or those reporting reliable contraception, as pregnancy must be excluded before proceeding with hormonal treatment or imaging 1, 2
Do not rely on transabdominal ultrasound alone in sexually active women, as transvaginal approach provides superior endometrial assessment 1
Do not overlook thyroid dysfunction in patients presenting with both hair changes and menstrual irregularities, as hypothyroidism is frequently associated with increased endometrial thickness and AUB 4
Do not attribute all bleeding to uterine causes without performing speculum examination to exclude cervical or vaginal sources 1