Which test is compulsory before advising contraception to a 43‑year‑old woman with heavy vaginal bleeding?

Endometrial Biopsy is Compulsory Before Advising Contraception

Before prescribing any contraceptive method to a 43-year-old woman with heavy vaginal bleeding, endometrial biopsy is compulsory to exclude endometrial hyperplasia and malignancy. 1

Why Endometrial Sampling is Mandatory

• Women aged 35 years and older presenting with abnormal uterine bleeding require endometrial sampling before initiating hormonal contraception, as this age group carries increased risk for endometrial pathology including hyperplasia and carcinoma. 1

• At 43 years of age, this patient falls into the high-risk category where benign-appearing endometrial cells and heavy bleeding may be associated with significant endometrial pathology that must be ruled out before masking symptoms with hormonal treatment. 1

• Endometrial biopsy is preferred over dilation and curettage because it is less invasive, safer, and has lower cost while maintaining reliability for diagnosing endometrial hyperplasia or cancer. 1

The Clinical Algorithm

Step 1: Mandatory Endometrial Sampling

• Perform endometrial biopsy first in any woman ≥35 years with heavy vaginal bleeding before considering contraceptive options. 1

• The biopsy must be obtained even if you plan to start medical management, because hormonal contraceptives will alter the endometrial lining and potentially delay diagnosis of underlying malignancy. 1

Step 2: Additional Evaluation (Concurrent with Biopsy)

• Pelvic ultrasound should be performed to assess for structural lesions (fibroids, polyps, adenomyosis) that may contribute to bleeding, but this does not replace the need for tissue diagnosis. 1, 2

• Pregnancy testing must be done to exclude pregnancy even in perimenopausal women before any intervention. 3

• If endometrial biopsy is insufficient or fails, or if focal lesions are suspected on ultrasound, hysteroscopy with directed biopsy provides the highest diagnostic accuracy. 4

Step 3: Only After Pathology is Benign

• Once endometrial hyperplasia and malignancy are excluded, combined oral contraceptives containing 30-35 μg ethinyl estradiol become first-line treatment for heavy menstrual bleeding in this age group. 3, 5

Why the Other Options Are Insufficient

• Pelvic ultrasound alone (Option A) cannot reliably diagnose endometrial hyperplasia or carcinoma—it requires tissue confirmation. 2, 6

• Ultrasound combined with endometrial biopsy is the reliable method for diagnosing endometrial pathology, but ultrasound by itself is insufficient for tissue diagnosis. 2

• Advanced endometrial carcinoma has been documented in cases without noticeable endometrial thickness on ultrasound, making tissue sampling essential regardless of imaging findings. 6

• CT scan (Option B) has no role in the initial evaluation of abnormal uterine bleeding and is not indicated for this clinical scenario.

Critical Pitfall to Avoid

The most dangerous error is initiating hormonal contraception without first obtaining endometrial tissue diagnosis in a woman over 35 years with heavy bleeding. Hormonal treatment will thin the endometrium and potentially mask or delay the diagnosis of endometrial cancer, allowing progression of malignancy while the clinician believes the patient is being "treated." 1

• Even if the patient urgently desires contraception, the 1-2 week delay for biopsy results is medically necessary and non-negotiable in this age group with this presentation. 1

• If bleeding is severe enough to cause hemodynamic instability, acute management with NSAIDs or high-dose progestins can be used while awaiting biopsy results, but tissue diagnosis cannot be skipped. 3