What is the recommended evaluation and management for abnormal uterine bleeding in a 43‑year‑old perimenopausal woman?

Evaluation and Management of Abnormal Uterine Bleeding in a 43-Year-Old Woman

A 43-year-old woman with abnormal uterine bleeding requires endometrial sampling regardless of ultrasound findings, because perimenopausal women face markedly elevated risk of endometrial hyperplasia and carcinoma from unopposed estrogen exposure during increasingly frequent anovulatory cycles. 1

Immediate Diagnostic Pathway

Step 1: Rule Out Pregnancy

• Obtain a point-of-care urine β-hCG test first, as pregnancy complications remain a differential diagnosis in reproductive-age women until definitively excluded. 1

Step 2: Endometrial Sampling—The Priority

• Perform office endometrial biopsy using a Pipelle or Vabra device immediately, without waiting for imaging results. 1, 2
• Women ≥45 years presenting with abnormal uterine bleeding require endometrial sampling based on high-quality guideline consensus from ACOG, NCCN, and ESMO—this is non-negotiable. 1
• At age 43, this patient falls into the perimenopausal window where anovulatory cycles create prolonged unopposed estrogen exposure, dramatically raising the risk of endometrial hyperplasia and carcinoma. 1, 3
• Office endometrial biopsy achieves 99.6% sensitivity (Pipelle) and 97.1% sensitivity (Vabra) for detecting endometrial carcinoma. 1

Step 3: Transvaginal Ultrasound—Concurrent Structural Assessment

• Order combined transvaginal and transabdominal ultrasound to evaluate endometrial thickness, identify structural lesions (polyps, fibroids, adenomyosis), and assess ovarian pathology. 1, 4
• TVUS is the first-line imaging modality (American College of Radiology appropriateness rating 7–9) but cannot replace tissue diagnosis—it merely signals the need for biopsy and identifies coexisting structural causes. 1
• Ultrasound sensitivity is 95–98% but specificity is only 35–47% at standard endometrial-thickness cut-offs; it cannot differentiate hyperplasia, polyps, or malignancy. 1

Step 4: Laboratory Evaluation

• Measure thyroid-stimulating hormone (TSH) and prolactin to assess endocrine contributors to ovulatory dysfunction, which is increasingly common in this age group. 1, 4
• Check complete blood count with platelets to evaluate for anemia and coagulopathy. 4

Management Based on Biopsy Results

If Biopsy Shows Benign Endometrium

• If symptoms persist despite a benign biopsy, escalate immediately to hysteroscopy with directed biopsy—office endometrial biopsies have a 10% false-negative rate, and blind sampling may miss focal lesions such as polyps or submucous fibroids. 1, 4
• Consider saline infusion sonohysterography (SIS) when focal lesions are suspected on TVUS; SIS demonstrates 96–100% sensitivity for detecting endometrial pathology and reliably distinguishes polyps from diffuse thickening. 1, 5

If Biopsy Shows Hyperplasia Without Atypia

• Treat with cyclic or continuous progestin therapy (e.g., medroxyprogesterone acetate for ≥3 months). 5, 6
• Close surveillance with repeat endometrial sampling is mandatory. 6

If Biopsy Shows Atypical Hyperplasia or Carcinoma

• Refer immediately to gynecologic oncology for definitive surgical management. 1
• Discontinue any estrogen-containing therapy. 1

Medical Management Options (After Malignancy Excluded)

First-Line Therapy

• Levonorgestrel-releasing intrauterine system (LNG-IUD) is the most effective first-line medical treatment, reducing menstrual blood loss by 71–95% with efficacy comparable to endometrial ablation. 4, 5
• The LNG-IUD is particularly appropriate for perimenopausal women who desire long-term bleeding control and contraception. 4

Alternative Hormonal Options

• Combined oral contraceptives are effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume. 4, 5
• Oral progestins (e.g., medroxyprogesterone acetate) administered for 21 days per month reduce menstrual blood loss and are effective for cyclic heavy bleeding. 4, 6

Non-Hormonal Options

• Tranexamic acid is FDA-approved for heavy menstrual bleeding with high efficacy, but avoid in patients with cardiovascular disease or thrombosis risk. 4, 7
• NSAIDs reduce menstrual bleeding and can be used in combination with hormonal methods. 4, 7

Surgical Management

Indications for Surgery

• Medical management failure, contraindications to medical therapy, or patient intolerance. 4, 5
• Confirmed hyperplasia with atypia or malignancy. 1
• Structural lesions (polyps, submucous fibroids) identified on imaging or hysteroscopy. 4, 3

Surgical Options

• Hysteroscopic polypectomy or myomectomy for focal intrauterine lesions. 3
• Endometrial ablation for women who have completed childbearing and desire a less invasive alternative to hysterectomy—efficacy is comparable to LNG-IUD. 4, 5
• Hysterectomy is the definitive treatment when medical management fails or is contraindicated, particularly appropriate for perimenopausal women with completed childbearing. 4, 5

Critical Pitfalls to Avoid

• Never accept an inadequate or negative endometrial biopsy as reassuring in a symptomatic perimenopausal woman—the 10% false-negative rate mandates escalation to hysteroscopy or fractional D&C if bleeding persists. 1
• Never initiate hormonal therapy before obtaining tissue diagnosis in women ≥45 years—unopposed estrogen from anovulatory cycles creates high risk for endometrial hyperplasia and carcinoma. 1
• Never rely on ultrasound alone to exclude malignancy—TVUS cannot provide histologic diagnosis and cannot differentiate benign from malignant endometrial pathology. 1, 5
• Never assume fibroids explain all bleeding—the presence of fibroids on ultrasound does not exclude concurrent endometrial pathology, including cancer. 5
• Endometrial biopsy alone has variable sensitivity for focal lesions; if initial sampling is non-diagnostic and symptoms persist, hysteroscopy with direct visualization is mandatory. 4