Evaluation and Management of Heavy Menstrual Bleeding in Perimenopausal Women

Initial Evaluation and Diagnostic Approach

The American College of Radiology recommends combined transabdominal and transvaginal ultrasound with Doppler as the initial imaging study to evaluate the uterus and endometrium in women with heavy menstrual bleeding, allowing assessment of endometrial thickness and identification of structural causes such as fibroids, polyps, and adenomyosis 1, 2
History and physical examination should focus on determining the pattern, duration, and severity of bleeding, with attention to risk factors for endometrial cancer such as obesity, diabetes, and family history 1, 3
Laboratory tests should include pregnancy test to rule out pregnancy-related bleeding, and thyroid-stimulating hormone and prolactin levels to identify endocrine causes 3, 4

MRI of the pelvis without and with contrast is the next appropriate imaging study if the initial ultrasound is inconclusive or the endometrium cannot be fully visualized, superior for visualizing the endometrium when ultrasound is limited 1, 6
Sonohysterography should be performed if a polyp is suspected on the original ultrasound, allowing better visualization of intracavitary lesions 2
Endometrial biopsy is essential in perimenopausal women with heavy menstrual bleeding to rule out endometrial cancer or hyperplasia, even with normal imaging due to the high risk of malignancy in this age group 1, 2, 3, 4

For fibroids, characterization of location, size, and number is crucial, and submucosal fibroids are most likely to cause heavy bleeding 5, 7, 8
For adenomyosis, MRI is more sensitive than ultrasound for diagnosis, and often coexists with fibroids, affecting treatment success 9, 10

The American College of Radiology emphasizes that endometrial cancer risk increases significantly in perimenopausal women, and thorough evaluation is necessary to avoid assuming bleeding is due to perimenopause 1, 2
Endometrial biopsy is essential even with normal imaging in perimenopausal women with heavy bleeding, and coexisting pathologies such as adenomyosis should not be missed 3, 4, 9, 10