Initial Investigations for Perimenopausal Abnormal Uterine Bleeding

Immediate Assessment

The American College of Obstetricians and Gynecologists recommends checking hemodynamic stability first, with urgent evaluation needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 1
A speculum examination should be performed to visualize the cervix and vagina, excluding cervical or vaginal sources of bleeding 1
A bimanual examination should be conducted to assess uterine size, contour, mobility, and adnexal masses 1
The abdomen should be palpated for an enlarged uterus or masses 1

The American College of Obstetricians and Gynecologists recommends a pregnancy test (β-hCG) as mandatory in all reproductive-age women with abnormal uterine bleeding (AUB) 1
Thyroid-stimulating hormone (TSH) levels should be checked as part of the standard diagnostic workup, with a strength of evidence supported by the American Family Physician 2, 1
Prolactin levels should be evaluated for hyperprolactinemia as a cause of ovulatory dysfunction, with a strength of evidence supported by the American Family Physician 2, 1

The American College of Obstetricians and Gynecologists recommends combined transabdominal and transvaginal ultrasound with Doppler as the most appropriate initial imaging study for identifying structural causes of AUB, including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1
Transvaginal ultrasound serves as the primary modality for evaluating the endometrium and myometrium 1
In perimenopausal women, an endometrial thickness <4 mm has nearly 100% negative predictive value for cancer 1
Transabdominal imaging is useful for assessing other structural abnormalities when the transvaginal approach is limited 2

Saline infusion sonohysterography (SIS) should be performed when initial ultrasound findings are unclear or suggest intracavitary lesions, with a sensitivity of 96-100% and negative predictive value of 94-100% for uterine and endometrial pathology 2, 1
SIS can distinguish between leiomyomas and endometrial polyps with 97% accuracy 1
SIS confirms the presence of intracavitary lesions and determines myometrial involvement with leiomyomas 2
SIS is more accurate than transvaginal ultrasonography alone for endometrial assessment 2

The American College of Obstetricians and Gynecologists recommends performing endometrial biopsy in perimenopausal women with risk factors for endometrial cancer, including obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, and failed medical management 1

Hysteroscopy should be reserved for cases where medical treatment has failed, imaging suggests focal lesions that may have been missed by endometrial sampling, or saline infusion sonohysterography identifies intracavitary masses requiring surgical management 2, 1
Hysteroscopy allows direct visualization of the endometrial cavity and endocervix, helping diagnose focal lesions possibly missed by endometrial sampling 2

Pregnancy testing should not be skipped, even in perimenopausal women, as pregnancy must be excluded 1
Transabdominal ultrasound alone should not be relied upon in non-virgins, as the transvaginal approach provides superior endometrial assessment 2
Routine endometrial biopsy should not be performed in all perimenopausal women, but rather targeted to those with risk factors for endometrial cancer or failed medical management 1
Cervical or vaginal sources of bleeding should not be missed, and a speculum examination should always be performed before attributing bleeding to uterine causes 1

Referral to gynecology is recommended when failed medical management occurs, or when endometrial thickness ≥4 mm with persistent bleeding is present 1