Heavy Menstrual Bleeding at 45: Sampling Before Surgery

Differential, using the PALM-COEIN frame:

• AUB-O - chronic anovulation related to obesity; most likely here.
• AUB-L - leiomyoma.
• AUB-P - endometrial polyp.
• Endometrial hyperplasia or carcinoma - she is 45, obese, and likely anovulatory. This is the diagnosis you must not miss.
• Adenomyosis, coagulopathy (von Willebrand disease), thyroid disease, hyperprolactinemia - pregnancy is already excluded.

Studies today:

• Urine hCG - done and negative; pregnancy must be excluded before any hormonal therapy or imaging interpretation.
• CBC and ferritin - Hgb 9.8 with ferritin 6 confirms iron deficiency anemia and gives a baseline for monitoring response.
• TSH - thyroid dysfunction is a common and inexpensive exclusion in heavy bleeding.
• Transvaginal ultrasound as first-line imaging - assesses endometrial thickness, the cavity, myometrium, ovaries, and fibroids. It is the appropriate first test rather than MRI or immediate hysteroscopy.
• Prolactin only if she develops amenorrhea or galactorrhea; a structured bleeding-history screen (ISTH-BAT) only if she has had heavy menses since menarche or other bleeding symptoms.

Do not start a hormonal method before imaging and sampling, because it obscures the diagnostic picture.

Next step: office endometrial biopsy (Pipelle). Age over 45 with any abnormal uterine bleeding warrants tissue sampling, and a 15-mm endometrium in a woman who is obese and likely anovulatory raises the pretest probability of hyperplasia. Ultrasound cannot reliably distinguish hyperplasia from a secretory endometrium, so imaging alone is insufficient - a uniformly thickened stripe does not exclude disease.

Logistics: perform it in the office when she is not actively bleeding; use misoprostol or a paracervical block per your protocol; send the specimen for histology. If the sample is insufficient, or if the result is discordant with the ultrasound, proceed to saline-infusion sonohysterography or hysteroscopy with directed biopsy.

Branching on the result:

• Proliferative or secretory endometrium - treat the bleeding as described below.
• Hyperplasia without atypia - a 52-mg levonorgestrel IUD is first-line and treats both the bleeding and the hyperplasia; re-biopsy in 3-6 months.
• Atypical hyperplasia or carcinoma - gynecologic oncology referral, with hysterectomy as the usual definitive treatment.

Answering the hysterectomy question: validate her frustration, then explain that hysterectomy is a definitive option but is not the first step. There is no tissue diagnosis yet; she is obese, which raises surgical and anesthetic risk; and several effective reversible options remain untried. Hysterectomy stays on the table if she fails medical therapy or if biopsy shows atypia or malignancy.

Plan:

• Anemia: ferrous sulfate 325 mg (65 mg elemental iron) every other day, not daily - alternate-day dosing improves absorption by avoiding hepcidin up-regulation. Take with vitamin C and recheck CBC and ferritin in 4-6 weeks. Add dietary counseling.
• Bleeding control: offer the 52-mg levonorgestrel IUD as first-line. It reduces menstrual blood loss by 70-95%, provides endometrial protection, and fits her desire to avoid pregnancy. Counsel explicitly about 3-6 months of irregular bleeding and cramping so she is not caught off guard.
• Bridging or adjuncts: tranexamic acid 1.3 g PO three times daily during menses. NSAIDs are an option but use caution with hypertension and renal function.
• If she prefers a pill: a combined oral contraceptive is acceptable with controlled hypertension, but at 45 with a BMI of 36 it raises VTE risk - counsel accordingly, or use cyclic medroxyprogesterone instead.
• Follow-up: 4-6 weeks to assess bleeding and repeat the Hgb, then review the biopsy and confirm the plan. Escalate urgently for bleeding with hemodynamic instability or a falling hemoglobin despite treatment.