A 35-year-old nulliparous woman with irregular, heavy menstrual bleeding for 2 years is found to have a normal pelvic examination and normal hemoglobin. Transvaginal ultrasound shows a 3 cm intracavitary lesion with a stalk. What is the most appropriate next investigation to confirm the diagnosis and assess resectability?

## Clinical Presentation The patient has abnormal uterine bleeding with a **3 cm intracavitary lesion with a stalk** on transvaginal ultrasound — highly suggestive of a **submucosal fibroid (leiomyoma)**. The stalk indicates a pedunculated lesion. ## Investigation of Choice: Diagnostic Hysteroscopy with 3D Reconstruction **Key Point:** Hysteroscopy is the gold standard for evaluating submucosal fibroids. It allows direct visualization, assessment of lesion morphology, and determination of resectability. **High-Yield:** Hysteroscopy provides: - Direct visualization of the fibroid and its attachment point - Assessment of degree of intracavitary extension - Determination of FIGO classification (critical for surgical planning) - Real-time evaluation of resectability before hysteroscopic myomectomy ## FIGO Classification of Submucosal Fibroids | Type | Characteristics | Resectability | | --- | --- | --- | | Type 0 | Pedunculated, entirely intracavitary | Easily resectable | | Type 1 | <50% myometrial invasion | Resectable | | Type 2 | >50% myometrial invasion | Difficult; may need staged procedure | **Clinical Pearl:** A 3 cm pedunculated lesion (likely Type 0 or 1) is an ideal candidate for hysteroscopic myomectomy. Hysteroscopy with 3D reconstruction allows precise measurement and surgical planning. **Mnemonic:** **HYSTEROSCOPY = H.E.L.P.** - **H**ysteroscopic visualization - **E**valuation of extent - **L**esion localization - **P**rocedural planning ## Why Other Investigations Are Suboptimal | Investigation | Why Not First Choice | | --- | --- | | Diagnostic laparoscopy | Visualizes external uterus only; cannot assess intracavitary pathology | | MRI pelvis | Useful for multiple fibroids or deep myometrial involvement; overkill for a single intracavitary lesion | | Endometrial biopsy | Invasive; does not characterize the lesion; no role in fibroid diagnosis | **Tip:** Remember: intracavitary lesion → hysteroscopy; intramural/subserosal lesion → MRI or laparoscopy.