## Clinical Approach to Menorrhagia **Key Point:** In a woman with heavy menstrual bleeding and normal pelvic examination, imaging is the first-line investigation before considering invasive procedures or empirical treatment. ### Rationale for Transvaginal Ultrasound Transvaginal ultrasound is the gold-standard first-line imaging modality in menorrhagia because it: - Detects structural abnormalities (fibroids, adenomyosis, polyps, hyperplasia) - Has superior resolution for endometrial and subendometrial pathology compared to transabdominal ultrasound - Is non-invasive, readily available, and cost-effective - Guides further management decisions (medical vs. surgical) ### When to Proceed to Hysteroscopy Diagnostic hysteroscopy is reserved for: - Abnormal findings on ultrasound (e.g., focal lesions, irregular endometrium) - Persistent bleeding despite medical therapy - Abnormal endometrial echo on imaging - Suspicion of intrauterine pathology not visualized on ultrasound **Clinical Pearl:** In this case, normal pelvic examination and regular cycles suggest likely dysfunctional uterine bleeding (DUB) or adenomyosis, but structural causes must be excluded first. ### Management Algorithm ```mermaid flowchart TD A[Menorrhagia + Normal Exam]:::outcome --> B[Transvaginal Ultrasound]:::action B --> C{Structural Pathology?}:::decision C -->|Yes: Fibroid/Polyp| D[Hysteroscopy ± Treatment]:::action C -->|Yes: Adenomyosis| E[Medical Management ± Hysterectomy]:::action C -->|No: Normal| F[Dysfunctional Uterine Bleeding]:::outcome F --> G[First-line: COC or Levonorgestrel IUS]:::action ``` **High-Yield:** The sequence is: **imaging first → then invasive procedures → then medical therapy**. Do not empirically treat without excluding structural causes. [cite:Jeffcoate's Principles of Gynaecology Ch 10]
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