## Clinical Context This patient presents with **menorrhagia** (heavy menstrual bleeding) and clinical signs suggestive of **uterine fibroids** (leiomyomas): uniformly enlarged firm uterus, heavy bleeding with clots, and secondary anemia. ## Investigation of Choice **Key Point:** Transvaginal ultrasound (TVS) is the **first-line imaging modality** for evaluating abnormal uterine bleeding and suspected fibroids. ### Why Transvaginal Ultrasound? 1. **High sensitivity and specificity** for fibroid detection (>95%) 2. **Non-invasive**, no radiation, cost-effective 3. **Excellent visualization** of endometrial and myometrial pathology 4. **Real-time assessment** of fibroid location, size, and number 5. **Doppler capability** to assess vascularity 6. **No anesthesia required**; can be done in outpatient setting ## Comparison of Investigations | Investigation | Role in AUB | When Used | |---|---|---| | **Transvaginal ultrasound** | First-line imaging for structural causes | All patients with AUB | | Diagnostic hysteroscopy | Therapeutic + diagnostic for intrauterine pathology (polyps, septum, adhesions) | When TVS shows abnormal endometrium or when AUB persists despite normal imaging | | Endometrial biopsy | Rule out endometrial malignancy in high-risk patients | Age >45 with AUB, or <45 with risk factors (obesity, PCOS, unopposed estrogen) | | MRI pelvis | Problem-solving tool; detailed fibroid mapping for surgical planning | Preoperative assessment before myomectomy; complex fibroid anatomy | **High-Yield:** TVS is the **gold standard first-line investigation** for AUB in reproductive-age women. MRI is reserved for **surgical planning**, not initial diagnosis. ## Clinical Pearl In this case, TVS will likely show **multiple intramural/submucosal fibroids**, explaining both the menorrhagia and the uniformly enlarged uterus. This finding would guide further management (medical vs. surgical). [cite:Park 26e Ch 12]
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