A 32-year-old woman presents with menorrhagia for the past 6 months. Menarche was at age 13, and cycles are regular (28 days) with duration of 7–8 days. She denies intermenstrual bleeding, postcoital bleeding, or pelvic pain. On examination, the uterus is normal size, mobile, and non-tender; no adnexal masses are palpable. Haemoglobin is 9.8 g/dL. Coagulation profile and thyroid function are normal. Pelvic ultrasound shows a normal uterus and ovaries with no focal lesions. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has **dysfunctional uterine bleeding (DUB)** — regular, heavy menstrual bleeding with no structural, systemic, or coagulation abnormality on investigation. ### Key Diagnostic Features - Regular cycles (28 days) with heavy flow (7–8 days) - No red flags: no intermenstrual or postcoital bleeding, no pelvic pain - Normal pelvic examination - Normal haemoglobin, coagulation, and thyroid function - Normal pelvic ultrasound (excludes fibroids, polyps, adenomyosis) **Key Point:** In reproductive-age women with DUB and normal investigations, structural pathology has been excluded. Hysteroscopy is NOT indicated in the absence of focal ultrasound findings or risk factors for endometrial pathology (age >45, obesity, unopposed oestrogen, atypical bleeding pattern). ### Management Algorithm for Menorrhagia ```mermaid flowchart TD A[Menorrhagia + Regular cycles]:::outcome --> B{Structural pathology<br/>on ultrasound?}:::decision B -->|Yes: fibroid, polyp| C[Hysteroscopy ± treatment]:::action B -->|No| D{Age ≥45 or<br/>risk factors?}:::decision D -->|Yes| E[Hysteroscopy + biopsy]:::action D -->|No| F[Medical management]:::action F --> G[First-line: LNG-IUS or COCP]:::action G --> H{Response in<br/>3 months?}:::decision H -->|Good| I[Continue]:::outcome H -->|Poor| J[Add tranexamic acid<br/>or NSAIDs]:::action ``` ### First-Line Medical Therapies for DUB | Agent | Mechanism | Efficacy | Notes | |-------|-----------|----------|-------| | **Levonorgestrel-IUS (Mirena)** | Local endometrial suppression | 80–90% reduction in flow | Gold standard; also provides contraception | | **Combined oral contraceptive** | Inhibits ovulation; stabilizes endometrium | 50–80% reduction | Convenient; contraceptive benefit | | **Tranexamic acid** | Antifibrinolytic | 40–50% reduction | Used adjunctively; short cycle use only | | **NSAIDs (ibuprofen, mefenamic acid)** | Inhibit prostaglandin synthesis | 30–40% reduction | Adjunctive; GI side effects | **High-Yield:** LNG-IUS is the most effective medical option and is now preferred over oral agents in many guidelines, especially in women not desiring systemic hormones. ### Why NOT Hysteroscopy Here? **Clinical Pearl:** Hysteroscopy is reserved for: - Structural lesions visible on ultrasound (fibroids, polyps, septate uterus) - Age ≥45 years (endometrial cancer risk) - Abnormal bleeding pattern (intermenstrual, postcoital, or prolonged) - Failed medical management This patient is 32, has regular cycles, normal ultrasound, and no alarm features — hysteroscopy is **not indicated** and exposes her to unnecessary operative risk. ### Why NOT Empirical Tranexamic Acid Alone? While tranexamic acid and NSAIDs are effective, they are **second-line agents** used adjunctively or when hormonal methods fail or are contraindicated. Starting with LNG-IUS or COCP offers superior efficacy and additional benefits (contraception, endometrial protection). **Warning:** Do not confuse "medical management" with "NSAIDs only." Hormonal therapies are the cornerstone of DUB treatment.