What are the recommended first-line investigations for a patient presenting with abnormal vaginal bleeding?

Recommended first-line investigations for a patient presenting with abnormal vaginal bleeding include:

• A thorough history and physical examination to assess the nature of bleeding, related symptoms, and impact on quality of life. Physical examination should be performed before investigations or intrauterine device fittings if symptoms suggest additional pathology ¹.
• A full blood count test should be carried out for all women presenting with heavy menstrual bleeding, in parallel with any treatment offered ¹.
• Consider testing for coagulation disorders if there is a personal or family history suggesting such disorders and bleeding has been present since menarche ¹.
• Pelvic ultrasound is recommended as a first-line imaging investigation, especially if the uterus is palpable abdominally, there is a history or examination suggesting a pelvic mass, or examination is inconclusive or difficult (e.g., obesity) ¹.
• Transvaginal ultrasound is preferred for women with suspected adenomyosis or significant dysmenorrhoea and a bulky, tender uterus on examination ¹.
• Outpatient hysteroscopy is recommended if history suggests submucosal fibroids, polyps, or endometrial pathology, particularly if there is persistent intermenstrual bleeding or risk factors for endometrial pathology ¹.
• Endometrial biopsy should be considered at the time of hysteroscopy for women at high risk of endometrial pathology, but blind endometrial biopsy is not recommended ¹.
• If hysteroscopy is declined or not suitable, pelvic ultrasound may be offered with explanation of its limitations ¹.
• Do not use saline infusion sonography, MRI, or dilatation and curettage alone as first-line diagnostic tools for heavy menstrual bleeding ¹.