What is the initial work up and management for a patient presenting with prolonged vaginal bleeding?

Initial Workup and Management of Prolonged Vaginal Bleeding

The initial workup for a patient presenting with prolonged vaginal bleeding should include transvaginal and transabdominal ultrasound with Doppler, complete blood count, pregnancy test, and assessment of hemodynamic stability, followed by targeted evaluation based on age and risk factors. 1

Initial Assessment

Hemodynamic Evaluation

• Assess vital signs immediately (blood pressure, heart rate, respiratory rate)
• Evaluate for signs of hypovolemia or shock
• Determine severity of bleeding (number of pads/tampons used, presence of clots)

Essential Laboratory Tests

• Complete blood count with platelets
• Pregnancy test (βhCG)
• Coagulation studies (PT/INR, PTT) if heavy bleeding or suspicion of coagulopathy
• Thyroid function tests
• Liver and renal function tests

Imaging

• First-line imaging: Combined transabdominal and transvaginal ultrasound with Doppler 1

  • Evaluates endometrial thickness
  • Identifies structural abnormalities (polyps, fibroids, adenomyosis)
  • Assesses for retained products of conception if post-pregnancy
  • Evaluates ovaries for pathology

• If ultrasound is inconclusive: MRI of the pelvis without and with contrast 1

  • Particularly useful when ultrasound cannot adequately visualize the endometrium
  • Superior for diagnosing adenomyosis and complex uterine pathology
  • Diffusion-weighted imaging improves sensitivity for detecting malignancy

Age-Specific Considerations

Reproductive Age Women

• Focus on:
  • Pregnancy complications (miscarriage, ectopic pregnancy)
  • Structural causes (fibroids, polyps, adenomyosis)
  • Hormonal imbalances
  • Contraceptive-related bleeding
  • Infection (cervicitis, PID)

Perimenopausal Women

• Focus on:
  • Anovulatory bleeding
  • Structural causes (fibroids, polyps)
  • Endometrial hyperplasia
  • Pre-malignant conditions

Postmenopausal Women

• All postmenopausal bleeding requires urgent referral 2
• Endometrial cancer present in approximately 10% of cases
• Endometrial thickness >5mm on transvaginal ultrasound warrants endometrial biopsy

Cause-Specific Evaluation

Structural Causes

• Endometrial polyps, adenomyosis, leiomyoma (fibroids)
• Sonohysterography if polyp is suspected on initial ultrasound 1
• Hysteroscopy may be indicated for direct visualization and tissue sampling

Non-Structural Causes

• Coagulopathies: Additional testing including bleeding time, von Willebrand panel
• Ovulatory dysfunction: Hormonal evaluation (FSH, LH, estradiol)
• Iatrogenic: Review of medications (anticoagulants, hormonal contraceptives)
• Endocrine disorders: Prolactin levels, comprehensive thyroid panel

Contraceptive-Related Bleeding

• For patients using hormonal contraceptives with bleeding irregularities:
  • Rule out underlying conditions before attributing to contraceptive 3
  • Consider NSAIDs for 5-7 days during bleeding episodes 1
  • For implant or injectable users with heavy bleeding, consider short-term hormonal treatment with low-dose combined oral contraceptives (10-20 days) 1

Management Algorithm

1. Stabilize if hemodynamically unstable:

   • IV fluid resuscitation
   • Blood transfusion if severe anemia (Hgb <7 g/dL)

2. Initial management based on severity:

   • Mild-moderate bleeding: Outpatient management with follow-up
   • Severe bleeding: Consider hospital admission

3. Targeted treatment based on etiology:

   • Hormonal causes: Hormonal therapy (combined oral contraceptives, progestins)
   • Structural causes: Surgical consultation for polyp/fibroid removal
   • Malignancy: Urgent gynecologic oncology referral
   • Pregnancy-related: Obstetric management

Common Pitfalls to Avoid

• Assuming all bleeding is hormonal: Always rule out structural causes and malignancy
• Incomplete evaluation in postmenopausal women: All postmenopausal bleeding requires thorough evaluation for malignancy
• Missing coagulopathies: Consider bleeding disorders, especially in adolescents with heavy menstrual bleeding
• Attributing bleeding to contraceptives without ruling out other causes: Always exclude pregnancy, infection, and structural abnormalities 4
• Relying solely on physical examination: In one study, pelvic examination alone changed management in only 6% of cases of women with abdominal pain or vaginal bleeding 5

Follow-up Recommendations

• Patients with undiagnosed persistent or recurrent abnormal vaginal bleeding require additional evaluation to rule out malignancy 4
• Follow-up timing depends on severity and suspected etiology
• If bleeding persists despite initial management, consider referral to gynecology for advanced diagnostic procedures (hysteroscopy, endometrial biopsy)