Evaluation and Management of Unexplained Bruising with Heavy Menstrual Bleeding
This patient requires immediate laboratory evaluation for an underlying bleeding disorder, as the combination of a large unexplained bruise and 6 months of heavy menstrual bleeding strongly suggests a coagulation abnormality that needs urgent diagnosis and treatment to prevent serious morbidity.
Initial Laboratory Workup
The presence of both spontaneous bruising without trauma and prolonged heavy menstrual bleeding creates a high probability of an underlying bleeding disorder that requires specific testing 1, 2:
- Complete blood count (CBC) with peripheral blood smear to assess for anemia from chronic blood loss and platelet abnormalities 3
- Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to screen for coagulation factor deficiencies 1, 3
- Fibrinogen level to detect fibrinogen defects 1
- Serum ferritin to assess iron stores, as heavy menstrual bleeding commonly causes iron deficiency 4
Von Willebrand disease testing is essential in this patient, as it is the most common inherited bleeding disorder and has a particularly high incidence in adolescents and women with heavy menstrual bleeding 1, 5. Standard PT and aPTT may not reliably detect von Willebrand disease, so specific testing must be requested 1.
Key Clinical Features Supporting Bleeding Disorder
Heavy menstrual bleeding affects approximately 90% of women with underlying bleeding disorders 2. The combination of:
- Spontaneous bruising >10 cm without recalled trauma 1
- Six months of heavy menses (likely meeting criteria for "flooding" or large clots) 2
- No clear traumatic mechanism 1
This constellation strongly suggests a systemic coagulation problem rather than isolated trauma 1, 2.
Critical Pitfalls to Avoid
Do not assume the bruise is traumatic simply because the patient cannot recall injury - bleeding disorders can cause spontaneous bruising or bruising from minor unrecognized trauma 1. The American Academy of Pediatrics emphasizes that medical conditions causing bleeding must be carefully considered when bruising appears unexplained 1.
Do not delay hematology referral - if initial screening suggests abnormalities or if clinical suspicion remains high despite normal initial tests, consultation with a hematologist is recommended for specialized testing including platelet function studies and specific factor assays 1, 3.
Additional Considerations
The patient's pre-diabetes and heart palpitations warrant attention but are less immediately relevant to the bleeding presentation:
- Review all medications including over-the-counter drugs and supplements that may affect coagulation 1
- Assess for other bleeding symptoms such as epistaxis, gum bleeding, or excessive bleeding after dental procedures 1
- Obtain family history of bleeding disorders, as many are inherited 1, 3
Management Strategy Based on Results
If bleeding disorder is confirmed:
- Hemostatic therapy may include tranexamic acid or desmopressin depending on the specific diagnosis 2, 4
- For heavy menstrual bleeding with bleeding disorders, the 52-mg levonorgestrel intrauterine device has superior efficacy and is safe in this population 5
- Combined hormonal contraceptives or oral progestins are alternative options 4
If initial workup is normal but clinical suspicion remains high:
- Proceed with specialized platelet function testing (PFA-100) and platelet aggregation studies 1
- Consider consultation with hematology for evaluation of rare bleeding disorders 1
The priority is preventing serious bleeding complications including potential intracranial hemorrhage, which can occur with mild bleeding disorders after minor trauma 1. Prompt diagnosis allows for appropriate prophylaxis before surgeries or dental procedures and guides safe medication use 4.