Should I perform a CT scan with intravenous contrast to assess the source of vaginal bleeding in a patient with severe anemia?

Management of Severe Anemia from Vaginal Bleeding

No, do not perform a CT abdomen-pelvis (CTAP) to assess for vaginal bleeding—this imaging modality is designed for gastrointestinal and intra-abdominal hemorrhage, not gynecologic sources. Your patient requires immediate resuscitation, direct gynecologic examination, and targeted evaluation of the vaginal/uterine source.

Immediate Resuscitation Priority

Your patient has life-threatening anemia (hemoglobin dropped from 8.4 to 4.8 g/dL) and requires urgent management:

• Initiate aggressive fluid resuscitation and prepare for urgent blood transfusion to maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg 1
• Check vital signs immediately to assess hemodynamic stability and determine if the patient is in hypovolemic shock 1, 2
• Obtain blood typing and cross-matching given the severe anemia 1, 2
• Assess coagulation parameters (PT/INR, aPTT, platelet count) as coagulopathy may contribute to ongoing bleeding 1, 2

Direct Source Identification

The appropriate diagnostic approach for vaginal bleeding is direct visualization and examination, not cross-sectional imaging:

• Perform immediate pelvic examination including speculum exam to identify the bleeding source (cervical, vaginal, uterine) 2
• Conduct digital examination to assess for masses, retained products, or other palpable abnormalities 2
• Consider pelvic ultrasound as the first-line imaging modality if structural evaluation is needed (fibroids, retained products of conception, endometrial pathology) 2

When CT Is Actually Indicated

CT abdomen-pelvis with IV contrast is highly sensitive (85-90%) and specific (92%) for gastrointestinal bleeding with active extravasation 1. However, this is not applicable to your clinical scenario because:

• CT angiography is designed to detect intraluminal GI blood or contrast extravasation into the bowel lumen 1
• Vaginal bleeding originates from the gynecologic tract, which requires direct visualization rather than cross-sectional imaging
• CT would only be appropriate if you suspected concurrent intra-abdominal pathology (ruptured ectopic pregnancy, hemorrhagic ovarian cyst) causing hemoperitoneum—not for vaginal bleeding itself

Specific Diagnostic Algorithm

For reproductive-age women with severe anemia from vaginal bleeding:

• Obtain pregnancy test immediately to rule out pregnancy-related hemorrhage (ectopic, miscarriage, placental complications) 1
• Perform transvaginal ultrasound to evaluate endometrial thickness, intrauterine pathology, and adnexal masses 2
• Consider endometrial biopsy or hysteroscopy if structural lesions or malignancy suspected 1

For postmenopausal women:

• Endometrial evaluation is mandatory given cancer risk of 4.8% in patients with severe bleeding 3
• Pelvic ultrasound followed by endometrial sampling should be performed once stabilized 1

Critical Pitfalls to Avoid

• Do not delay resuscitation while pursuing diagnostic workup—transfuse first, investigate second 3
• Do not assume benign etiology even if patient reports "normal" bleeding patterns—7.8% of women with life-threatening anemia described their bleeding as normal 3
• Do not discharge without definitive bleeding control plan—33.9% of patients with severe menstrual anemia were discharged without therapy to prevent recurrence, and 26.8% required multiple subsequent transfusions 3
• Consider rare causes in appropriate contexts: leech infestation in rural areas with non-potable water exposure 4, or hematologic malignancy (acute leukemia can present as vaginal bleeding with severe anemia and thrombocytopenia) 5

Definitive Management Considerations

Once stabilized and source identified:

• Hormonal therapy for menorrhagia if fertility preservation desired 6
• Uterine artery embolization for refractory bleeding from fibroids 6
• Surgical intervention (endometrial ablation, hysterectomy) may be necessary for definitive control 3, 6
• Treat underlying coagulopathy if identified 1

The key principle: CT imaging has no role in evaluating vaginal bleeding—focus on direct gynecologic assessment, resuscitation, and source control.