What is the initial workup and treatment for a patient experiencing intermenstrual bleeding (spotting between cycles)?

Initial Workup for Intermenstrual Bleeding (Spotting Between Cycles)

Before initiating any treatment for spotting between cycles, you must rule out pregnancy, sexually transmitted infections, medication interactions, and structural uterine pathology. 1

Immediate Diagnostic Steps

Essential Laboratory Testing

• Pregnancy test (β-hCG) is mandatory for all reproductive-age women presenting with intermenstrual bleeding 2
• STD screening (gonorrhea and chlamydia) is necessary as these infections commonly cause irregular bleeding patterns 1
• Thyroid-stimulating hormone and prolactin levels should be obtained to exclude endocrine causes 2

Imaging Evaluation

• Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study to identify structural causes including polyps, fibroids, adenomyosis, and endometrial pathology 2
• Ultrasound should be performed early in the workup rather than waiting for treatment failure 1

Medication Review

• Assess for drug interactions that may affect hormonal contraceptive efficacy, including antibiotics, anticonvulsants, and other medications 1
• Review anticoagulation therapy if applicable, as approximately 70% of women on anticoagulation experience abnormal bleeding 2

Treatment Algorithm Based on Contraceptive Status

For Women Using Combined Hormonal Contraceptives

• Provide reassurance that unscheduled spotting during the first 3-6 months is common, generally not harmful, and typically improves with continued use 3, 1
• Emphasize consistent pill timing as irregular use is a primary cause of breakthrough bleeding 3
• If spotting persists beyond 3-6 months and occurs after the first 21 days of use, consider a 3-4 day hormone-free interval which has been shown to improve bleeding in clinical trials 3, 1
• NSAIDs are NOT recommended during the first 21 days of extended or continuous CHC use, and should not be used more than once per month as contraceptive effectiveness may be reduced 3

For Women Using Progestin-Only Methods (Implants)

• First-line treatment: NSAIDs for 5-7 days during bleeding episodes (such as ibuprofen or naproxen) 3, 1
• Second-line treatment if NSAIDs fail: Low-dose combined oral contraceptives for 10-20 days OR estrogen therapy for 10-20 days (if medically eligible) 3, 1
• Approximately 22% of implant users experience amenorrhea by one year, which requires only reassurance 3, 4

For Women Using Levonorgestrel IUD

• Reassure that spotting during the first 3-6 months is expected and generally not harmful, with bleeding typically decreasing over time 3, 1
• NSAIDs for 5-7 days can be used for treatment of persistent spotting or heavy bleeding 3
• Hormonal treatment options include combined oral contraceptives or estrogen for 10-20 days if medically eligible 3
• Heavy or prolonged bleeding is uncommon with LNG-IUD and warrants evaluation for device displacement or underlying pathology 3, 1

For Women Using Copper IUD

• NSAIDs for 5-7 days are effective for both spotting and heavy bleeding (options include indomethacin, mefenamic acid, flufenamic acid, or diclofenac sodium) 3, 1
• Avoid aspirin as it may increase bleeding 1

For Women Not Using Contraception

• The workup focuses on identifying structural causes through the PALM-COEIN classification system: Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 2
• Up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder, particularly von Willebrand disease 5, 6

When to Refer to Gynecology

Immediate referral is indicated for: 2

• Endometrial sampling showing hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm on ultrasound
• Failed medical management after appropriate trial
• Bleeding that saturates a large pad or tampon hourly for at least 4 hours 2

Critical Pitfalls to Avoid

• Never initiate treatment without excluding pregnancy, STDs, and structural pathology first 1
• Do not use NSAIDs or tranexamic acid in patients with cardiovascular disease due to association with MI and thrombosis 2
• Avoid starting treatment during the first 21 days of extended/continuous CHC use as this may compromise contraceptive effectiveness 3, 1
• Do not dismiss persistent bleeding - if bleeding continues despite treatment or the patient finds it unacceptable, counsel on alternative contraceptive methods and offer to switch 3, 1

Enhanced Counseling Reduces Discontinuation

Proactive counseling about expected bleeding patterns before initiating hormonal contraception significantly reduces method discontinuation in clinical trials 3. Patients should understand that irregular bleeding during the first 3-6 months is normal, not harmful, and typically improves with continued use 3.