What is the cause of prolonged vaginal bleeding in a female patient on new oral birth control with a negative pregnancy test and how should it be managed?

Assessment of Clinical Documentation Quality

This clinical note demonstrates appropriate initial evaluation and management of breakthrough bleeding in a patient on new oral contraceptives, with proper exclusion of pregnancy and ectopic pregnancy, appropriate STI screening given risk factors, and correct patient education about breakthrough bleeding expectations.

Strengths of the Clinical Documentation

Appropriate Differential Diagnosis and Workup

• The provider correctly identified ectopic pregnancy as a concern and appropriately ruled it out with HCG testing, which is essential before attributing bleeding to breakthrough bleeding 1
• STI testing was appropriately ordered given the unprotected sexual encounter with a new partner, as STIs must be excluded before diagnosing breakthrough bleeding 1, 2
• Physical examination appropriately assessed for concerning findings including hemodynamic stability and peritoneal signs 1

Correct Diagnosis and Patient Education

• The diagnosis of breakthrough bleeding is appropriate given the 2-week duration since starting new oral contraceptives in the context of negative pregnancy test and absence of concerning physical findings 3
• Patient education correctly informed the patient that breakthrough bleeding can persist for 3-6 months after starting combined hormonal contraceptives 3, 1
• The provider appropriately counseled on warning signs (weakness, dizziness, worsening bleeding) that would warrant emergency evaluation 1

Areas for Enhancement

Missing Treatment Recommendations

• The note lacks documentation of first-line treatment with NSAIDs for 5-7 days during bleeding episodes, which is the CDC-recommended initial management for breakthrough bleeding 1, 4
• Specific NSAID options such as mefenamic acid 500 mg three times daily or celecoxib 200 mg daily could have been offered for significant bleeding cessation within 7 days 1

Incomplete Follow-Up Planning

• While the note mentions follow-up with primary care, it should specify that re-evaluation is needed if bleeding persists beyond 3-6 months or worsens, as this may indicate underlying gynecological pathology 1, 2
• The note should document that no routine follow-up visit is required for contraceptive users unless the patient has concerns or persistent symptoms 1

Documentation of Medication Interactions

• The note does not document assessment of other medications that might interfere with contraceptive efficacy, which the American College of Obstetricians and Gynecologists recommends 1

Clinical Management Recommendations for This Patient

Immediate Management

• Prescribe NSAIDs (such as ibuprofen 400-600 mg three times daily or mefenamic acid 500 mg three times daily) for 5-7 days during bleeding episodes 1, 4
• Reassure the patient that breakthrough bleeding is expected during the first 3-6 months of new oral contraceptive use and generally decreases with continued use 3, 1

Follow-Up Strategy

• Advise the patient to continue her oral contraceptives as prescribed without interruption 3
• Instruct the patient to return if bleeding persists beyond 6 months, significantly worsens, or if she develops new symptoms 1, 2
• Ensure STI results are followed up and treated if positive 1

Common Pitfalls to Avoid

• Do not recommend a hormone-free interval during the first 21 days of contraceptive use, as this can reduce contraceptive effectiveness 1
• Do not dismiss persistent bleeding without ruling out IUD displacement (if applicable), pregnancy, infection, or structural pathology 1, 2
• Avoid premature discontinuation of the contraceptive method before allowing the 3-6 month adjustment period 3, 1