What is the most appropriate next management step for a patient presenting with prolonged menstrual bleeding, anemia, and symptoms of dizziness and fatigue?

Most Appropriate Next Management Step

The most appropriate next management step is D: Complete blood count and BhCG. This patient presenting with 15 days of continuous bleeding, drowsiness, easy fatigue, and syncope requires immediate assessment of hemoglobin levels to quantify anemia severity and pregnancy testing to rule out pregnancy-related bleeding complications before any intervention 1.

Rationale for Simultaneous CBC and BhCG

All reproductive-age women with abnormal uterine bleeding must be tested for pregnancy 1. This is a non-negotiable first step that cannot be delayed, as pregnancy complications (ectopic pregnancy, miscarriage, molar pregnancy) require entirely different management than non-pregnancy-related bleeding 1.

The complete blood count is equally urgent because:

• Symptoms of drowsiness, easy fatigue, and syncope strongly suggest severe anemia requiring immediate quantification 2, 3
• Hemoglobin levels will determine whether this patient needs urgent transfusion, hospitalization, or can be managed outpatient 1
• Patients with hemodynamic instability or severe anemia (hemoglobin <5 g/dL) may require blood transfusion before any other intervention 3, 4

Why Other Options Are Premature

Ultrasound (Option A) should wait until pregnancy is excluded and anemia severity is quantified 5. While transvaginal ultrasound is the ideal first imaging step for evaluating abnormal uterine bleeding, it cannot be performed before knowing if the patient is pregnant and whether she is hemodynamically stable enough for the procedure 5.

Urine pregnancy test alone (Option B) is insufficient because it fails to address the potentially life-threatening anemia suggested by her symptoms 3, 4. A patient with syncope from prolonged bleeding needs both pregnancy testing AND hemoglobin assessment simultaneously 1.

Dilatation and curettage (Option C) is premature and potentially dangerous without first knowing:

• Whether the patient is pregnant (D&C for pregnancy requires different technique and consent) 1
• The severity of anemia (may need transfusion first if hemoglobin <7 g/dL) 1
• Whether hemodynamic stabilization is needed before any procedure 1

Critical Next Steps After Initial Testing

Once CBC and BhCG results return, management diverges based on findings:

If pregnancy test is positive:

• Urgent obstetric consultation for pregnancy-related bleeding complications 1
• Ultrasound to determine pregnancy location and viability 5

If hemoglobin <7 g/dL with ongoing bleeding:

• Immediate blood transfusion to maintain hemoglobin ≥7 g/dL 1
• Gynecologic consultation for bleeding control (may require hormonal therapy or surgical intervention) 1
• Consider high-dose progestin therapy for acute bleeding control 1

If hemoglobin 7-10 g/dL:

• Transvaginal ultrasound to identify structural causes (fibroids, polyps, adenomyosis) 5
• Initiate oral iron supplementation (ferrous sulfate 200 mg once daily) 6, 7
• Hormonal therapy to control bleeding (combined oral contraceptives or levonorgestrel IUD) 1, 5

If hemoglobin >10 g/dL:

• Outpatient workup with ultrasound and possible endometrial sampling 5
• Oral iron supplementation and hormonal therapy as needed 6, 5

Common Pitfalls to Avoid

Never delay pregnancy testing in any reproductive-age woman with abnormal bleeding, regardless of contraceptive use or sexual history 1. Up to 7.8% of women with severe anemia from menstrual bleeding describe their bleeding as "normal," demonstrating poor insight into disease severity 3.

Never perform invasive procedures (D&C, endometrial biopsy, hysteroscopy) before confirming pregnancy status and assessing anemia severity 1, 5. Approximately 43% of adolescents with heavy menstrual bleeding and iron deficiency anemia require blood transfusion at presentation 4.

Never assume the bleeding is "just menstrual" without excluding pregnancy, as 40.5% of women with severe menstrual-related anemia had received at least one previous transfusion, indicating recurrent severe disease 3. Cancer was detected in 4.8% of women presenting with severe anemia from abnormal uterine bleeding 3.

Recognize that two-thirds of women with life-threatening anemia (hemoglobin <5 g/dL) from menstrual bleeding had recognized heavy bleeding for more than 6 months without seeking help 3. This patient's 15-day bleeding episode with syncope represents a medical emergency requiring immediate laboratory assessment 2, 3.