What is the appropriate evaluation and treatment for a patient of reproductive age with vaginal bleeding, considering potential causes such as hormonal imbalances, pregnancy-related complications, or underlying medical conditions like cancer?

Evaluation and Management of Vaginal Bleeding in Reproductive-Age Women

For reproductive-age women with vaginal bleeding, immediately rule out pregnancy with a beta-hCG test, then assess for life-threatening causes (ectopic pregnancy, hemorrhage) before proceeding with systematic evaluation based on bleeding pattern and structural versus non-structural etiologies. 1, 2

Immediate Assessment

Hemodynamic Stability

• Assess vital signs and volume status first, as vaginal bleeding can result in significant blood loss requiring resuscitation 3
• Stabilize hemodynamically unstable patients before proceeding with diagnostic evaluation 3

Pregnancy Status (Critical First Step)

• Obtain beta-hCG testing immediately in all reproductive-age women with vaginal bleeding 1, 4
• Abnormal uterine bleeding in reproductive-age women should be considered pregnancy-related until proven otherwise 4
• If pregnancy is confirmed, avoid digital pelvic examination until placenta previa, low-lying placenta, and vasa previa are excluded by ultrasound 1

Diagnostic Evaluation

History and Physical Examination

• Document menstrual cycle pattern, duration and volume of bleeding, associated pain, and timing relative to last menstrual period 3
• Obtain personal and family bleeding history to screen for coagulopathies, particularly in adolescents with menorrhagia 4
• Assess for sexually transmitted infection risk factors, as STIs must be excluded before initiating hormonal treatment 2
• Perform speculum examination to identify cervical or vaginal sources (polyps, cervicitis, lacerations, foreign bodies) 1

Laboratory Studies

• Beta-hCG (pregnancy test) 1, 4
• Complete blood count to assess for anemia 3
• Thyroid-stimulating hormone and prolactin levels 1
• Coagulation studies if menorrhagia in adolescents or history suggesting bleeding disorder 4

Imaging

• Transvaginal ultrasonography is the primary imaging modality for evaluating structural causes in non-pregnant patients 1
• Saline infusion sonohysterography has 96-100% sensitivity for detecting intracavitary pathology (polyps, submucosal fibroids) 1
• Endometrial biopsy is indicated for women ≥45 years or those with risk factors for endometrial cancer to rule out malignancy 1

Differential Diagnosis by Category

Structural Causes (PALM)

• Polyps, Adenomyosis, Leiomyoma (submucosal), Malignancy/hyperplasia 1
• These require imaging or hysteroscopy for diagnosis 1

Non-Structural Causes (COEIN)

• Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 1
• Ovulatory dysfunction is common in adolescents and perimenopausal women 1

Medical Management

First-Line Treatment for Heavy Menstrual Bleeding

Combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are first-line therapy, reducing menstrual blood loss by inducing regular shedding of a thinner endometrium 2

• Monophasic formulations are preferred 2
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 2
• Screen for thrombotic risk factors before prescribing, as COCs increase venous thromboembolism risk 3-4 fold 2

Alternative Medical Options

Levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective option, achieving 71-95% reduction in menstrual blood loss 5

• Three FDA-approved formulations: Mirena (52 mg), Liletta (52 mg), and Skyla (13.5 mg) are equally effective 5
• Counsel patients that irregular bleeding is common in first 3-6 months but typically resolves, with many women developing amenorrhea by 2 years 1, 5
• Particularly beneficial for women with severe thrombocytopenia as it treats bleeding and reduces bleeding risk 5

NSAIDs (mefenamic acid, indomethacin, diclofenac) reduce menstrual blood loss acutely 2

• Use for 5-7 days during bleeding episodes 2
• Avoid aspirin as it may increase bleeding 5

Tranexamic acid reduces menstrual blood loss by 20-60% 2

• Appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 2
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2

Managing Breakthrough Bleeding on Hormonal Therapy

• Reassure patients that unscheduled bleeding is common during first 3-6 months of hormonal therapy and generally not harmful 2
• First-line: NSAIDs for 5-7 days during bleeding episodes 2
• Second-line: Short course of hormonal treatment for 10-20 days if NSAIDs fail 2
• Re-evaluate for underlying gynecological problems (STDs, structural lesions, pregnancy) if bleeding persists beyond initial months 1, 2

Critical Pitfalls to Avoid

Age-Specific Considerations

• Perimenopausal/postmenopausal bleeding should be considered malignancy until proven otherwise 4
• Adolescent menorrhagia should be attributed to coagulopathy until proven otherwise 4

Pregnancy-Related Bleeding

• Never perform digital pelvic examination in second/third trimester bleeding until placenta previa and vasa previa are excluded by ultrasound 1
• When beta-hCG reaches 1,500-2,000 mIU/mL, a normal pregnancy should show gestational sac on transvaginal ultrasound 6
• Absence of adnexal mass or free pelvic fluid does not exclude ectopic pregnancy 6

Contraceptive Management

• Rule out pregnancy, STIs, and structural lesions before attributing bleeding to hormonal contraception 5
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 2
• If bleeding persists despite treatment and is unacceptable to patient, counsel on alternative contraceptive methods 1, 2

Surgical Management

If medical treatment fails, is contraindicated, or not tolerated, or if concomitant significant intracavitary lesions exist, surgical options include endometrial ablation and hysterectomy 1

Follow-Up

• No routine follow-up required for patients on combined oral contraceptives, but patients should return for side effects or concerns 2
• Assess satisfaction with method and any health status changes at follow-up visits 2
• Monitor blood pressure in patients on combined oral contraceptives 2