What is the appropriate management for a patient of reproductive age with heavy, prolonged vaginal bleeding, potentially accompanied by abdominal pain or fever, and with a possible history of previous surgeries, medications, or underlying medical conditions?

Management of Vaginal Bleeding in Reproductive-Age Women

For reproductive-age women with heavy, prolonged vaginal bleeding, immediately rule out pregnancy (including ectopic pregnancy), infection, and structural lesions, then initiate combined oral contraceptives containing 30-35 μg ethinyl estradiol as first-line medical therapy. 1

Initial Critical Assessment

Immediate Exclusions Required Before Treatment

• Pregnancy testing is mandatory - evaluate for both intrauterine and ectopic pregnancy, as bleeding with pregnancy carries significant morbidity and mortality risk 2, 1
• Screen for sexually transmitted infections - particularly in reproductive-aged women before initiating any hormonal therapy 1
• Assess for structural pathology - fibroids, polyps, and malignancy must be excluded before medical management 1, 3

Hemodynamic Stability Assessment

• Evaluate for significant blood loss - vaginal bleeding can result in substantial circulating volume loss requiring urgent intervention 4, 5
• Check for signs of infection - fever with vaginal bleeding may indicate septic abortion (life-threatening) or pelvic inflammatory disease 2, 6

First-Line Medical Management

Combined Oral Contraceptives (COCs)

Monophasic COCs containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are the initial therapy of choice - these reduce menstrual blood loss by inducing regular shedding of a thinner endometrium 1

• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 1
• Screen for thrombotic risk factors before prescribing - COCs increase venous thromboembolism risk three to fourfold 1
• Monitor blood pressure at follow-up visits 1

Expected Timeline and Patient Counseling

• Reassure patients that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and is generally not harmful 1
• Re-evaluate for underlying gynecological problems if bleeding persists beyond 3-6 months 1

Management of Persistent Bleeding Despite COC Therapy

Adjunctive Medical Options

Add NSAIDs for 5-7 days during bleeding episodes as first-line adjunctive therapy - mefenamic acid, indomethacin, or diclofenac reduce menstrual blood loss by 20-60% 1, 3, 7

Consider tranexamic acid - reduces menstrual blood loss by 20-60% and is appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 1, 3

• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

Hormonal Adjustments

• For extended/continuous COC regimens with heavy bleeding: consider a hormone-free interval of 3-4 consecutive days, but avoid hormone-free intervals during the first 21 days or more than once per month 1
• If bleeding remains unacceptable despite treatment: counsel on alternative contraceptive methods and offer another method if desired 1

Special Considerations for IUD Users

IUD with Pregnancy

If an IUD user is found to be pregnant with visible strings, remove the IUD as soon as possible - leaving the IUD in place substantially increases risks of spontaneous abortion (including life-threatening septic abortion), preterm delivery, and infection 2

• Always evaluate for ectopic pregnancy first 2
• Advise that IUD removal reduces but does not eliminate pregnancy risks 2
• If strings are not visible: perform ultrasound to locate the IUD before attempting removal 2, 8

IUD with Pelvic Inflammatory Disease

Treatment outcomes do not generally differ between women with PID who retain the IUD versus those who have it removed - appropriate antibiotic treatment and close clinical follow-up are necessary 2

• One randomized trial showed faster recovery of clinical signs and symptoms with IUD removal 2

Malpositioned or Embedded IUD

Remove a malpositioned IUD as soon as possible if it is low-lying, extending into the cervix, or embedded in the myometrium, especially when associated with pelvic pain 8, 9

• Do not replace the IUD on the same day - wait at least 4-6 weeks to allow myometrial healing 9
• Advise patients to return promptly for heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever 8, 9

Second and Third Trimester Bleeding

Critical Imaging Considerations

Avoid digital pelvic examination until placenta previa, low-lying placenta, and vasa previa have been excluded by ultrasound - these conditions can cause life-threatening hemorrhage if disturbed 2

• Transabdominal ultrasound is the mainstay of obstetrical imaging 2
• Transvaginal ultrasound is both accurate and safe for diagnosis of placenta previa and cervical-related causes of bleeding 2

Follow-Up and Monitoring

• No routine follow-up is required for patients on COCs who are doing well 1
• Patients should return for side effects or concerns 1
• Assess satisfaction with the method and any health status changes at follow-up visits 1

When to Consider Surgical Management

If medical management fails and bleeding remains unacceptable, refer to gynecology for consideration of:

• Endometrial ablation or uterine artery embolization for women not desiring future fertility 2, 3, 7
• Hysterectomy provides definitive resolution but should be avoided if less invasive procedures are available due to increased complications and long-term cardiovascular risks 2