What are the appropriate evaluation and treatment steps for a woman of reproductive age experiencing vaginal bleeding, particularly if it's heavy, prolonged, or accompanied by symptoms like severe abdominal pain, dizziness, or fever?

Evaluation and Management of Vaginal Bleeding in Women of Reproductive Age

Immediately assess hemodynamic stability and rule out pregnancy-related causes first, as pregnancy complications remain the most critical differential diagnosis until proven otherwise. 1

Initial Stabilization and Risk Stratification

Immediate Assessment

• Evaluate for hemodynamic instability by checking vital signs for tachycardia, hypotension, or orthostatic changes, as significant vaginal bleeding can result in substantial circulating volume loss requiring urgent resuscitation 2, 3
• Obtain quantitative β-hCG immediately in all women of reproductive age, as pregnancy complications (threatened abortion, ectopic pregnancy, incomplete abortion, missed abortion, trophoblastic disease) must be excluded first 1
• Assess for signs of acute infection including fever, purulent discharge, and severe abdominal pain with peritoneal signs, which may indicate septic abortion or pelvic inflammatory disease 4

Critical Red Flags Requiring Urgent Intervention

• Severe abdominal pain with positive β-hCG suggests ectopic pregnancy requiring immediate ultrasound and surgical consultation 1
• Fever with vaginal bleeding and cramping raises concern for septic abortion or pelvic inflammatory disease, necessitating broad-spectrum antibiotics and possible surgical intervention 4
• Dizziness or syncope indicates significant blood loss requiring IV access, fluid resuscitation, and consideration of transfusion 2, 3

Diagnostic Evaluation Based on Pregnancy Status

If β-hCG Positive (Pregnancy-Related)

• Perform transvaginal ultrasound immediately to determine pregnancy location and viability, as clinical assessment alone shows only 38.8% concordance with ultrasound findings 5
• For suspected ectopic pregnancy (β-hCG positive with no intrauterine pregnancy on ultrasound), obtain surgical consultation urgently 1
• If IUD is present with positive pregnancy test, evaluate for ectopic pregnancy first, then advise immediate IUD removal if strings are visible, as leaving the IUD increases risks of spontaneous abortion, septic abortion, and preterm delivery 4

If β-hCG Negative (Non-Pregnancy Related)

• Investigate for structural causes including fibroids, polyps, endometrial hyperplasia, or malignancy, particularly in perimenopausal women where cancer must be excluded 1
• Screen for coagulopathy in adolescents with menorrhagia or women with heavy bleeding unresponsive to treatment, as von Willebrand disease and other bleeding disorders are more common than typically recognized 1
• Consider systemic diseases including hypothyroidism, cirrhosis, and coagulation disorders as potential causes 1

Management of Heavy or Prolonged Bleeding

For IUD Users with Heavy Bleeding

• Counsel that irregular or heavy bleeding during the first 3-6 months of copper IUD use is common and generally not harmful, decreasing with continued use 4
• If bleeding persists beyond 6 months, evaluate for IUD displacement, sexually transmitted disease, pregnancy, or new pathologic uterine conditions (polyps, fibroids) 4
• Treat with NSAIDs (indomethacin, mefenamic acid, or flufenamic acid) for 5-7 days during bleeding episodes, as these significantly reduce menstrual blood loss in copper IUD users 4

For Non-IUD Users

• Before initiating hormonal contraception for unexplained heavy bleeding, the CDC assigns a Category 3 classification (risks usually outweigh benefits), requiring evaluation to exclude serious underlying pathology first 4
• Unexplained vaginal bleeding suspicious for serious conditions warrants Category 4 classification (unacceptable health risk) for IUD initiation until evaluation is complete 4

Specific Clinical Scenarios

Bleeding with Severe Abdominal Pain

• Prioritize ectopic pregnancy, ovarian torsion, or ruptured ovarian cyst in the differential diagnosis 1
• Consider non-gynecologic causes including appendicitis, urinary tract pathology (interstitial cystitis), and gastrointestinal sources, as bladder-origin pelvic pain frequently masquerades as gynecologic disease 6

Bleeding with Fever

• Initiate empiric broad-spectrum antibiotics immediately if pelvic inflammatory disease or endometritis is suspected 4
• For IUD users with PID, appropriate antibiotic treatment with close follow-up is necessary, though IUD removal versus retention shows similar treatment outcomes in most studies 4

Postmenopausal or Perimenopausal Bleeding

• Assume malignancy until proven otherwise and obtain endometrial sampling urgently 1
• Perform transvaginal ultrasound to assess endometrial thickness and refer for gynecologic evaluation 1

When to Refer Urgently

• Hemodynamically unstable patients require immediate gynecologic consultation 2, 3
• Suspected ectopic pregnancy needs urgent surgical evaluation 1
• Postmenopausal bleeding requires prompt gynecologic referral for malignancy workup 1
• Heavy bleeding unresponsive to medical management warrants gynecologic consultation for possible surgical intervention 3