What is the best course of action for a 26-year-old female with irregular periods, heavy menstrual bleeding, new onset acne, and facial hair, who has a history of two spontaneous miscarriages and is concerned about potential retained products of conception, and also has a history of smoking?

Management of Irregular Periods with Heavy Bleeding and Hyperandrogenic Features

The best course of action is to complete the comprehensive diagnostic workup already initiated (pregnancy test, hormonal panel including FSH/LH/testosterone/SHBG, pelvic ultrasound, and STI screening), then manage the heavy menstrual bleeding with NSAIDs while awaiting results, as this patient's presentation strongly suggests polycystic ovary syndrome (PCOS) requiring confirmation before definitive treatment. 1

Immediate Diagnostic Priorities

Rule Out Critical Conditions First

• Pregnancy must be excluded immediately given the history of two recent miscarriages and concern about retained products of conception 2, 3
• STI screening is essential as infections can cause irregular bleeding and must be identified before attributing symptoms to hormonal causes 2, 4
• Structural pathology (polyps, fibroids, retained products) requires evaluation via pelvic ultrasound, particularly given the tissue-like material noted during last period 2, 1

Assess for PCOS as Primary Diagnosis

The clinical presentation strongly suggests PCOS based on:

• Irregular cycles with anovulation (missing months, then heavy periods) 1
• New-onset hyperandrogenic features (acne and facial hair) 1
• Heavy menstrual bleeding pattern consistent with anovulatory cycles 1

The hormonal workup ordered (testosterone, LH/FSH ratio, SHBG) will confirm PCOS if testosterone >2.5 nmol/L, LH/FSH ratio >2, and ultrasound shows >10 peripheral cysts of 2-8mm diameter 1. The mid-luteal progesterone (<6 nmol/L indicates anovulation) would further support this diagnosis 1.

Management of Heavy Menstrual Bleeding

First-Line Treatment During Bleeding Episodes

NSAIDs should be initiated for symptomatic relief during heavy bleeding days:

• Mefenamic acid 500 mg three times daily for 5 days during bleeding episodes 2, 1, 3
• Alternative: Celecoxib 200 mg daily for 5 days 1, 3
• NSAIDs demonstrate statistically significant reductions in menstrual blood loss and are appropriate first-line therapy 2, 1

Avoid Aspirin

Do not use aspirin as it may increase blood loss in women with baseline menstrual blood loss patterns like this patient's 2, 1

Consider Tranexamic Acid with Caution

While tranexamic acid significantly reduces menstrual blood loss, it is contraindicated in women with smoking history due to increased thrombosis risk 2, 1. Given this patient's smoking history (even though cutting down), tranexamic acid should be avoided 2, 1.

Definitive Long-Term Management

If PCOS is Confirmed

Low-dose combined oral contraceptives (30-35 μg ethinyl estradiol with levonorgestrel or norgestimate) provide:

• Cycle regulation and predictable bleeding patterns 3
• Reduction in hyperandrogenic symptoms (acne, hirsutism) 3
• Safe throughout reproductive years 3

Alternative Long-Term Option

Levonorgestrel-releasing IUD (LNG-IUD) is the most effective long-term approach, reducing menstrual blood loss by 71-95% 1. However, counseling about initial irregular bleeding for 3-6 months is essential 2.

Critical Pitfalls to Avoid

Do Not Assume Functional Bleeding

Never attribute irregular bleeding to "hormonal imbalance" without excluding structural pathology, especially given the concern about retained products of conception 4, 3. The pelvic ultrasound is mandatory 3.

Address Smoking Cessation

Smoking increases thrombotic risk and limits treatment options (contraindication to tranexamic acid, relative caution with combined hormonal contraceptives) 2. Smoking cessation counseling should be prioritized 2.

Monitor for Anemia

With heavy bleeding (3 fully soaked pads on day 1 with clots), check ferritin and hemoglobin to assess for iron deficiency anemia, which commonly accompanies heavy menstrual bleeding 5. The FBC ordered will identify this 5.

Evaluate Thyroid and Prolactin

Thyroid dysfunction and hyperprolactinemia are common endocrine causes of menstrual irregularity and must be excluded before attributing symptoms solely to PCOS 3. The ordered thyroid function and prolactin tests are appropriate 3.

Follow-Up Strategy

Reassess After Initial Results

• Review all laboratory and imaging results within 1-2 weeks 4, 3
• If PCOS confirmed, initiate combined oral contraceptives for cycle regulation and hyperandrogenic symptom management 1, 3
• If structural pathology identified (retained products, polyps, fibroids), refer for gynecological management 2, 1
• If STIs detected, treat according to CDC guidelines before initiating hormonal therapy 2, 4

Ongoing Monitoring

Reassess bleeding patterns after 3 months of hormonal treatment to ensure adequate response 4, 3. If bleeding persists despite appropriate therapy, further investigation for underlying pathology is warranted 2, 1.