How do I approach a 45-year-old female patient presenting with vaginal bleeding?

Approach to Vaginal Bleeding in a 45-Year-Old Woman

Immediately determine pregnancy status with urine or serum beta-hCG testing, as this fundamentally changes your entire diagnostic and management pathway. 1

Initial Assessment

Assess hemodynamic stability first by checking vital signs and evaluating for signs of significant blood loss. 1 A 45-year-old woman can be either pregnant or non-pregnant, and this distinction is critical before proceeding with any examination or imaging.

If Pregnancy Test is Positive

• Do NOT perform digital pelvic examination until ultrasound excludes placenta previa, low-lying placenta, and vasa previa, as examination before imaging can precipitate catastrophic hemorrhage. 2, 3, 1
• Order transvaginal ultrasound immediately as the primary diagnostic tool, which provides superior resolution compared to transabdominal approach. 2, 1
• Obtain quantitative beta-hCG level regardless of ultrasound findings to help identify ectopic pregnancies and guide interpretation. 2, 3
• Order complete blood count if bleeding is moderate to heavy. 2

Key differential diagnoses in pregnancy:

• Placenta previa (most common diagnosis in late pregnancy bleeding, affecting 1 in 200 pregnancies at delivery) 3
• Placental abruption (affects ~1% of pregnancies, though ultrasound misses up to 50% of cases) 3, 1
• Ectopic pregnancy (7-20% of pregnancy of unknown location cases) 2, 1
• Threatened abortion or early pregnancy loss 2
• Approximately 50% of cases have no identifiable reason 3, 1

If Pregnancy Test is Negative

Now you can safely proceed with speculum and digital pelvic examination. 1 Focus your evaluation on:

• Speculum examination to assess for cervical lesions, polyps, cervicitis, or visible masses. 4, 1
• Digital examination to evaluate uterine size, masses, and adnexal pathology. 1

Key differential diagnoses in non-pregnant patients:

• Dysfunctional uterine bleeding (anovulatory vs. ovulatory patterns) 5
• Endometrial pathology including hyperplasia or malignancy 5
• Cervical cancer or precancerous lesions 4
• Uterine fibroids or polyps 5, 6
• Coagulopathy or systemic illness 7
• Iatrogenic causes (medications, IUD) 6

History Taking Priorities

Obtain specific details about:

• Bleeding pattern: intermenstrual, post-coital, or post-menopausal bleeding are common but non-specific symptoms that may indicate cervical cancer. 4
• Volume and duration of bleeding to assess severity 6
• Associated symptoms: pain, lightheadedness, fever 7
• Medication history: anticoagulants, hormonal therapy 6
• Sexual history including possibility of trauma or abuse 7

Critical Red Flags Requiring Urgent Referral

Refer urgently if malignancy is suspected on examination (visible ulcerating or fungating cervical lesion). 4 The probability of cervical cancer in a woman aged 45-54 with post-coital bleeding is approximately 1 in 2,400. 4

Laboratory Investigations

• Complete blood count with hemoglobin/hematocrit 5
• Platelet count and coagulation studies if heavy bleeding or suspicion of bleeding disorder 5
• Pregnancy test (already done as first step) 5
• Consider testing for Chlamydia trachomatis if symptoms suggest infection 4

Imaging Approach

For non-pregnant patients with concerning findings:

• Pelvic ultrasound to evaluate endometrial thickness and uterine pathology 5
• Consider hysteroscopy with biopsy for abnormal ovulatory bleeding, which is superior to routine dilation and curettage 5
• Endometrial biopsy or dilation and curettage may be necessary to rule out endometrial hyperplasia or malignancy, especially with anovulatory bleeding 5

Common Pitfalls to Avoid

• Never perform digital examination before ultrasound in pregnant patients, as this can cause life-threatening hemorrhage with placenta previa or vasa previa. 2, 3, 1
• Do not order "unscheduled smears" outside the screening program, as these are not recommended. 4
• Do not assume normal vital signs exclude serious pathology—placental abruption can present with normal hemodynamics initially but rapidly deteriorate. 3
• Remember that ultrasound misses up to 74% of ectopic pregnancies initially, making serial beta-hCG monitoring critical when initial ultrasound is non-diagnostic in pregnancy of unknown location. 2

Follow-Up and Referral

• Immediate specialist consultation for confirmed or suspected ectopic pregnancy 2
• Gynecology referral for pregnancy of unknown location requiring serial monitoring 1
• Multidisciplinary team referral for any diagnosed malignancy 4
• For continuing pregnancies with bleeding, schedule follow-up ultrasound in 1-2 weeks 2, 3