What is the appropriate evaluation and management for a 45-year-old woman with vaginal bleeding?

Evaluation and Management of Vaginal Bleeding in a 45-Year-Old Woman

Immediate First Steps

The first priority is to determine pregnancy status with urine or serum beta-hCG testing, as this fundamentally changes the entire diagnostic and management pathway. 1

• Assess hemodynamic stability by checking vital signs and evaluating for signs of significant blood loss 1, 2
• Obtain quantitative beta-hCG level in all cases, as pregnancy remains possible at age 45 despite perimenopausal status 1, 3

If Pregnancy is Confirmed

Critical Safety Rule

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. 1, 3, 2

Imaging Approach

• Order transvaginal ultrasound immediately as the primary diagnostic tool, which provides superior resolution compared to transabdominal approach 1, 3
• Transabdominal ultrasound should be performed first to assess placental location, followed by transvaginal ultrasound if transabdominal is inconclusive 4, 3
• Add Doppler velocimetry to identify vasa previa, as vessels overlying the internal cervical os can be subtle and life-threatening if missed 4, 3

Key Differential Diagnoses in Pregnancy

• Placenta previa: affects approximately 1 in 200 pregnancies at delivery 3, 2
• Placental abruption: affects ~1% of pregnancies, though ultrasound misses up to 50% of cases 1, 3
• Ectopic pregnancy: occurs in 7-20% of pregnancy of unknown location cases 1, 2
• Miscarriage or threatened abortion 2, 5

Management Based on Findings

• If intrauterine pregnancy is confirmed, ectopic pregnancy is essentially ruled out except in rare heterotopic cases 3, 2
• For pregnancy of unknown location, obtain serial beta-hCG measurements 48 hours apart and repeat ultrasound when beta-hCG reaches 1,500-2,000 mIU/mL (discriminatory threshold) 3, 2
• Immediate specialist consultation is required for confirmed or suspected ectopic pregnancy 1, 2

If Pregnancy is Excluded

Physical Examination Approach

• Perform speculum examination first to assess for cervical lesions, polyps, cervicitis, or visible masses 1, 2
• Digital bimanual examination to evaluate uterine size, masses, and adnexal pathology 1

Key Differential Diagnoses in Non-Pregnant Patients

• Cervical cancer or precancerous lesions: probability is approximately 1 in 2,400 in women aged 45-54 with post-coital bleeding 4, 1
• Endometrial pathology: including hyperplasia, polyps, or endometrial cancer (peak incidence 65-75 years, but can occur earlier) 6
• Cervical polyps or cervicitis 4, 2
• Hormonal causes: perimenopausal anovulatory bleeding is common at age 45 7
• Genital tract atrophy (less common at age 45 but possible) 6

Diagnostic Testing

• Test for Chlamydia trachomatis, as intermenstrual and post-coital bleeding may be associated with infection 4
• Consider transvaginal ultrasound to measure endometrial thickness and identify structural abnormalities 6
• Endometrial biopsy provides histological diagnosis if endometrial pathology is suspected 6

Red Flags Requiring Urgent Referral

Refer urgently if malignancy is suspected on examination, such as a visible ulcerating or fungating cervical lesion. 4, 1

• Any suspicious cervical lesion on speculum examination 4, 1
• Postmenopausal bleeding (if patient is truly postmenopausal) should be referred urgently, as endometrial cancer is present in ~10% of cases 6
• All diagnosed malignancies require multidisciplinary team referral 4, 1

Common Pitfalls to Avoid

• Never assume a 45-year-old cannot be pregnant – always check beta-hCG first 1, 2
• Never perform digital examination before ultrasound in pregnant patients – this can cause life-threatening hemorrhage with placenta previa or vasa previa 1, 3, 2
• Do not order unscheduled cervical cytology (Pap smear) outside the screening program – this is not recommended for evaluation of vaginal bleeding 4
• Do not dismiss post-coital bleeding – while the probability of cervical cancer is relatively low (1 in 2,400 for this age group), it requires proper evaluation 4
• Normal vital signs do not exclude significant pathology such as placental abruption or early ectopic pregnancy 3

Specific Management Considerations

For Post-Coital Bleeding

• Test for Chlamydia and treat if positive 4
• Perform speculum examination to visualize cervix 4
• Refer urgently if cervical lesion is visible 4

For Intermenstrual Bleeding

• Similar approach to post-coital bleeding with speculum examination and infection screening 4
• Consider hormonal causes given perimenopausal age 7