What is the appropriate management for a female of reproductive age presenting with mid-cycle vaginal bleeding, pain, and blood clots?

Management of Mid-Cycle Vaginal Bleeding with Pain and Blood Clots

The first priority is to rule out pregnancy with a beta-hCG test, as any vaginal bleeding in a reproductive-age woman must be considered pregnancy-related until proven otherwise, followed by evaluation for structural pathology and coagulopathy. 1

Immediate Diagnostic Evaluation

Essential First Steps

• Obtain a pregnancy test (beta-hCG) immediately in all reproductive-age women presenting with vaginal bleeding, as complications of pregnancy (ectopic pregnancy, threatened abortion, or trophoblastic disease) are the most critical diagnoses to exclude 2, 1
• Perform a focused history documenting: timing of bleeding relative to menstrual cycle, quantity of bleeding (number of pads/tampons saturated per hour), presence and severity of pain, contraceptive use (especially IUDs or hormonal methods), and any history of easy bruising or bleeding disorders 3
• Conduct pelvic examination with speculum to identify the bleeding source (cervical, vaginal, or uterine) and rule out cervical lesions, trauma, or foreign bodies 1

Laboratory Workup

• Measure hemoglobin/hematocrit to assess severity of blood loss and need for resuscitation 4
• Check TSH and prolactin levels to identify reversible causes of ovulatory dysfunction 2
• Screen for coagulopathy in patients with heavy bleeding, particularly if adolescent or if bleeding fails to respond to standard therapy, as up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 5

Imaging Studies

• Obtain transvaginal ultrasound to assess endometrial thickness, exclude structural abnormalities (polyps, fibroids, adenomyosis), evaluate for ovarian masses, and measure endometrial thickness 2, 3
• Consider saline infusion sonohysterography if ultrasound shows polypoid lesions or asymmetric endometrial thickening to better characterize intracavitary pathology 3

Acute Management Based on Severity

For Active Heavy Bleeding

• Initiate ibuprofen 600-800 mg orally every 6-8 hours for the first 24 hours, which reduces menstrual blood flow by 20-60% through prostaglandin inhibition 6, 7
• Add tranexamic acid 1300 mg three times daily for 5 days during the bleeding episode if NSAIDs alone are insufficient, as this provides superior bleeding control when combined with NSAIDs 7, 6
• Continue NSAID therapy for 5-7 days maximum during the bleeding episode 3, 7

Critical Contraindications

• Avoid aspirin, as it paradoxically increases bleeding 6
• Exercise caution with NSAIDs in patients with cardiovascular disease, particularly those with history of spontaneous coronary artery dissection 6

Hormonal Management if Medical Therapy Fails

If Bleeding Persists Beyond 5-7 Days

• Initiate combined oral contraceptives containing 30-35 μg ethinyl estradiol as first-line hormonal therapy if the patient can tolerate estrogen and contraception is acceptable 6, 2
• For patients who cannot use estrogen: consider cyclic progestin therapy (medroxyprogesterone acetate 10 mg daily for 10-14 days per month) 2
• If patient is willing to use injectable contraception: depot medroxyprogesterone acetate (DMPA) can be considered, with NSAIDs for 5-7 days used for any breakthrough bleeding 7

For Contraceptive Users with Breakthrough Bleeding

• If using IUD (copper or levonorgestrel): NSAIDs for 5-7 days are first-line treatment 3
• For LNG-IUD users with persistent bleeding: consider adding hormonal treatment with combined oral contraceptives or estrogen for 10-20 days if medically eligible 3
• If using extended/continuous combined hormonal contraceptives: avoid hormone-free intervals more than once per month as this reduces contraceptive effectiveness 3

When to Escalate Care

Indications for Further Evaluation

• If bleeding persists despite 5-7 days of NSAID therapy and hormonal treatment, perform hysteroscopy to visualize the endometrial cavity and diagnose focal lesions that may have been missed by endometrial sampling 3
• Consider endometrial biopsy if patient is over 35 years old, has risk factors for endometrial hyperplasia/cancer, or has persistent irregular bleeding unresponsive to medical management 3
• Evaluate for underlying conditions including coagulation disorders (particularly von Willebrand disease), thyroid disease, or structural pathology if bleeding disorder persists or is unacceptable to the patient 3, 5

Common Pitfalls to Avoid

• Never assume non-pregnancy status without testing - ectopic pregnancy can present with mid-cycle bleeding and pain with clots 1
• Do not perform blind dilation and curettage without hysteroscopy, as endometrial biopsy is safer, less invasive, and more cost-effective for diagnosing endometrial pathology 3
• Recognize that mid-cycle bleeding with pain could represent ovulation (mittelschmerz) if mild, but the presence of blood clots suggests heavier bleeding requiring evaluation 4
• If patient is on anticoagulation therapy, bleeding management becomes more complex and may require switching anticoagulation agents or temporary cessation in consultation with the prescribing physician 8

Follow-Up Protocol

• Reassess at 3-6 months to evaluate treatment response, menstrual pattern normalization, and patient satisfaction 2
• If bleeding disorder persists or woman finds it unacceptable, counsel on alternative methods and offer another contraceptive or treatment option 3, 2