What test is compulsory for a patient with heavy vaginal bleeding seeking contraceptive methods before advising any treatment?

Pregnancy Testing is Compulsory Before Contraceptive Initiation in Heavy Vaginal Bleeding

Before advising any contraceptive method to a patient with heavy vaginal bleeding, pregnancy testing is the single compulsory test—ruling out pregnancy and its complications (threatened abortion, ectopic pregnancy, trophoblastic disease) is mandatory, as these are the most critical causes of abnormal bleeding in reproductive-age women. 1, 2

Why Pregnancy Testing Takes Priority

• Abnormal uterine bleeding in any woman of reproductive age must be considered a complication of pregnancy until proven otherwise, as pregnancy-related bleeding (threatened/incomplete abortion, ectopic pregnancy, gestational trophoblastic disease) can be life-threatening 2
• The U.S. Medical Eligibility Criteria classifies pregnancy as "Not Applicable" (NA) for all contraceptive methods, meaning contraception cannot be initiated until pregnancy is definitively excluded 1
• Unexplained vaginal bleeding suspicious for serious conditions receives a Category 2-4 rating (depending on method) before evaluation, emphasizing the need to rule out pregnancy and other serious pathology first 1

The Clinical Algorithm for This Patient

Step 1: Immediate Pregnancy Exclusion

• Perform urine or serum β-hCG testing before any contraceptive counseling 1, 2
• If positive, manage pregnancy complications appropriately and defer contraceptive initiation 2

Step 2: Risk Stratification Based on Age and Risk Factors

Once pregnancy is excluded, the evaluation pathway depends on endometrial cancer risk:

High-risk patients requiring endometrial biopsy 3:

• Women ≥35 years with recurrent anovulation
• Women <35 years with risk factors for endometrial cancer (obesity, PCOS, diabetes, prolonged unopposed estrogen)
• Any patient with excessive bleeding unresponsive to initial medical therapy

Lower-risk patients 3:

• May proceed with hormonal contraceptive trial after pregnancy exclusion
• Endometrial biopsy reserved for treatment failures

Step 3: Additional Targeted Testing (Not Compulsory, But Important)

• Pelvic ultrasound is valuable but not mandatory before contraceptive initiation—it helps identify structural causes (fibroids, polyps, adenomyosis) but doesn't preclude starting contraception 1, 3, 4
• STI screening for gonorrhea/chlamydia if IUD placement is planned, though screening can occur at time of insertion without delaying placement 1
• Coagulation studies if adolescent with menorrhagia or history suggesting bleeding disorder 3, 2
• Thyroid function tests if clinical suspicion of thyroid dysfunction 3

Why the Other Options Are Not Compulsory

Pelvic ultrasound (Option A): While helpful for identifying structural abnormalities, it is not required before initiating most contraceptive methods. The U.S. MEC does not mandate ultrasound before contraception, though it may guide method selection 1. Ultrasound becomes more important if considering IUD placement with suspected anatomical distortion 1, 5.

CT scan (Option B): Never indicated as routine evaluation for heavy vaginal bleeding before contraceptive counseling—this would only be considered for suspected malignancy or complex pelvic pathology after initial evaluation 3, 2.

Endometrial biopsy (Option C): Required only for high-risk patients (age ≥35 with anovulation, younger patients with endometrial cancer risk factors, or treatment failures)—not universally compulsory before contraceptive initiation 3.

Common Pitfalls to Avoid

• Never assume bleeding is "just dysfunctional" without excluding pregnancy first—this is the most dangerous oversight 2
• Don't delay contraceptive counseling for extensive workup in low-risk patients once pregnancy is excluded 1
• Remember that hormonal contraceptives themselves can be therapeutic for heavy bleeding while providing contraception 6, 3, 7
• If starting hormonal contraception with uncertain pregnancy status in low-risk patients, the CDC notes benefits may exceed risks, but follow-up pregnancy testing in 2-4 weeks is essential 1

The answer is: Pregnancy test (not explicitly listed but implied as the compulsory first step). Among the given options, endometrial biopsy (C) would be the most appropriate for high-risk patients, but it is not universally compulsory before contraceptive initiation.