What is the appropriate diagnostic and management approach for a healthy‑looking 30‑year‑old woman presenting with frequent spontaneous bruising?

Diagnostic Approach to Frequent Spontaneous Bruising in a 30-Year-Old Woman

Begin with a structured bleeding history focusing on specific red-flag symptoms, then proceed to first-line laboratory screening that includes CBC with platelet count, PT, aPTT, and fibrinogen—but recognize that normal results do NOT exclude von Willebrand disease or platelet function disorders, which require additional targeted testing. 1, 2

Critical History Elements

Bleeding Symptom Assessment:

• Significant post-procedural bleeding after dental extractions, wisdom tooth removal, or tonsillectomy strongly suggests an underlying hemostatic disorder 1
• Heavy menstrual bleeding requiring pad/tampon changes more frequently than every 2 hours, lasting >7 days, or causing anemia indicates possible coagulopathy 1, 3
• Prolonged or recurrent epistaxis requiring medical intervention or cauterization is a red flag 1
• Bleeding after minor wounds that is difficult to control or recurs after initial hemostasis 4
• Gastrointestinal or urinary bleeding without anatomic explanation 1

Medication and Supplement Review:

• NSAIDs (ibuprofen, naproxen) impair platelet function and alter coagulation test results 1, 2
• Herbal supplements including ginkgo biloba, fish oil, and garlic increase bleeding tendency 1
• Document all anticoagulants, antiplatelets, and corticosteroids 2

Family History:

• Von Willebrand disease in a family member is highly significant, as this is the most common inherited bleeding disorder affecting 1 in 1,000 individuals with autosomal inheritance 1, 3
• Maternal history of bleeding disorder supports hereditary etiology 3

Bruising Pattern Analysis:

• Bruises on soft tissues (thighs, upper arms, trunk) are more suggestive of bleeding disorder than bruises over bony prominences 1
• Absence of adequate trauma history to explain bruising distribution warrants hemostatic evaluation 1
• Patterned bruising suggests external trauma rather than primary bleeding disorder 1

Physical Examination Findings

Systemic Disease Indicators:

• Skin hyperextensibility or fragility may indicate Ehlers-Danlos syndrome, which can coexist with abnormal bleeding despite normal coagulation studies 1, 5
• Constitutional symptoms (fever, weight loss, night sweats) may signal malignancy or infiltrative disorders 1
• Signs of nutritional deficiencies (scurvy, vitamin K deficiency) 1

First-Line Laboratory Testing

Essential Initial Panel:

• Complete blood count with platelet count and peripheral smear to identify thrombocytopenia, abnormal platelet morphology, or hematologic malignancies 1, 2
• Prothrombin time (PT/INR) to evaluate extrinsic pathway and detect vitamin K deficiency, liver disease, or factor VII deficiency 2
• Activated partial thromboplastin time (aPTT) to assess intrinsic pathway and screen for hemophilia and other factor deficiencies 2
• Fibrinogen level if PT or aPTT are abnormal, as fibrinogen disorders are missed by routine coagulation testing 1, 2

Critical Pitfall: Normal Screening Does Not Exclude Bleeding Disorders

Normal PT/aPTT results do NOT rule out:

• Von Willebrand disease (most common inherited bleeding disorder) 1, 2, 3
• Factor XIII deficiency 1, 2
• Platelet function disorders 1, 2

Second-Line Testing When Initial Screening is Normal

If clinical suspicion remains high despite normal PT, aPTT, platelet count, and fibrinogen:

• Von Willebrand factor testing panel including VWF antigen, VWF ristocetin cofactor activity, and Factor VIII coagulant activity 2, 3
• Platelet function testing (platelet aggregation studies) when platelet count is normal but clinical suspicion for platelet dysfunction is high 2
• Factor XIII assay if other tests are normal but severe bruising persists 2
• Liver function tests to assess hepatic synthetic function 2
• Renal function tests because uremia affects platelet function 2

Interpretation of Common Laboratory Patterns

Prolonged aPTT with normal PT:

• Indicates intrinsic pathway defect, consistent with von Willebrand disease or hemophilia 3
• Mildly decreased factor VIII activity occurs because VWF carries and stabilizes factor VIII; VWF deficiency leads to secondary factor VIII reduction 3

Normal platelet count with abnormal bleeding:

• Rules out immune thrombocytopenia but does not exclude platelet function disorders 3
• Requires platelet function testing for diagnosis 2

When to Refer to Hematology

Referral is indicated when:

• Initial laboratory evaluation indicates a bleeding disorder 1
• High clinical suspicion remains despite normal laboratory workup 1, 6
• Specialized testing (platelet function studies, VWF multimer analysis) is needed 1, 2
• Complex cases require expert interpretation 1

Bleeding Disorder of Unknown Cause (BDUC)

If comprehensive testing remains normal but bleeding history is convincing:

• This condition affects up to 60-70% of patients investigated for mild-moderate bleeding disorders 4
• Bleeding phenotype is indistinguishable from established disorders like VWD or platelet function defects 4
• 75% of clinicians formally register such patients even without laboratory abnormalities 4
• Management includes tranexamic acid for procedures and consideration of hormonal therapy for heavy menstrual bleeding 4