How should a woman with two weeks of vaginal bleeding be evaluated and managed?

Evaluation and Management of Two Weeks of Vaginal Bleeding

A woman with two weeks of vaginal bleeding requires immediate pregnancy testing and assessment of hemodynamic stability, followed by pelvic ultrasound to exclude life-threatening causes, with combined oral contraceptives (30-35 μg ethinyl estradiol) or NSAIDs as first-line medical therapy once structural pathology is ruled out.

Immediate Assessment and Risk Stratification

First, determine if the patient is pregnant or hemodynamically unstable, as these scenarios require urgent intervention. 1, 2

• Obtain a urine pregnancy test (β-hCG) immediately—this is mandatory regardless of the patient's reported contraceptive use or menstrual history 1
• If pregnant, manage according to obstetric protocols and avoid digital pelvic examination until placenta previa and vasa previa are excluded by ultrasound 3
• Assess vital signs and volume status; significant vaginal bleeding can cause substantial blood loss requiring resuscitation 4

Diagnostic Workup for Non-Pregnant Patients

After excluding pregnancy, perform targeted testing to identify structural, infectious, and endocrine causes:

• Screen for sexually transmitted infections (gonorrhea and chlamydia) in all reproductive-aged women, as cervicitis is a common treatable cause 1
• Order transvaginal ultrasound to evaluate for structural abnormalities including polyps, fibroids, adenomyosis, and endometrial pathology 1
• Check TSH and prolactin levels to assess for thyroid disease and hyperprolactinemia 1
• Consider saline infusion sonohysterography if transvaginal ultrasound is inconclusive, as it has 96-100% sensitivity for intracavitary pathology 1

A critical pitfall: Do not perform digital pelvic examination in pregnant patients until ultrasound excludes placenta previa, low-lying placenta, and vasa previa, as examination can trigger catastrophic hemorrhage. 3

First-Line Medical Management

For hemodynamically stable patients without structural pathology, initiate medical therapy immediately:

NSAIDs as Initial Treatment

• Start mefenamic acid 500 mg three times daily for 5-7 days during bleeding episodes—this reduces menstrual blood loss by 20-60% acutely and is the recommended first-line therapy 5, 1
• Alternative NSAIDs include ibuprofen or indomethacin if mefenamic acid is unavailable 5
• NSAIDs work quickly and can be used while awaiting further diagnostic results 5

Hormonal Therapy

• If NSAIDs alone are insufficient, add monophasic combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 6, 1
• For acute heavy bleeding, consider a short course (10-20 days) of hormonal therapy if medically eligible 5
• Counsel patients that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and generally not harmful—this counseling improves adherence 5, 1

Important safety consideration: Assess thrombotic risk factors before prescribing combined oral contraceptives, as they increase venous thromboembolism risk 3-4 fold. 1

Management of Persistent Bleeding

If bleeding continues despite initial medical therapy:

• Re-evaluate for underlying gynecological problems including pregnancy, STIs, and new structural pathology (polyps, fibroids) 5
• Consider adding a 3-4 day hormone-free interval if using extended/continuous COC regimens, but avoid this during the first 21 days of use 6, 5
• Counsel about alternative contraceptive methods if current treatment is unacceptable 5

When to Consider Surgical Management

Surgical options should be considered if:

• Medical treatment fails, is contraindicated, or not tolerated 1
• Significant intracavitary lesions are identified 1
• The patient desires definitive management 5

Options include endometrial ablation, myomectomy (if fertility preservation desired), or hysterectomy 1

Special Populations

Postmenopausal Women

• All postmenopausal bleeding (bleeding ≥12 months after last menstrual period) requires urgent referral, as endometrial cancer is present in approximately 10% of cases 7
• Measure endometrial thickness by transvaginal ultrasound; if <5 mm with normal examination and resolved bleeding, no further action is needed 7

Adolescents

• Combined oral contraceptives with 30-35 μg ethinyl estradiol are first-line treatment for heavy menstrual bleeding in adolescents 6
• Smoking is not a contraindication to COC use in patients younger than 35 years 6

Follow-Up and Monitoring

• No routine follow-up visit is required for patients on hormonal therapy, but they should return for side effects or concerns 6, 1
• Monitor blood pressure at follow-up visits for patients on combined oral contraceptives 6, 1
• Reassess satisfaction with the method and any health status changes 6