What is the appropriate evaluation and treatment for a patient with prolonged vaginal spotting lasting about 15 days each month?

Management of Prolonged Vaginal Spotting (15 Days per Month)

Start combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate as first-line treatment after ruling out pregnancy, sexually transmitted infections, and structural uterine lesions. 1

Initial Evaluation

Before initiating any treatment, perform the following assessments:

• Pregnancy test – Exclude pregnancy even in perimenopausal women 1, 2
• STI screening – Test for sexually transmitted infections, particularly in reproductive-aged women 1, 2
• Pelvic examination and transvaginal ultrasound – Rule out structural pathology including polyps, fibroids, or endometrial lesions 1, 2, 3
• Medication review – Assess for drugs that may interfere with hormonal contraceptive efficacy 2
• Bleeding disorder screening – Consider coagulation studies if history suggests inherited bleeding disorder 4

First-Line Medical Treatment

Monophasic combined oral contraceptives (COCs) are the initial therapy of choice:

• Use formulations containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 1
• These reduce menstrual blood loss by inducing regular shedding of a thinner endometrium 1
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 1
• No backup contraception is needed if started within the first 5 days of menstrual bleeding; if started after day 5, use backup contraception for 7 days 5

Before prescribing COCs, assess thrombotic risk factors:

• COCs increase venous thromboembolism risk three to fourfold 1
• Monitor blood pressure at follow-up visits 1

Managing Persistent Breakthrough Bleeding

Reassure the patient that unscheduled bleeding during the first 3-6 months of hormonal therapy is common, generally not harmful, and typically decreases with continued use. 1, 2

If bleeding persists beyond 3-6 months:

• Re-evaluate for underlying gynecological problems including inconsistent pill use, medication interactions, cigarette smoking, STDs, pregnancy, or new pathologic uterine conditions 6, 1, 2

If no underlying problem is found and bleeding continues:

• Add NSAIDs (mefenamic acid 500 mg three times daily or ibuprofen) for 5-7 days during bleeding episodes – This reduces menstrual blood loss by 20-60% acutely 1, 2
• For extended/continuous COC regimens with heavy bleeding, consider a hormone-free interval of 3-4 consecutive days – Do NOT use this approach during the first 21 days of continuous use and not more than once per month, as contraceptive effectiveness may be reduced 6, 1, 2

Alternative Treatment Options if COCs Fail or Are Contraindicated

Levonorgestrel-releasing intrauterine system (LNG-IUS):

• Reduces menstrual blood loss by 71-95% 5
• Can be inserted at any point in the menstrual cycle if pregnancy is excluded 5
• No backup contraception needed if inserted within 7 days of menses onset 5
• Expect irregular spotting for 3-6 months after insertion; treat persistent bleeding with NSAIDs for 5-7 days 2, 5

Tranexamic acid:

• Reduces menstrual blood loss by 20-60% 1
• Appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 1
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

Oral medroxyprogesterone acetate:

• Administer 10 mg daily for 10-21 days per month 7, 8
• Reduces menstrual blood loss by approximately 87% 5
• Useful when estrogen-containing methods are contraindicated 7

Critical Pitfalls to Avoid

• Do NOT dismiss bleeding without ruling out pregnancy, infection, or structural pathology 2
• Do NOT recommend hormone-free intervals during the first 21 days of extended/continuous CHC regimens 2
• Do NOT use copper IUDs in patients with heavy bleeding, as they may exacerbate symptoms 5
• Do NOT proceed to surgical intervention without exhausting medical options first 1

Follow-Up

• No routine follow-up visit is required for contraceptive users 2, 5
• Patients should return for side effects, concerns, or if bleeding persists beyond 6 months 1, 2
• If bleeding remains unacceptable despite medical management, counsel on alternative contraceptive methods or consider referral for endometrial ablation or hysterectomy 6, 1