What is the recommended approach to evaluate and manage vaginal bleeding, including emergency treatment, diagnostic work‑up, and medical therapy for varying severity and menopausal status?

Evaluation and Management of Vaginal Bleeding

Immediately determine pregnancy status with urine or serum beta-hCG testing, as this fundamentally changes the entire diagnostic and management approach, and perform transvaginal ultrasound before any digital pelvic examination to avoid catastrophic hemorrhage from placental abnormalities. 1, 2

Initial Emergency Assessment

Hemodynamic Stabilization

• Assess vital signs immediately to determine severity of bleeding and need for resuscitation 3
• Obtain complete blood count to evaluate degree of anemia and guide transfusion decisions 1
• Check coagulation studies (PT/INR, aPTT), especially if patient is on anticoagulants or has bleeding diathesis 1
• Perform blood typing and cross-matching if severe bleeding is present 3

Critical First Step: Pregnancy Testing

• Obtain quantitative beta-hCG level immediately in all reproductive-age women, regardless of contraceptive use or reported sexual activity 2, 4
• This single test determines whether you follow a pregnancy-related or non-pregnancy pathway 2, 4

Diagnostic Approach by Clinical Scenario

For Pregnant Patients (Positive Beta-hCG)

Never perform digital pelvic examination before ultrasound imaging in second or third trimester bleeding, as this can precipitate catastrophic hemorrhage with placenta previa or vasa previa. 3, 2

Imaging Protocol

• Transvaginal ultrasound is the primary diagnostic tool and provides superior resolution compared to transabdominal ultrasound 3, 2, 4
• Evaluate for placental location, inferior placental margin distance from internal cervical os, and any vessels overlying the cervix 3
• Use color Doppler velocimetry to identify vasa previa by distinguishing fetal from maternal vessels 3
• Transabdominal ultrasound may be inadequate due to bladder filling, maternal symphysis shadowing, or body habitus 3

Key Diagnoses to Exclude

• Placenta previa is the most common pathologic diagnosis in late pregnancy bleeding, affecting 1 in 200 pregnancies at delivery 3, 4
• Placental abruption affects approximately 1% of pregnancies but is associated with worse perinatal outcomes; ultrasound misses up to 50% of cases, so clinical correlation is essential 2
• Ectopic pregnancy occurs in 7-20% of pregnancy of unknown location cases 2, 4
• Approximately 50% of second/third trimester bleeding cases have no identifiable cause after thorough evaluation 3, 2

Management Based on Ultrasound Findings

• If intrauterine pregnancy with fetal cardiac activity is confirmed, ectopic pregnancy is essentially ruled out (except rare heterotopic pregnancy) 2, 4
• For pregnancy of unknown location, perform serial beta-hCG measurements every 48 hours and repeat ultrasound when beta-hCG reaches 1,500-2,000 mIU/mL discriminatory threshold 4
• Pathologic bleeding with placenta previa, vasa previa, placental abruption, or uterine rupture requires immediate specialist consultation and may require hospitalization and/or delivery 2

For Postmenopausal Patients (Negative Beta-hCG, >12 Months Since Last Menses)

Any postmenopausal vaginal bleeding must be presumed malignant until proven otherwise, as approximately 10% of cases are endometrial cancer. 1, 5

Immediate Diagnostic Steps

• Perform speculum examination to identify bleeding source: cervical lesions, polyps, inflammation, vaginal atrophy, or lacerations 1
• Avoid digital bimanual examination initially until imaging excludes structural pathology 1
• Obtain complete medication history, specifically asking about anticoagulants, antiplatelet agents, tamoxifen, and hormone replacement therapy 1, 5

Imaging and Tissue Diagnosis

• Transvaginal ultrasound is the first-line imaging test to assess endometrial thickness and detect intrauterine pathology 1
• If endometrial thickness is <5 mm on transvaginal ultrasound, examination is normal, and bleeding has stopped, no further action is needed 5
• Endometrial biopsy is mandatory for any postmenopausal bleeding to exclude endometrial carcinoma 1
• Office endometrial biopsy has a 10% false-negative rate; if negative but bleeding persists, proceed to fractional dilation and curettage under anesthesia 1
• Hysteroscopy may be helpful if persistent bleeding remains undiagnosed after initial workup, particularly to identify polyps or focal lesions 1
• If transvaginal ultrasound cannot fully visualize the endometrium due to body habitus, uterine position, leiomyomas, or adenomyosis, pelvic MRI should be considered 1

Management of Malignancy

• If malignancy is identified, immediate referral to gynecologic oncology for staging and treatment planning is necessary 1
• Do not delay referral, as survival is significantly better with early-stage disease 1

Anticoagulation Management

• Do not routinely discontinue anticoagulation unless bleeding is life-threatening or uncontrolled 1
• For life-threatening bleeding on warfarin, administer 4-factor prothrombin complex concentrate plus 5 mg IV vitamin K, targeting INR <1.5 1
• For DOAC-related bleeding, consider specific reversal agents only if bleeding is uncontrolled and DOAC levels are measurable 1

For Premenopausal/Perimenopausal Patients (Negative Beta-hCG)

Initial Evaluation

• Perform speculum examination to assess for cervical lesions, polyps, or inflammation 6
• Rule out sexually transmitted diseases and measure hemoglobin, iron levels, and thyroid hormones in selected cases 6
• Transvaginal ultrasound is the ideal first step for evaluation 6
• Saline or gel contrast sonohysterography improves diagnostic accuracy for focal lesions 6

Diagnostic Workup

• Based on ultrasound findings, plan invasive procedures such as endometrial biopsy or hysteroscopy 6
• Ultrasound is significantly better than hysteroscopy at detecting fibroids, but hysteroscopy is significantly better for polyps 7
• Once premalignant and malignant causes are excluded, evaluate necessity for treatment in collaboration with the patient 6

Treatment Options

• Heavy menstrual bleeding causing anemia needs immediate treatment 6
• In less severe cases and intermenstrual bleeding, expectant management can be considered 6
• Hormonal treatment options include oral progestogens, combined oral contraceptives, or levonorgestrel intrauterine system for anovulatory bleeding 6
• Antifibrinolytic and non-steroidal anti-inflammatory drugs can reduce bleeding amount 6
• Focal intrauterine lesions such as endometrial polyps or submucous myomas may require operative hysteroscopic procedures 6
• Endometrial ablation or resection are good choices in selected cases, but some women will need hysterectomy 6

Common Pitfalls to Avoid

• Never perform digital pelvic examination before ultrasound in pregnant patients with second/third trimester bleeding 3, 2
• Never accept a negative office endometrial biopsy as definitive in postmenopausal bleeding if bleeding persists; proceed to D&C under anesthesia 1
• Never assume postmenopausal bleeding is benign without tissue diagnosis 1, 5
• Remember that ultrasound misses up to 50% of placental abruptions, so clinical correlation is essential 2
• In pregnancy of unknown location, approximately 7-20% will be ectopic pregnancies, so close follow-up with serial beta-hCG is mandatory 2, 4