What is the likely cause of bleeding that began four days after dilation and curettage in a 45-year-old woman who had high‑dose combined oral contraceptive pills stopped on the day of the procedure?

Post-D&C Bleeding After OCP Discontinuation

The most likely cause of bleeding starting 4 days after D&C in your patient is withdrawal bleeding from the abrupt discontinuation of high-dose oral contraceptives, which is an expected physiological response that typically begins 2-7 days after stopping combined hormonal contraceptives. 1

Primary Mechanism: Hormonal Withdrawal

Withdrawal bleeding occurs when estrogen and progestin levels drop precipitously after stopping OCPs, triggering endometrial shedding. This is the expected response in women who discontinue combined oral contraceptives, particularly high-dose formulations. 1

• The timing (4 days post-discontinuation) falls within the typical window for withdrawal bleeding to begin 1
• High-dose OCPs provide substantial hormonal support to the endometrium; their sudden removal creates a more pronounced withdrawal effect 1
• This bleeding is physiologic and self-limited, typically lasting 3-7 days 1

Critical Differential Diagnoses to Exclude

While withdrawal bleeding is most likely, you must systematically rule out other causes:

Immediate Post-Procedural Complications

• Uterine perforation or cervical laceration from the D&C itself, though these typically present with immediate bleeding rather than delayed onset 2
• Retained products of conception or polyp fragments, though the pathology was reported as unremarkable 2, 3

Underlying Pathology

• Missed endometrial pathology: D&C has a false-negative rate up to 10% for detecting endometrial cancer or complex hyperplasia 1, 3, 4
• New or persistent endometrial polyps or fibroids that could cause bleeding 5, 6
• Adenomyosis, which can cause significant bleeding after uterine instrumentation, though this typically presents with heavier bleeding 7

Infection

• Endometritis or retained infected tissue, though this would typically present with fever, pain, and purulent discharge in addition to bleeding 5, 6

Recommended Clinical Approach

Initial Assessment

• Obtain a detailed bleeding history: quantify flow (number of pads/hour), presence of clots, associated pain, fever, or foul-smelling discharge 6
• Perform a focused physical examination: assess hemodynamic stability, abdominal tenderness, and perform a speculum exam to visualize the cervix and quantify bleeding 6
• Rule out pregnancy with a urine or serum β-hCG, even though she just had a D&C 5, 6

Laboratory Evaluation

• Complete blood count to assess for anemia if bleeding is heavy 6
• Consider coagulation studies only if bleeding is severe or the patient has risk factors for coagulopathy 7

Management Algorithm

For light to moderate bleeding consistent with withdrawal:

• Reassure the patient that withdrawal bleeding is expected and typically self-limited 1
• Observe without intervention if bleeding is manageable and the patient is hemodynamically stable 5
• NSAIDs (e.g., ibuprofen 600-800 mg three times daily for 5-7 days) can reduce flow if bleeding is bothersome 5, 6

For heavy or prolonged bleeding (>7 days or soaking >1 pad/hour):

• First-line: NSAIDs (mefenamic acid 500 mg three times daily or ibuprofen 800 mg three times daily for 5-7 days) 5, 6
• Second-line: Short course of low-dose combined oral contraceptives (30-35 μg ethinyl estradiol for 10-20 days) if medically eligible and bleeding persists despite NSAIDs 5, 6
• Alternative: Oral progestin (medroxyprogesterone acetate 10 mg daily for 10 days) if estrogen is contraindicated 6

Red flags requiring urgent evaluation:

• Hemodynamic instability (tachycardia, hypotension, orthostasis) 2
• Fever >38°C suggesting infection 5, 6
• Severe pain suggesting perforation or hematometra 2
• Bleeding requiring >1 pad change per hour for >2 hours 5

Follow-Up Considerations

Schedule follow-up in 2-4 weeks to ensure bleeding has resolved and to discuss long-term management of her heavy menstrual bleeding 6

Important Caveats for This Patient

• At age 45, she is at increased risk for endometrial pathology compared to younger women, with a 9.7% incidence of malignancy or complex hyperplasia in women over 40 with abnormal bleeding 8
• If bleeding recurs after resolution, she requires repeat endometrial sampling (office endometrial biopsy or hysteroscopy with directed biopsy) as D&C alone has limited sensitivity 1, 3, 4
• Consider transvaginal ultrasound to measure endometrial thickness if bleeding persists beyond 7-10 days; an endometrial stripe >3-4 mm warrants further investigation 1
• Do not restart OCPs immediately unless bleeding becomes unmanageable, as this may mask underlying pathology 5

Long-Term Management Planning

Once acute bleeding resolves, address the underlying heavy menstrual bleeding:

• Levonorgestrel-releasing IUD reduces menstrual blood loss by 71-95% and is an excellent option for perimenopausal women 6
• Cyclic progestins (medroxyprogesterone acetate 10 mg days 16-25 of cycle) for anovulatory bleeding 6
• Endometrial ablation or hysterectomy if medical management fails and she has completed childbearing 3