In a 45-year-old perimenopausal woman who stopped a high-dose combined oral contraceptive on the day of dilation and curettage and now has spotting beginning four days later, could the bleeding be from the base of a retained polyp?

Spotting Four Days After D&C: Retained Polyp Base as a Cause

Yes, bleeding from a retained polyp base is a plausible cause of spotting four days after dilation and curettage, but withdrawal bleeding from abrupt cessation of high-dose combined oral contraceptives is the more likely explanation in this clinical scenario. 1

Primary Differential: Withdrawal Bleeding vs. Retained Polyp

Withdrawal Bleeding (Most Likely)

• Stopping combined oral contraceptives on the day of D&C creates an immediate hormone-free interval, triggering withdrawal bleeding that typically begins 2-7 days after cessation. 1
• The timing of spotting at day 4 post-procedure aligns precisely with expected withdrawal bleeding patterns following abrupt discontinuation of hormonal contraception. 1
• High-dose combined oral contraceptives produce more robust endometrial proliferation, which can result in heavier withdrawal bleeding when discontinued. 2

Retained Polyp Base (Possible but Less Common)

• Endometrial polyps are recognized structural causes of abnormal uterine bleeding, and incomplete removal during D&C can leave a bleeding polyp base. 1, 2
• Polyps identified during hysteroscopy or imaging should be considered as potential bleeding sources when spotting occurs post-procedure. 1
• However, polyps themselves are not consistently associated with increased bleeding risk—one study found no significant association between endometrial polyps and abnormal bleeding patterns. 3

Critical Evaluation Steps

Rule Out High-Risk Causes First

• Obtain an immediate pregnancy test, as ectopic pregnancy and other pregnancy complications can present as spotting and must be excluded before attributing bleeding to other causes. 2
• Screen for sexually transmitted infections, which can cause irregular uterine bleeding independent of the procedure. 2
• Assess for signs of infection, retained products of conception, or uterine perforation—all potential D&C complications requiring urgent intervention. 1

Assess for Structural Pathology

• If bleeding persists beyond 7-10 days or becomes heavy, consider transvaginal ultrasound to evaluate for retained polyp tissue, incomplete evacuation, or new pathology. 1
• Ultrasound has limitations in visualizing the endometrium completely, particularly in the presence of adenomyosis or fibroids; MRI with diffusion-weighted imaging provides superior tissue characterization when ultrasound is inadequate. 1
• Hysteroscopy remains the gold standard for direct visualization of retained polyp bases or other intrauterine abnormalities when imaging is inconclusive. 1

Consider Hormonal Factors

• Review whether the patient was on extended or continuous combined oral contraceptive use prior to stopping, as unscheduled bleeding is common during the first 3-6 months of such regimens and may persist briefly after discontinuation. 1, 2
• Cigarette smoking increases breakthrough bleeding risk in combined oral contraceptive users and may contribute to post-cessation spotting. 2, 4

Management Algorithm

Days 1-7 Post-D&C

• Reassure the patient that light spotting for 4-7 days after D&C is normal, and withdrawal bleeding from stopping combined oral contraceptives typically resolves within one week. 1
• Advise expectant management unless bleeding becomes heavy (soaking more than one pad per hour for 2+ consecutive hours) or is accompanied by fever, severe pain, or foul-smelling discharge. 1

Days 8-14 Post-D&C

• If spotting persists beyond 7-10 days, perform transvaginal ultrasound to assess endometrial thickness and identify retained tissue or polyp remnants. 1
• Measure serum beta-hCG if pregnancy test was not performed initially or if clinical suspicion for pregnancy-related bleeding exists. 2

Beyond 14 Days or Heavy Bleeding

• Refer for hysteroscopy if imaging suggests retained polyp base or if bleeding continues despite normal ultrasound findings. 1, 2
• Consider endometrial sampling if the patient is over 30 years old or has risk factors for endometrial hyperplasia or malignancy. 1

Common Pitfalls to Avoid

• Do not attribute all post-procedure bleeding to the D&C itself without excluding pregnancy, infection, and structural pathology—these require specific treatment and delaying diagnosis worsens outcomes. 2, 4
• Do not assume polyps always cause bleeding; research shows endometrial polyps are not consistently associated with increased bleeding risk, so their presence alone does not confirm causation. 3
• Do not overlook the temporal relationship between stopping high-dose combined oral contraceptives and the onset of spotting—withdrawal bleeding is the most parsimonious explanation when timing aligns. 1
• Do not restart combined oral contraceptives immediately without addressing the underlying cause of bleeding, as this may mask pathology requiring intervention. 2, 4