What is the appropriate work‑up and treatment for a 24‑year‑old woman with two‑month continuous abnormal uterine bleeding?

Work-Up and Treatment for 24-Year-Old with Two-Month Continuous Bleeding

Begin with a pregnancy test and transvaginal ultrasound combined with transabdominal imaging to identify structural causes, then proceed to hormonal management if imaging is reassuring and no risk factors for endometrial cancer are present. 1

Initial Diagnostic Steps

Mandatory First Tests

• Obtain a urine β-hCG immediately to exclude pregnancy, as this is the most critical first step in any reproductive-age woman with abnormal bleeding 1, 2
• Order combined transvaginal and transabdominal ultrasound with Doppler as the first-line imaging study to identify structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia 1
• Measure thyroid-stimulating hormone (TSH) and prolactin levels to assess for endocrine causes of ovulatory dysfunction 1, 2
• Check complete blood count to evaluate for anemia from prolonged bleeding 2

Physical Examination Priorities

• Perform speculum examination to visualize the cervix and vagina and exclude cervical or vaginal sources of bleeding 1
• Conduct bimanual examination to assess uterine size, contour, mobility, and adnexal masses 1
• Assess hemodynamic stability and palpate for an enlarged uterus or masses on abdominal examination 1

When to Perform Endometrial Biopsy

At age 24, endometrial biopsy is NOT routinely indicated unless specific risk factors are present. 3, 4

Risk Factors Requiring Biopsy in Young Women

• Long-standing unopposed estrogen exposure (chronic anovulation, polycystic ovary syndrome) 3
• Obesity, diabetes mellitus, or hypertension 3
• Tamoxifen therapy 3
• Family history of Lynch syndrome or endometrial cancer 3
• Bleeding that persists despite 3 months of appropriate medical therapy 2, 4

Advanced Imaging When Initial Ultrasound Is Inadequate

• Proceed to saline infusion sonohysterography (SIS) if focal lesions are suspected or if standard transvaginal ultrasound inadequately visualizes the endometrium, as SIS demonstrates 96-100% sensitivity for detecting endometrial pathology 1, 2
• Consider hysteroscopy with directed biopsy as the definitive diagnostic step when initial evaluation is nondiagnostic or symptoms persist despite negative work-up 2

First-Line Medical Management

Hormonal Options (Choose Based on Contraceptive Need)

• Prescribe combined hormonal contraceptives (CHCs) as first-line therapy for ovulatory dysfunction bleeding, particularly effective when contraception is also desired 1, 2, 4
• Use cyclic oral progestin therapy (medroxyprogesterone acetate 10 mg daily for 10-14 days per month) for patients who cannot use estrogen-containing products 2, 4
• Offer levonorgestrel-releasing intrauterine device (LNG-IUD) as the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation 2, 4

Non-Hormonal Adjuncts

• Add nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce bleeding volume, which can be combined with hormonal contraceptives for enhanced effect 2, 4
• Consider tranexamic acid for heavy menstrual bleeding with high efficacy, though it is more expensive 2, 4

Management Algorithm for Persistent Bleeding

If Bleeding Continues After 3 Months of Treatment

• Reassess compliance with the prescribed regimen, as misuse of oral contraceptives is a frequent cause of breakthrough bleeding 5
• Perform or repeat transvaginal ultrasound if not done initially or if structural etiology is now suspected 2
• Consider supplemental estrogen and/or NSAID during bleeding episodes for women on progestin-only methods 5
• Switch to an oral contraceptive with higher estrogen content or a different progestin formulation 5

When Medical Management Fails

• Refer to gynecology for consideration of surgical options including endometrial ablation or hysterectomy 1, 2
• Perform hysteroscopy to visualize the endometrial cavity and diagnose focal lesions possibly missed by endometrial sampling 2

Common Pitfalls to Avoid

• Do not skip pregnancy testing even if the patient reports contraceptive use or believes pregnancy is impossible 1, 2
• Do not accept inadequate ultrasound visualization as reassuring—if the endometrium cannot be adequately seen due to body habitus or uterine position, proceed directly to endometrial sampling rather than relying on the incomplete scan 1
• Do not perform routine endometrial biopsy in women under 35 without risk factors, as the yield is extremely low and the procedure is unnecessary 3, 4
• Counsel patients that breakthrough bleeding is common during the first 3 months of hormonal contraceptive use—reassurance and continuation of therapy is appropriate during this period 5
• Remember that up to 20% of patients on progestogen therapy may still ovulate, so assess the need for non-hormonal contraception if pregnancy prevention is desired 2

Special Consideration for Cardiovascular Disease

• Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to association with myocardial infarction and thrombosis 1, 2
• Prefer the levonorgestrel-releasing IUD in this population due to minimal systemic absorption 2