What are the possible causes and recommended evaluation for a woman with prolonged vaginal bleeding lasting two months?

Evaluation of Two Months of Vaginal Bleeding in Women

Any woman experiencing two months of continuous vaginal bleeding requires immediate evaluation with transvaginal ultrasound and endometrial sampling to exclude malignancy, structural lesions, and pregnancy complications—this is not a benign symptom that can be managed empirically. 1

Immediate Diagnostic Steps

1. Rule Out Pregnancy First

• Obtain a urine β-hCG test immediately in all women of reproductive age, regardless of contraceptive use or reported sexual activity, because pregnancy complications (threatened abortion, ectopic pregnancy, trophoblastic disease) are life-threatening causes of prolonged bleeding. 1, 2

2. Assess Hemodynamic Stability

• Evaluate for signs of hemodynamic compromise (tachycardia, hypotension, pallor, fatigue) because prolonged bleeding for two months places the patient at high risk for severe anemia requiring urgent intervention. 3
• Order complete blood count to quantify anemia severity and guide transfusion decisions. 3

3. Obtain Focused History

• Document bleeding pattern specifics: daily pad/tampon use, presence of clots, intermenstrual versus continuous bleeding, and associated symptoms (pelvic pain, pressure, weight loss, fever). 4, 3
• Elicit risk factors for endometrial cancer: age ≥45 years, obesity (BMI >30), diabetes, hypertension, polycystic ovary syndrome, unopposed estrogen exposure, tamoxifen use, nulliparity, and family history of Lynch syndrome. 1, 5
• Screen for coagulopathy risk factors: personal or family history of easy bruising, prolonged bleeding after dental procedures or childbirth, menorrhagia since menarche (suggesting von Willebrand disease). 2, 6

Diagnostic Evaluation by Age and Risk

For Women ≥45 Years or Any Age with Risk Factors

Endometrial sampling is mandatory regardless of ultrasound findings because this age group and high-risk patients have elevated endometrial cancer risk, and two months of bleeding represents prolonged unopposed estrogen exposure. 1, 5

• Perform office endometrial biopsy with Pipelle device (sensitivity 99.6% for carcinoma) as the first-line tissue diagnosis. 1, 5
• Order transvaginal ultrasound concurrently to assess endometrial thickness, identify structural lesions (polyps, fibroids, adenomyosis), and evaluate ovarian pathology. 1, 6
• If initial biopsy is inadequate, non-diagnostic, or symptoms persist despite benign results, escalate immediately to hysteroscopy with directed biopsy because blind sampling has a 10% false-negative rate and misses focal lesions. 1, 5

For Women <45 Years Without Risk Factors

Begin with transvaginal ultrasound combined with transabdominal imaging to differentiate structural from non-structural causes before proceeding to endometrial sampling. 1, 6

• If ultrasound shows endometrial thickness ≥10 mm, focal lesions, or structural abnormalities, proceed to endometrial biopsy. 1
• If ultrasound is normal and patient has no risk factors, consider anovulatory bleeding as the diagnosis and initiate hormonal therapy. 6
• However, if bleeding persists beyond 3 months total or patient requests definitive diagnosis, perform endometrial biopsy regardless of ultrasound findings. 1, 5

Laboratory Evaluation

• Measure serum TSH and prolactin to identify reversible endocrine causes of ovulatory dysfunction (hypothyroidism, hyperthyroidism, hyperprolactinemia). 1, 6
• In adolescents or women with menorrhagia since menarche, screen for coagulopathy with CBC, PT/PTT, and von Willebrand panel because coagulation disorders are more common than clinicians realize. 2, 6

Contraceptive-Related Bleeding

If the patient is using hormonal contraception (IUD, implant, DMPA, combined hormonal contraceptives), two months of bleeding warrants evaluation for underlying pathology before attributing symptoms to the contraceptive method alone. 7

• For Cu-IUD or LNG-IUD users with prolonged bleeding, trial NSAIDs for 5–7 days; if bleeding persists, evaluate for structural lesions with ultrasound and consider endometrial sampling if clinically warranted. 7
• For implant or DMPA users, NSAIDs for 5–7 days or short-course hormonal treatment (COCs or estrogen for 10–20 days if medically eligible) may control bleeding, but persistent symptoms require structural evaluation. 7

Common Pitfalls to Avoid

• Never assume prolonged bleeding is "just hormonal" without excluding pregnancy, malignancy, and structural lesions—this delay can miss curable early-stage endometrial cancer. 7, 1
• Do not accept a negative office endometrial biopsy as definitive in a symptomatic patient; the 10% false-negative rate mandates escalation to hysteroscopy if bleeding continues. 1, 5
• Avoid performing digital pelvic examination in pregnant patients with vaginal bleeding until placenta previa and vasa previa are excluded by ultrasound to prevent catastrophic hemorrhage. 1
• Do not rely on Pap smear to evaluate abnormal uterine bleeding; it screens for cervical cancer, not endometrial pathology. 1

Advanced Imaging When Indicated

• Saline-infusion sonohysterography provides 96–100% sensitivity for detecting endometrial polyps and submucous fibroids when standard ultrasound is equivocal or shows focal lesions. 1, 6
• Hysteroscopy enables direct visualization of the endometrial cavity, targeted biopsy of suspicious areas, and simultaneous removal of polyps—it is the definitive diagnostic step when initial sampling is non-diagnostic. 1, 5
• MRI is reserved for preoperative staging after histologic confirmation of endometrial cancer and should not be used for initial diagnostic evaluation. 1

Treatment Approach After Diagnosis

If Structural Cause Identified

• Endometrial polyps or submucous fibroids: hysteroscopic polypectomy or myomectomy. 6
• Adenomyosis or intramural fibroids: levonorgestrel-releasing IUD, GnRH agonists, or uterine artery embolization if medical management fails. 6

If Anovulatory Bleeding Without Structural Pathology

• Initiate combined oral contraceptives or cyclic progestin (medroxyprogesterone acetate 10 mg daily for 10–14 days per month) to regulate cycles and prevent endometrial hyperplasia. 8, 6
• Levonorgestrel-releasing IUD is highly effective for reducing menstrual blood loss in ovulatory menorrhagia. 6

If Medical Therapy Fails or Is Contraindicated

• Offer surgical options: endometrial ablation (for women who have completed childbearing) or hysterectomy (definitive treatment). 6