Initial Workup for Irregular Bleeding

Immediate First Steps

The American College of Obstetricians and Gynecologists recommends obtaining urine or serum β-hCG testing first in all reproductive-age women, as pregnancy-related bleeding requires a completely different evaluation pathway 1
Document timing relative to menstrual cycle (intermenstrual vs. heavy menstrual bleeding) 1
Assess duration, volume, and frequency of bleeding episodes 1
The American College of Obstetricians and Gynecologists suggests assessing hormonal contraceptive use, as it can cause breakthrough bleeding 1
The American College of Obstetricians and Gynecologists recommends assessing anticoagulant or antiplatelet medications, as they increase bleeding risk 1
A personal bleeding history, including easy bruising, nosebleeds, prolonged bleeding from minor cuts, and heavy bleeding after dental procedures or surgery, should be assessed 4, 5

A speculum examination should be performed to visualize the cervix and vagina for trauma, cervicitis, cervical polyps, lacerations, or masses 1, 6
The American College of Obstetricians and Gynecologists recommends performing cervical cytology if age-appropriate (typically ≥21 years) 1
If cervical lesions are visualized, consider colposcopy with directed biopsy 1
The American College of Obstetricians and Gynecologists suggests assessing uterine size and contour, as an enlarged uterus may suggest fibroids or adenomyosis 1
Palpate for adnexal masses or tenderness 1
Inspect external genitalia for vulvar lesions 1
Look for signs suggesting systemic causes, such as ecchymoses, petechiae, hepatosplenomegaly, jaundice, joint hypermobility (Ehlers-Danlos), and telangiectasias 2, 7

The American Society of Hematology recommends ordering a complete blood count (CBC) with platelet count to assess for anemia and thrombocytopenia 2, 3, 6
The American Society of Hematology suggests ordering prothrombin time (PT) to screen for factor VII deficiency and liver disease 2
The American Society of Hematology recommends ordering activated partial thromboplastin time (PTT) to screen for factors VIII, IX, XI, XII deficiencies 2
If a strong mucocutaneous bleeding history is present, order initial von Willebrand disease (VWD) assays, including VWF antigen (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo), and factor VIII coagulant activity (FVIII) 2, 7

The American College of Radiology recommends transvaginal ultrasound (TVUS) as the primary imaging modality to evaluate endometrial thickness and appearance, myometrium for leiomyomas and adenomyosis, ovaries for masses or cysts, and cervical canal for polyps or structural abnormalities 1

Calculate the shock index (heart rate ÷ systolic blood pressure) to assess hemodynamic stability, with a value >1 indicating unstable bleeding requiring urgent intervention 3
The American College of Emergency Physicians suggests using the Oakland score to stratify lower GI bleeding severity, although it was developed for GI bleeding, its principles apply to assessing bleeding severity 3
Signs of severe bleeding requiring urgent management include hemodynamic instability, severe anemia (hemoglobin <7 g/dL), and active heavy bleeding requiring transfusion 3, 6

The American Society of Hematology recommends being aware of factors that can falsely elevate VWF levels, including acute stress, anxiety, recent exercise, acute or chronic inflammatory illness, pregnancy or estrogen/oral contraceptive use, and blood group O individuals having 25% lower baseline VWF levels 4, 5
Ensure atraumatic blood draw at room temperature when ordering VWD studies 4
The American Society of Hematology suggests referring patients to hematology if abnormal coagulation studies, low VWF levels, or strong bleeding history with normal initial tests are present 2