Management of Spotting After Dilation and Curettage (D&C)

Withdrawal Bleeding

Stopping combined oral contraceptives on the day of D&C creates an immediate hormone‑free interval that triggers withdrawal bleeding, which typically begins 2–7 days after cessation. 1
Spotting that appears on day 4 after the procedure aligns precisely with the expected timing of withdrawal bleeding following abrupt discontinuation of hormonal contraception. 2
High‑dose combined oral contraceptives induce robust endometrial proliferation; when discontinued, they can produce heavier withdrawal bleeding. 3
Light spotting for 4–7 days after D&C is considered normal, and withdrawal bleeding from stopping combined oral contraceptives usually resolves within one week. 1
The temporal relationship between stopping high‑dose combined oral contraceptives and the onset of spotting is the most parsimonious explanation when the timing matches. 2

Endometrial polyps are recognized structural causes of abnormal uterine bleeding; incomplete removal during D&C can leave a bleeding polyp base. 4
Polyps identified on hysteroscopy or imaging should be considered potential bleeding sources when spotting occurs after the procedure. 4

Obtain an immediate pregnancy test to exclude ectopic pregnancy or other pregnancy‑related complications that can present as spotting. 3
Screen for sexually transmitted infections, which may cause irregular uterine bleeding independent of the D&C. 3
Assess for signs of infection, retained products of conception, or uterine perforation—complications of D&C that require urgent intervention. 4

If spotting persists beyond 7–10 days or becomes heavy, perform transvaginal ultrasound to evaluate endometrial thickness and identify retained tissue or polyp remnants. 4
When ultrasound is limited (e.g., due to adenomyosis or fibroids), MRI with diffusion‑weighted imaging provides superior tissue characterization. 4
Hysteroscopy is the gold‑standard for direct visualization of retained polyp bases or other intra‑uterine abnormalities when imaging is inconclusive. 4

Review whether the patient was on an extended or continuous combined oral‑contraceptive regimen before stopping; unscheduled bleeding is common during the first 3–6 months of such regimens and may persist briefly after discontinuation. 1
Cigarette smoking increases the risk of breakthrough bleeding in combined oral‑contraceptive users and may contribute to post‑cessation spotting. 6

Reassure the patient that light spotting is normal; adopt expectant management unless bleeding becomes heavy (soaking > 1 pad per hour for ≥ 2 consecutive hours) or is accompanied by fever, severe pain, or foul‑smelling discharge. 4

If spotting persists, obtain transvaginal ultrasound to assess for retained tissue.
Measure serum β‑hCG if a pregnancy test was not performed initially or if pregnancy‑related bleeding is suspected. 3

Refer for hysteroscopy when imaging suggests a retained polyp base or when bleeding continues despite a normal ultrasound. 4
Consider endometrial sampling in patients > 30 years old or those with risk factors for endometrial hyperplasia or malignancy. 4

Do not attribute all post‑procedure bleeding to the D&C without first excluding pregnancy, infection, and structural pathology, as these conditions require specific treatment. 3
Do not assume that the presence of polyps automatically explains bleeding; evidence shows polyps are not consistently associated with increased bleeding risk.
Do not restart combined oral contraceptives immediately without addressing the underlying cause of spotting, as this may mask pathology requiring intervention. 6