The 34-Year-Old with Abnormal Uterine Bleeding and a Normal Pelvic Exam
A 34-year-old woman, G2P2, presents with 3 months of heavy, irregular menses-bleeding 8–9 days with clots, soaking a pad every 2 hours on the heaviest days. She has no intermenstrual bleeding, no postcoital bleeding, and a normal pelvic exam. She is not on hormonal contraception; she uses condoms. She has no known bleeding disorder, but her sister has von Willebrand disease. Her BMI is 31. She is not currently trying to conceive but wants more children in the future. Hemoglobin is 10.8.
1. What is your initial evaluation, and does her family history change it?
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Heavy menstrual bleeding in a reproductive-aged woman warrants a structured workup: pregnancy test, CBC (done-mild anemia), TSH, and coagulation screening-specifically a von Willebrand panel (vWF antigen, ristocetin cofactor, factor VIII) given the sister's diagnosis, even though she has no personal history. Pelvic ultrasound to assess for fibroids, polyps, adenomyosis, and endometrial thickness. Endometrial biopsy is not routinely indicated at 34 without risk factors, but consider it if she has chronic anovulation, obesity, or fails therapy. The family history is the key judgment: it moves coagulation testing from optional to indicated, and results may change management (e.g., avoid NSAIDs, involve hematology before procedures).
2. How do you treat her bleeding while preserving fertility?
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First-line for acute/chronic heavy bleeding without structural cause is a hormonal method-a levonorgestrel IUD is highly effective, reduces bleeding, and is contraceptive but reversible, which fits her future fertility goals. Alternatively, combined hormonal contraception or cyclic progestin. Treat the anemia with iron and recheck. If a structural cause is found (e.g., submucosal fibroid or polyp), hysteroscopic resection preserves fertility. Tranexamic acid is an option for bleeding days but is contraindicated if she has a bleeding disorder until clarified-so wait for the vWF panel. Avoid endometrial ablation, which is not for someone who wants future pregnancy. Coordinate with hematology if von Willebrand disease is confirmed, especially for any procedure.