Irregular bleeding (spotting, intermenstrual bleeding) on hormonal contraception

Laboratory tests

• Serum β-hCG (a urine test is enough)
• TSH (if signs of thyroid dysfunction)if needednon-French guidelineSigns of thyroid dysfunction associated with the bleeding: the 2024 US guidelines cite thyroid disorders among the causes to consider if the clinical picture points to it (implant, injection, hormonal IUD, continuous combined pill) ^[2]. NICE, on heavy periods, also reserves this test for women with other signs of thyroid disease ^[3]. The FSRH (2015) does not cite the thyroid ^[1].

Vaginal sample (self-collection possible)

• Chlamydia trachomatis and Neisseria gonorrhoeae NAAT (PCR) (if aged 25 or under, or STI risk factor)if neededSexually active woman aged 15 to 25 years inclusive (routine screening), or older in case of a risk factor: at least two partners in the year, recent change of partner, STI in the patient or her partner, history of STI ^[4]. Chlamydia is asymptomatic in 60 to 70% of cases and abnormal bleeding may be its only sign ^[1,4].
• Multiplex NAAT (PCR) for Chlamydia, gonococcus and Mycoplasma genitalium (instead of the previous one if cervicitis)if neededAcute cervicitis on speculum examination (inflamed cervix, discharge, contact bleeding); the NABM reserves testing for M. genitalium for symptomatic cervicitis and excludes it from screening in an asymptomatic patient ^[5].

Cervical cancer screening (only if not up to date)

• Cervical cytology (25 to 29 years, screening not up to date)if neededFrom 25 to 29 years: two cytology tests one year apart, then 3 years later if they are normal ^[6]. Only to be done if this schedule has not been followed ^[1].
• High-risk HPV test (30 to 65 years, screening not up to date)if neededFrom 30 years: HPV test 3 years after the last normal cytology, then every 5 years if negative ^[6]. Only to be done if this schedule has not been followed ^[1].