The short answer: which tests you need depends on your age, whether you could be pregnant and the bleeding pattern. Most women start with an examination, a pregnancy test if relevant, blood tests and an ultrasound. Only some women need a biopsy or a camera test (hysteroscopy). To understand the causes of abnormal bleeding first, start there. If your periods have already stopped for good, see tests after postmenopausal bleeding.
On this page
- Investigating Abnormal Vaginal Bleeding: What Happens Next
- Step 1: Clinical History and Examination
- Blood Tests and Swabs
- Step 2: Transvaginal Ultrasound
- Step 3: Endometrial Biopsy (Pipelle)
- Step 4: Hysteroscopy
- When Cancer Is Confirmed
What Happens Next
Once abnormal vaginal bleeding has been identified, the clinical workup is structured and usually rapid. Most tests are done in the clinic without a hospital stay, and a diagnosis — or reassurance that nothing serious is going on — can usually be reached within a few clinic visits.
Step 1: Clinical History and Examination
A detailed history characterises the bleeding: timing, volume, duration, relationship to the menstrual cycle and intercourse, associated symptoms (pain, discharge, pressure, weight loss). A pelvic examination — including speculum examination to visualise the cervix — is essential. Many cervical cancers can be seen directly on speculum examination before any imaging or blood tests.
Blood Tests and Swabs
- Pregnancy test — if there is any chance of pregnancy.
- Full blood count — checks for anaemia (low haemoglobin) caused by heavy periods.
- Thyroid test (TSH) — an under- or over-active thyroid can change periods.
- Hormone tests — sometimes, for irregular periods: for example prolactin, or hormones checked when PCOS is suspected.
- Clotting tests — if periods have been very heavy since your first period or you bruise or bleed easily.
- Swabs — for infections such as chlamydia, especially with bleeding after sex or between periods.
- Cervical screening (HPV test or Pap smear) — if you are due, or if you have bleeding after sex.
Step 2: Transvaginal Ultrasound
Transvaginal ultrasound (TVUS) is the first-line imaging investigation. It is a scan with a small probe placed in the vagina, and it looks at the thickness of the womb lining (endometrial thickness), the shape of the womb (uterine morphology), the ovaries and any lumps in the pelvis. In postmenopausal women, an endometrial thickness above 4 mm requires further investigation. TVUS can also identify polyps, fibroids, and ovarian cysts that may be contributing to abnormal bleeding. Often the scan shows a benign cause such as a fibroid or polyp — read about fibroids and their treatment pathways.
Step 3: Endometrial Biopsy (Pipelle)
An endometrial biopsy is advised if the womb lining is thickened or looks abnormal on ultrasound, if bleeding continues despite treatment, or if you have risk factors for womb-lining changes (such as being over 45, obesity or PCOS). After menopause, a biopsy is advised if the lining is over 4 mm or the bleeding comes back. The pipelle is a thin plastic tube passed through the cervix to gently draw up a small sample of the womb lining. The procedure takes 2–3 minutes, causes brief cramping, and provides a tissue diagnosis within 5–7 working days. It finds about 9 in 10 endometrial cancers (a sensitivity of approximately 90%), which is why a hysteroscopy may still be advised if bleeding continues despite a normal result. Read how a biopsy is performed.
Step 4: Hysteroscopy
Where the pipelle sample does not give an answer, where a polyp is suspected, or where direct visualisation of the cavity is needed, a hysteroscopy is performed. A thin camera is passed through the cervix under local or general anaesthesia, allowing direct inspection of the entire uterine cavity. Polyps and targeted biopsies can be managed in the same procedure.
When Cancer Is Confirmed
A biopsy confirming endometrial or cervical cancer triggers further staging investigations — pelvic MRI to see how deep the cancer has grown and whether lymph nodes are involved, and a CT scan of the chest, abdomen and pelvis to check for spread. Staging determines the surgical approach. For most Stage I endometrial cancers, minimally invasive hysterectomy achieves cure with an excellent quality of life outcome.
Dr. Nishtha Tripathi Patel performs outpatient endometrial biopsies and hysteroscopy in Ahmedabad. Contact: +91 76988 00333.