Stable

No abnormalities are detected on abdominal and vaginal examination.

1. Insertion of a levonorgestrel-releasing intrauterine device. 
2. Hysteroscopy and biopsy. 
3. Pipelle aspiration. 
4. Therapeutic trial with norethisterone. 
5. Transvaginal ultrasound scanning.

Transvaginal ultrasound scanning

The possibility of a structural lesion or endometrial malignancy should be considered, because the woman is more than 45 years of age and has continuous bleeding. Therefore, the next step in the management is to perform a transvaginal ultrasound scan, to exclude structural lesions which can cause continuous bleeding, such as endometrial polyps, endometrial hyperplasia and endometrial carcinoma. Hysteroscopy or pipelle aspiration is performed to confirm the diagnosis of endometrial hyperplasia or endometrial carcinoma suspected by the ultrasound scan. Insertion of a LNGIUS or treatment with norethisterone is commenced only after excluding structural lesions. 

Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 121:891–6.

Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol. 2016 Jan;214(1):31-44. doi: 10.1016/j.ajog.2015.07.044. Epub 2015 Aug 5. PMID: 26254516.