Acute Vaginal Bleeding as the Initial Manifestation of Multifactorial Thrombocytopenia: A Case Report.

Thrombocytopenia is a common hematologic abnormality with a broad differential diagnosis, often requiring careful evaluation to identify overlapping and potentially reversible etiologies. Medication-induced thrombocytopenia is well recognized, particularly with valproic acid, while substance use such as cocaine may further exacerbate bleeding through platelet dysfunction and vascular effects. We present the case of a 39-year-old woman with a history of seizure disorder treated with valproic acid and comorbid psychiatric illness, including a prior suicide attempt, who presented with acute heavy vaginal bleeding. Laboratory evaluation revealed thrombocytopenia without evidence of hemolysis or coagulopathy. Peripheral smear was unremarkable aside from nonspecific red blood cell changes, and imaging studies did not demonstrate hepatosplenomegaly or structural abnormalities. Further history revealed recent cocaine use, raising concern for a multifactorial process. Valproic acid was discontinued due to suspected drug-induced thrombocytopenia, and the patient was transitioned to an alternative antiepileptic regimen. With supportive care and cessation of the offending agents, the patient demonstrated stabilization of platelet counts and resolution of bleeding. This case highlights the importance of recognizing multifactorial thrombocytopenia, particularly in patients with concurrent medication exposure and substance use. Early identification of reversible contributors is critical, as prompt discontinuation of offending agents can lead to rapid clinical improvement and prevent unnecessary invasive evaluation. Additionally, this case underscores the need for a multidisciplinary approach that integrates hematologic, neurologic, and psychiatric considerations in complex presentations while comparing the case with the current literature.