365) A 26 year old woman presents to the outpatient gynecology clinic with complaints of for intermittent vaginal bleeding. She has started Combination oral contraceptive pills 3 months ago. Initially, she had spotting in the first month after starting OC pills however, she now has frank bleeding for past 4 weeks. Her scheduled menstrual period usually, occurs during the pill free period of the month. She denies any dysuria , fever, vaginal discharge or post-coital bleeding. She smoked about 1 pack per day for the past eight years. She denies alcohol or drug use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative. Which of the following is the first step in managing this patient’s intermenstrual bleeding?
B) Smoking Cessation
C) Pelvic ultrasound
D) Increase Estrogen component of the pill
E) Change the progesterone component to Levonorgestrel