Vaginal Bleeding

Question 1

Sequence of Events

Answer 1

Open question

Timeline- how did it start, and progression

Question 2

Symptom Analysis (SOCRAT)

Answer 2

Site- is it definitely the vagina

Onset

Character- colour, clots, how much

Radiation- do you use tampons or pads? Does it soak them?

Associated symptoms- pain, discharge, menstruation, constitutional symptoms

Timing- is is there all the time, how often have you noticed it, could it be your period, does it occur mid cycle, does it come after sex

Question 3

Systems Review

Answer 3

Menstrual history
Pain
Sexual History
Vaginal discharge 
Obstetric history
Constitutional- FWARJNL (tired/breathless)

Question 4

Red flags for Vaginal Bleeding

Answer 4

Severe pain
5-12 weeks since LMP
Weight loss
Postmenopausal bleeding
Intermenstrual bleeding 
Postcoital bleeding
Missed cervical smears

Question 5

Patients Perspective

Answer 5

Feelings and effect on life

ICE

Question 6

Background

Answer 6

PMH (bleeding disorder, previous cancer)
DH (anticoagulants)
FH
SH

Question 7

Important point

Answer 7

NB- say “people can feel embarrassed about this issue but it is common, and I am here to help”

Question 8

Postcoital Bleed (Causes)

Answer 8

Cervical cancer

• HPV 16 18
• Can also be intermenstrual bleeding
• Many risk factors

Cervical ectropion
-Ring around cervical os on speculum exam

Cervical polyp

• May bleed on contact
• Intermenstrual bleeding too

Question 9

Postmenopausal Bleed (>12 months after LMP) (Causes)

Answer 9

Endometrial cancer

• Risk factors
• Also postcoital and intermenstrual bleeding

Atrophic vaginitis

• Dry itchy vagina with dyspareunia
• Urinary incontinence and recurrent UTI’s
• Very common due to low oestrogen (in menopause)

Endometrial Hyperplasia

• Diagnosed on biopsy
• Risk cancer for cancer development

Question 10

Intermenstrual

Answer 10

NB- some women have spotting around day 14 of cycle that is normal. Breakthrough bleeding may also occur a few months after starting hormonal contraception

Ectopic preganncy

• Severe sharp colicky pain in sexually active women
• Diarrhoea and vomiting may be present
• Rupture can lead to severe pain peritonism and shock
• around 5-12 weeks LMP
• IUD increases risk

Spontaneous abortion

• up to 24 weeks loss of pregnancy
• lower abdominal cramps, passing blood clots with tissue

STI

• Sexually active young woman with discharge that may be smelly
• Risk factors: adolescent, multiple or new partner, unprotected sex

Question 11

Investigations

Answer 11

Bedside- abdominal and pelvic exam, PV exam, urinary pregnancy test, STI screen (swabs), cervical smear (if due)

Bloods- FBC, bHCG,

Specialist- TV USS, colposcopy (after abnormal smear)

Question 12

Menorrhagia

Answer 12

DUB
Uterine fibroids
Endometriosis
Cervical or endometrial polyps
Adenomyosis
Pelvic inflammatory disease (PID)
Endometritis
Endometrial hyperplasia or carcinoma
Hypothyroidism
Bleeding disorders (e.g. Von Willebrand’s disease)
Iatrogenic (e.g. anticoagulant treatment; copper IUD)
Climacteric