[35] Intermenstrual, Breakthrough, and Post-coital Bleeding Flashcards
What is intermenstrual bleeding (IMB)?
Vaginal bleeding at any time during the menstrual cycle other than during normal menstruation
What can IMB be difficult to distinguish from sometimes?
Metrorrhagia
What is metrorrhagia?
Irregularly frequent periods
What is post-coital bleeding (PCB)?
Non-menstrual bleeding that occurs immediately after sexual intercourse
What is breakthrough bleeding?
Irregular bleeding associated with hormonal contraception
What are IMB and PCB classified as?
Symptoms
What is the result of IMB and PCB being symptoms?
They require further investigation
What is the biggest differentiator of causes of abnormal bleeding?
Age
What is an uncommon cause of PV bleeding in young women?
Malignancy
What happens to the likelihood of uterine polyps and fibroids with age?
Increases
What are the possible causes of PCB?
- Infection
- Cervical ectropion
- Cervical or endometrial polyps
- Vaginal cancer
- Cervical cancer
- Trauma or sexual abuse
- Vaginal atrophic change
What % of women with PCB have no specific cause found?
50%
What are the possible causes of intermenstrual bleeding?
- Pregnancy related
- Physiological
- Vaginal causes
- Cervical causes
- Uterine causes
- Iatrogenic causes
What pregnancy related causes can lead to IMB?
- Ectopic pregnancy
- Gestational trophoblastic disease
What can be a physiological cause of IMB?
Spotting during ovulation
What % of women have spotting during ovulation?
1-2%
What are the vaginal causes of IMB?
- Adenosis
- Vaginitis
- Tumours
What are the cervical causes of IMB?
- Infection
- Cancer
- Cervical polyps
- Cervical ectropion
What infections of the cervix can cause IMB?
- Chlamydia
- Gonorrhoea
What are the uterine causes of IMB?
- Fibroids
- Endometrial polyps
- Cancer
- Adenomyosis
- Endometriosis
What are the iatrogenic causes of IMB?
- Tamoxifen
- Following smear or cervix treatment
- Missed OCP
- Drugs altering clotting
What drugs that alter clotting can cause IMB?
- Anti-coagulants
- SSRIs
- Corticoteroids
When is breakthrough bleeding most common?
When a new contraceptive is started, and often settles without intervention
What type of hormonal contraceptives are more likely to cause bleeding problems?
Progesterone only
What should be asked about when taking a history for abnormal pre-menopausal vaginal bleeding?
- Menstrual history
- Obstetric history
- Gynaecological history
- Sexual history
- Medical history
- Current medication
What should be examined when assess abnormal pre-menopausal vaginal bleeding?
- BMI
- Abdomen
- Speculum
- Bimanual
What can be looked for on abdominal examination when a patient presents with abnormal pre-menopausal vaginal bleeding?
Presence of any pelvic masses
What should be looked for on vaginal examination in a woman with abnormal pre-menopausal vaginal bleeding?
Any obvious genital tract pathology
What are some common findings on vaginal examination in abnormal pre-menopausal vaginal bleeding?
- Cervical ectropion
- Cervical polyp
- Cervicitis
What investigations can be made into women with abnormal pre-menopausal vaginal bleeding?
- Pregnancy test
- Infection screen
- Blood tests
- Transvaginal USS
- Endometrial bopisy
What blood tests can help identify a cause of abnormal pre-menopausal vaginal bleeding?
- FBC
- Clotting
- TFTs
- FSH/LH
What can a transvaginal USS look for in a woman with abnormal vaginal bleeding?
Structural abnormalities
What does management of abnormal pre-menopausal vaginal bleeding depend on?
The type and cause of the bleeding
What is the first management step if cancer is the suspected cause of abnormal pre-menopausal vaginal bleeding?
Urgent referral for further investigation
What are the management steps if infection is the suspected cause of abnormal pre-menopausal vaginal bleeding?
Antibiotics (if appropriate) and contact tracing
What is the management if hormonal contraception is considered to be the cause of abnormal pre-menopausal vaginal bleeding?
Advise that it is normal in the first 3 months but can swap if persistent
How can cervical ectropion be treated?
- Conservatively
- Cauterisation
How is cervical ectropion cauterised?
With silver nitrate
How should cervical polyps be managed?
Evulsed and sent for histology
How can fibroids be managed?
- Hysteroscopic removal for small fibroids
- Uterine artery embolisation
- Medical management with oestrogen reducing drugs
