Intermenstrual bleeding, Post-coital bleeding, Dyspareunia

Question 1

Post-coital bleeding
First intercourse a year ago
Stable partner
Periods normal and regular
Taking COC
Cervix appears red on examination
Most likely diagnosis?

Answer 1

Ectropian

columnar cells around the OS of there cervix
more transparent - can see underlying blood vessels
more fragile - bleeding

Question 2

What are the main causes of post-menopausal bleeding?

Answer 2

endometrial carcinoma (early post-menopausal bleeding often sole presenting feature)
atrophic vaginitis

Question 3

Risk factors for endometrial carcinoma?

Answer 3

obesity
late menopause
nulliparity
hypertension

Question 4

What is the first line investigation for endometrial cancer and what is this followed by?

Answer 4

transvaginal ultrasound - assess endometrial thickness

followed by endometrial biopsy

Question 5

What are the two biggest risk factors for vaginal prolapse?

Answer 5

childbirth

age

Question 6

What changes in micturition are caused by a cystocoele?

Answer 6

increased frequency
increased urgency
feeling of incomplete emptying of the bladder

Question 7

How does vaginal prolapse usually present?

Answer 7

feeling of fullness, dragging sensation in the vagina

Question 8

Superficial dyspareunia
Post Menopausal
most likely diagnosis?

Answer 8

atrophic vaginitis – inflammation of the vagina due to atrophic changes (because of decreased Oestrogen)

Question 9

What is a threatened miscarriage?

Answer 9

A threatened miscarriage is characterised by vaginal blood loss but an external cervical os that remains closed, and the fetus is well. The majority of women with a threatened miscarriage do not go on to miscarry.

Question 10

What are the different stages of miscarriage?

Answer 10

1. threatened
2. inevitable
3. incomplete
4. complete

Question 11

There is vaginal bleeding, with cramping abdominal pain. There cervical OS is open. No products of conception have passed yet.
What stage of miscarriage is this?

Answer 11

inevitable

Question 12

US shows empty uterine cavity. The cervical OS is closed, products of conception have passed.
Why stage of miscarriage?

Answer 12

complete

Question 13

What is an in complete miscarriage?

Answer 13

currently happening
heavy and increased vaginal bleeding
intense lower abdominal pain
cervical OS open
passage of some products of conception
products of conception in the canal

Question 14

What is a missed miscarriage?

Answer 14

nonviable intrauterine pregnancy remained in the uterus - fetus has not spontaneously aborted

Question 15

What are the five points to check in pregnancy?

Answer 15

Dating

Location

Multiple pregnancy

Molar pregnancy

Nonviable pregnancy

• gestation sac >25mm with no yolk sac or embryo
• no cardiac activity (5.5-6weeks)

Question 16

Differential diagnoses of early pregnancy bleeding?

Answer 16

Miscarriage
Ectopic pregnancy
Molar Pregnancy
Implantation bleed
Genital tract trauma
Cervical pathology - ectropion, polyp, malignancy

Question 17

Important management of every miscarriage?

Answer 17

Haemodynamically stable
Rule out ectopic
Check rhesus status - if Rh- give anti-D

Question 18

A 33 year old woman has been referred to the gynaecologist by her GP with a history of post coital bleeding. There have been 3 episodes over the last 4 weeks. There are no other symptoms on systematic questioning. There is no history of previous illness

She lives with her partner of three months and 3 children, aged between 3 and 16. She smokes 15-20 cigarettes per day, drinks only occasionally. She had regular smear examinations until 3 years ago up until the birth of her last child.

In the family history her mother died of cancer at the age of 51. Her father is alive and well.

On examination she appears well. There are no abnormal findings in the chest or abdomen and no pelvic masses. She is slightly tender on pelvic examination and there is a small amount of blood on the examining glove. Bimanual examination of the uterus was difficult but the uterus feels diffusely enlarged

Speculum examination was difficult. The uterus was anteverted and anteflexed and the cervix could not be well seen with the axis directed to the posterior fornix.

What is the most likely diagnosis and why?

Answer 18

Cervical Carcinoma with local spread

Patient sexually active at a young age - HPV infection more likely

May have family history if cervical cancer

missed 3 years of screening

post-coital bleeding

cervical distortion - local invasion

Question 19

A clinical diagnosis of cervical cancer with local invasion has been made. What imaging investigation would you request initially and why?

Answer 19

Pelvic MRI
to determine local and lymph node spread

demonstrate size of cervical tumour, evidence outside the cevix into the uterus vagina and parametric and to the side wall.

demonstrate complications such as lymph node involvement and ureteric obstruction

CT will not clearly separately identify uterus and cervix and will not therefore accurately locally stage.

Question 20

What is Barrett’s Oesophagus?

Answer 20

The oesophagus is lined by stratified squamous epithelium.

Barrett’s oesophagus is a metaplastic condition where this epithelium is replaced by columnar epithelium, which lines the stomach and intestines.

It is a pre-malignant condition, and is commonly seen in people who have had long term gastro-oesophageal reflux disease.

Question 21

What is metaplasia?

Answer 21

An abnormal change in the nature of a tissue, from one type of tissue (e.g. stratified squamous epithelium) to another (e.g. columnar epithelium)