Intermenstrual bleeding, postcoital bleeding and postmenopausal bleeding

Question 1

What is intermenstrual bleeding?

Answer 1

Uterine bleeding between periods.

Question 2

What is the aetiology of intermenstrual bleeding?

Answer 2

Idiopathic, hormonal contraceptives, endometrial causes (polyp, cancer) cervical causes (ectropion, cervicitis, polyp, cancer) vaginal causes (atrophic vaginitis, cancer) bleeding disorders, STI.

Question 3

What is the epidemiology of intermenstrual bleeding?

Answer 3

15% women

Question 4

What is the history of intermenstrual bleeding?

Answer 4

Frequency, volume, duration of symptoms, time in cycle, hx of infections, contraception, smear hx.

Question 5

What is the exam of intermenstrual bleeding?

Answer 5

Speculum: examine vaginal walls, cervix (friable, discharge, evidence of IUD in situ)

Vaginal: assess for massess, cervical excitation or uterine tenderness (infection)

Question 6

What is the Ix of intermenstrual bleeding?

Answer 6

Bloods: FBC (anaemia), clotting.

USS: pelvis (endometrial pathology)

Microbiology HVS, endocervical/chlamydia swabs.

Other: pregnancy test, cervical smear, pipele biopsy if endomtrial anomlay detected on scan.

Question 7

What is the management of intermenstrual bleeding?

Answer 7

Medical: change contraceptive.

Surgical: if endometriosis, hysteroscopy with endometrial resection. Polypectomy if needed.

Question 8

What are the complications and prognosis of intermenstrual bleeding?

Answer 8

Depends on age and cause. 20-40yo risk of cancer low, increases with age.

Question 9

What is postcoital bleeding?

Answer 9

Vaginal bleeding during or after intercourse outside normal menstrual bleed.

Question 10

What is the aetiology of postcoital bleeding?

Answer 10

Idiopathic, cervical (CIN, cancer, polyps, infection) vaignal (trauma, infection, atrophy, cancer) endometrial (polyps, cancer). Pregnancy related (placenta praevia).

Question 11

What is the epidemiology of postcoital bleeding?

Answer 11

Point prevalence between 1-9%.

Question 12

What is the history of postcoital bleeding?

Answer 12

Elicit frequency, volume, smoking, previous smars, sex hx, vaignal discharge, symptoms of infection and partners.

Question 13

What is the exam of postcoital bleeding?

Answer 13

Speculum: Note any atrophy, examine cervix for ulceration, ectropion, polyp, IUCD, discharge.

Question 14

What is the Ix of postcoital bleeding?

Answer 14

Micro: HVS, endocervical/Chlamydial swabs.

Cervical smearL if no recent normal result.

OtherL consider USS pelvis/Pivelle biopsy if persistent PCB.

Question 15

What is the management of postcoital bleeding?

Answer 15

Treat if infection

Coloposcopy: fi cervix appears abnormal on speculum or smear abnormality.

Hysteroscopy: if persistent PCB with normal smear/coloposcopy.

Question 16

What are the complications and prognosis of postcoital bleeding?

Answer 16

nting with PCB have cervical cancer. Of those with cervical cancer 10% Present with PCB to begin with.

Question 17

What is the postmenopausal bleeding?

Answer 17

PV bleeding 12mo after last period.

Question 18

What is the aetiology of postmenopausal bleeding?

Answer 18

Endometrial: polyp, hyperplasia, cancer.

Vaginal: atrophy, cancer, polyp, caginitis, truama

Cervical: polyp, cancer.

Other: bleeding disorder, spontaneous ovarian activity

Question 19

What is the epidemiology of postmenopausal bleeding?

Answer 19

10% PM women.

Question 20

What is the history/ exam of postmenopausal bleeding?

Answer 20

General: anaemia if heavy.

1+ episodes of PV bleed.

Abdomen: assess for mass.

Speculum: assess vulva, vagina and cervix. Pipelle biopsy.

Vaginal: uterine size, movement, adenxal masses.

Question 21

What is the Ix for postmenopausal bleeding?

Answer 21

Blood: FBC.

Radiology: Pelvic USS (thick endometrium is >4mm in postmenopause)

Tissue diagnosis: Pipelle biopsy, or hysteroscopy and biopsy.

Question 22

What is the Mx of postmenopausal bleeding?

Answer 22

Depends on cause. If none found, reassure.

Question 23

What are the complications/ prognosis of postmenopausal bleeding?

Answer 23

Depedns on cause. Complicaitons of investigation (hysteroscopy). Most patients have no further problems, 10% develop endometrial cancer.