Work-up for Vaginal Bleeding

Question 1

What are the two main causes of vaginal bleeding in the first trimester of pregnancy?

Answer 1

1. Miscarriage - central, cramp, menstrual-like pain

2. Ectopic pregnancy - unilateral, constant pain

Question 2

What are the three main causes of vaginal bleeding in the second and third trimesters of pregnancy?

Answer 2

1. Placenta praevia - painless bleeding, diagnose on USS before bimanual exam
2. Placental abruption - abdominal pain and PV bleeding
3. Vasa praevia - blood at time of rupture of membranes

Question 3

What are the steps involved in a work-up for post-menopausal bleeding?

Answer 3

1. TV USS to exclude malignancy
2. Look for symptoms associated to malignancy - pelvic pain/mass, obstructive GI symptoms, weight loss, lower urinary tract symptoms
3. Hysteroscopy and biopsy for endometrial cancer
4. Smear for cervical cancer
5. Atrophic vaginitis is a diagnosis of exclusion
6. STI - swab for infection

Question 4

What are the differentials in bleeding confined to menstruation?

Answer 4

1. Dysfunctional uterine bleeding is a diagnosis of exclusion
2. Fibroids
3. Endometrial and cervical polyps
4. Adenomyosis
5. Malignancy/hyperplasia
6. Coagulopathy
7. IUD and discontinuation of COCP/IUS (POP can cause spotting and IMB)
8. Infection

Question 5

What should you check in bleeding confined to menstruation?

Answer 5

FBC, clotting, TFTs

Question 6

What are the differentials for post-coital bleeding?

Answer 6

1. Cervical cancer/ectropion/polyps

2. STI