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MRCOG PART 2 SBAs and EMQs

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Essay 321 - IMB

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		Posted by Sarika N. Thu Feb 18, 2010 03:53 am
A healthy 42 year old woman is referred to the gynaecology clinic with a 6 months history of inter-menstrual and post-coital bleeding. (a) Discuss and justify your clinical assessment [8 marks]. Initial assessment should include contraceptive history. Combined contaceptive pill can be associated with ectropion. Progesterone only pill, Implant, Mirena coil, Progesterone ingections can be associated with intermenstrual spotting. Sexual history should be obtained as presence of risk factors can be associated with infection, especially in presence of abnormal discharge. History of abnormal smear tests can indicate cervical pathology and increase the risk of cervical disease. If patient obese , she can be at increased risk of endometrial hyperplasia. Presence of associated weight loss and night sweats can be associated with underlying malignancy, which should be excluded as a priority. History of bleeding disorder and medications should be obtained as can be in a rare cases presenting with bleeding. Examination should include abdominal palpation to exclude pelvic masses, speculum examination to exclude vaginal, cervical pathology. The triple swabs should be taken as part of this examination to exclude infection. (b) Which investigations will you perform? [4 marks]. In presence of post-coital or intermenstrual bleeding in woman over 40 years old colposcopy is indicated, in majority of cases there is no underlining malignancy. Swabs to exclude infection if suspected should be performed. USS to exclude pelvic or uterine pathology can be helpful. (c) She is found to have cervical ectropion. Discuss the treatment options including your advice to the woman following treatment [8 marks]. Patient should be reassured as ectropion is a benign condition and does not lead to malignancy. Can be a result of combined pill or recent pregnancy as associated with estrogen exposure. Can be treated in outpatient setting by cryotherapy or diathermy, usually painless procedure. Written information regarding procedure should be provided and paitient should be fully informed regarding the risks of the procedure. There is a small risk of infection and can be associated with bleeding and excessive discharge for up to 3-4 weeks after the proceedure. Patient should be advised to avoid tampons after the procedure and educate for signs and symptoms of infection. She should contact her GP if any concerns. Leaflets should be given with full information about the condition and treatment.
		Posted by R S. Thu Feb 18, 2010 06:18 am
a… A carful history of other symptoms like vaginal discharge, lower abdominal pain and deep dyspareunia is explored as they indicate pelvic inflammatory disease. Menstrual history including her last menstrual period, type of contraception and compliance as she may has irregular intake of COC. Severity of her complaint and effect on her quality of life is also elicited. Past gynecological history is essential especially cervical smear history and results to rule out malignant or premalignant conditions. History of PCOS is associated with increased incidence of endometrial hyperplasia due to chronic Anovulation. Medical history is also taken like presence if DM or hypertension which considered risk factors for developing endometrial cancers. Smoking is also an additional risk factor. Drugs like tamoxifen taken for long time can cause endometrial hyperplasia also. Urinary and bowel symptoms are also explored to rule out underlying urinary or bowel symptoms. General examination is done including presence of lymphadenopathy. The abdomen is examined to rule out abdominal mass. Pelvic speculum examination allows visualization of cervix for any local cause like polyp or lesion, also help visualization of vagina for evidence of infection or presence of other lesions, masses or ulcer. Bimanual examination id done to detect uterine size, mobility and adnexal mass or tenderness. Cervical excitation goes with pelvic infection. b…Endocervical swab for gonorrhea microscopy and culture on charcol agar medium and further will be examined by NAAT. ELIZA test to detect Chlamydia is important as its common. TVS can rule out pelvic pathology also can measure endometrial thickness, a cut off point of 10 mm and more will require endometrial biopsy. Saline hysteroscopy can detect endometrial polyp. Presence of visible cervical lesion will require biopsy for histopathological examination. A new cervical smear is not mandatory if the woman is up to date with her schedule. c…Its benign condition, treatment is not necessary unless it causing distressing symptoms. Treatment options include electrical cauterization, it aim to destruct he columnar epithelium of the vaginal portion of cervix and thus relieving symptoms. The woman advised to avoid sexual intercourse for 3-4 weeks after treatment, also to avoid lifting heavy object or having strenuous exercise. Follow up appointment is arranged 4-6 weeks later on. The condition can recur particularly with estrogen containing contraceptives so we advice for progesterone only contraception or barrier methods. The patient given written information. The date of her next cervical smear will be according to her schedule and she will be recalled on time.
		Posted by R S. Thu Feb 18, 2010 06:20 am
Thank you very much Dr Paul. Your response is hugely appreciated. All the best.
		Posted by Bgk H. Thu Feb 18, 2010 11:16 am
a. Intermenstrual and postcoital bleed may signify a potential malignancy however majority are due to benign causes. The aim is to identify the cause and initiate the appropriate treatment. I will ask her regarding the severity of the bleeding including the amount, duration and associated symptoms like abdominal pain and anaemic symptoms. Bleeding for non gynaecological origin like urethral or per rectal bleeding need to be excluded. Impact on her quality of life need to be assessed. Her detail menstrual history including her cycle, duration of flow, associated dyssmenorrhoea need to be asked. Similar history of past episode if present and treatment received need to be asked. Her cervical smear history needs to be asked. Her fertility wishes and need of contraception should be asked. Her completion of family and reproductive intention is important for further management. Any present medications that she is now taking including hormonal tablets need to be enquired. Recent weight and appetite loss, family history of cancer may suggest malignancy. General condition of the patient needs to be assessed. Any palpable abdomino-pelvic mass needs to be elicited. Per speculum vaginal examination is needed to exclude visible cervical, vulval and vaginal pathology. b. I will perform transvaginal ultrasound to evaluate her endometrial thickness and any pelvic mass. I will do a pap smear and undertake endometrial sampling to rule out any preinvasive or invasive diseases. I would also would like to take High Vaginal Swab to detect any possibility of infection. Urine pregnancy test to exclude pregnancy. If neceessary, a colposcopy examination for furter assessment. c. I will explain to her regarding the diagnosis. I will reassure her that this is a benign condition. If it is mild and not disturbing her life style, no treatment required. The cause of ectropian like oral contraceptive need to be stopped. If there is significant bleeding, she can be subjected to thermal or cryo therapy to cauterise and ablate the area. If failed, surgical excision is a posssible option. Patient information sheet and contact number need to given. I will advice her to report to hospital if excessive bleeding.
		Posted by Ulduz A. Fri Feb 19, 2010 06:22 am
a)I will ask her how much this symptoms are disturbing her and how much they affect her life.I will ask her about any associated pain(dysmenorrhea).History of PCOS may be related to endometrial cancer.Contraception history to be taken to find out which contraception she is using.COCP use without good compliance can cause breakthrough bleeding.Use of POPs can cause irregular bleeding patterns.Injectables and Mirena coil can cause intermenstrual bleeding.Previous gynecological history,any problems,treatment and outcomes are asked.Smear history,any abnormal smears,treatment inquired.Any abnormal discharge can be sign of infection,such as STDs and PID.Sexual history asked.Drug history as use of Tamoxifen,which can cause endometrial hyperplasia asked as well. Weight loss,abdominal distention,bowel and bladder symptoms asked to rule out endometrial and ovarian malignancy.Examination includes abdominal examination to rule out abdominal masses,lympadenopathy.Speculium examination allows to reveal cervical polyps and ectropion. b)Cervical smear done if she hasn\'t recent one.Speculum examination allows to see cervical polyps and ectropion.History of vaginal discharge,sexual history suggestive of STDs will oblige the doctor to take HVS,triple swabs for Chlamydia,which can be a cause of intermenstrual bleeding.US pelvis may give an idea about uterine polyps,thickened endometrium(endometrial hyperplasia) and polyps.If uterine hyperplasia suspected,outpatient endometrial sampling done. c)If she wants definitive treatment i will offer her cryotherapy or diatermy.Precedure can be done in outpatient settings with local anaesthesia.Patient will have some bloody discharge for few days and pain can be managed with NSAIDs.She should avoid intercourse for 3-4 weeks.Follow-up appointment will be given after 4-6 weeks.Written information given.
		Posted by Bee N. Fri Feb 19, 2010 06:41 am
(Bee) A healthy 42 year old woman is referred to the gynaecology clinic with a 6 months history of inter-menstrual and post-coital bleeding. (a) Discuss and justify your clinical assessment [8 marks]. (b) Which investigations will you perform? [4 marks]. (c) She is found to have cervical ectropion. Discuss the treatment options including your advice to the woman following treatment [8 marks]. A) I will take a history of her menstrual period, including duration and cycle length. She could have prolonged period with fibroids. I will ask for her last menstrual period and when the symptoms started as the symptoms of PCB and IMB and may be related to pregnancy secondary to cervical ectropion. I will ask history of vaginal discharge and lower abdominal pain and fever to assess possibility of Pelvic inflammatory disease. I will ask if she has any family history of cancer since a history of endometrial cancer will place her at a higher risk of endometrial cancer. I will ask if she her smear test is up to date and if she has had any previous treatments to her cervix. This will assess her risk of cervical cancer. I will ask if she is on any hormonal contraceptive which can cause cervical ectropion and symptoms of IMB and PCB. I will ask how distressing these sypmtoms are to her as she may only want reassurance that nothing sinister is going on or may want definitive treatment even for a benign cause. I will start examination with the abdomen to check for tenderness which may point to an infection (PID). I will check for palpable pelvic masses especially to feel her uterus which may be enlarged by fibroids. I will then do a speculum examination to examine the cervix for any abormality including inflammation, tumour or fibroids and polyps and observe for any discharge. I will do a bimanual examination to check for size of uterus and assess for cervical excitation tenderness(infection). I will feel the adnexa to ensure no masses are felt. B) The investigations i will perform will include a full blood count and CRP if I think she may have an infection. I will also take endocervical swabs for chlamydia and gonorrhoea as well as high vaginal swab if this is the case. I will take a pipelle biopsy to rule out endometrial cancer. If i suspect an enlarged uterus or cant assess uterine size due to high BMI, I would arrange for pelvic ultrasound scan to check for fibroids. If there is any doubt as to whether she is pregnant or not (from LMP), I will do pregnancy test. C) I will inform her that polys are usually benign flesh like growth on the cervix. Treatment are not usually indicated except it is causing distress to the patient. We may therefore leave it alone. If she wanted, we may remove it as an out patient if is safe to do so (small size). If she is anxiuos about it or the polyp as a very large base, it may be better to remove it at day surgery. Patient choice will be taken into consideration to offer treament. Patient will be consented for any surgical procedure embarked upon. I will make a full documentation of our discussion and agreed management plan.I will try to reassure patient as women often think it is most likely cancer(it is mostly benign). The polyp will be sent to pathology for histology. Patient will be informed of result and need for any further management. Patient will be adviced that she can bleed or have discharge for a few days after polypectomy and a few women may require admission due to bleeding. I will inform her that infection can occur after removal which normally resolves with antibiotics. I will inform her that even afetr removal. polyp may reoccur afetr a few years. result of pathology will be made known to patient.
		Posted by L M. Fri Feb 19, 2010 08:02 am
(L.) A healthy 42 year old woman is referred to the gynaecology clinic with a 6 months history of inter-menstrual and post-coital bleeding. (a) Discuss and justify your clinical assessment [8 marks]. (b) Which investigations will you perform? [4 marks]. (c) She is found to have cervical ectropion. Discuss the treatment options including your advice to the woman following treatment [8 marks]. a) I would begin by taking a history. I would enquire as to whether she had a regular menstrual cycle, and if menstrual bleeding is heavy, prolonged or painful, to assess if menorrhagia or dysmenorrhoea are additional problems. I would ask when her LMP was, to ascertain whether pregnancy is possible. I would check if she is currently sexually active, and obtain a brief sexual history such as whether she has a new partner or uses condoms as this would help assess her risk of a sexually transmitted infection as a cause. Her contraceptive history is important, as some forms of hormonal contraception such as COCP can cause intermenstrual bleeding. Checking if she is up to date with her cervical smears and if they have been previously normal is important, as cervical cancer can present with these symptoms. I would clarify if she has any other symptoms that may indicate a specific cause, such as lower abdominal pain and vaginal discharge, which might indicate a genital tract infection. I would perform abdominal examination to check for findings of tenderness which may indicate a possible genital tract infection. Speculum examination can assess if the vulva, vagina and cervix appear normal, or show any obvious source of bleeding. Bimanual examination can demonstrate any tenderness suggesting infection, or an enlarged uterus suggesting possible fibroid. b) Investigations I would perform include swabs to check for infection, particularly an endocervical swab to test for Chlamydia and a charcoal medium endocervical swab to test for gonnorhoea. A high vaginal swab may identify other bacterial infections such as bacterial vaginosis. If she is not up to date with cervical smear tests I would take this. Given her age over 40 years, I would arrange a transvaginal scan to assess whether the endometrium appears regular, or if there is evidence of an endometrial polyp. If she had an irregular menstrual cycle in addition to IMB an endometrial biopsy (pipelle) could be taken to check for any evidence of abnormality. c) I would explain to the woman the nature of a cervical ectropion being a normal hormonal change, and therefore it will not cause her any harm. I would explain, possibly by drawing a diagram to demonstrate, that the normal columnar epithelium from the endocervical canal everts onto the ectocervvix and in response to the acidic environment of the vagina, it appears different at examination and can cause the symptoms that she has, and also sometimes vaginal discharge. Options available to her include; no treatment if she can tolerate the symptoms now that she knows it is not a serious problem or use of relactagel vaginal preparations which alter the environment of vagina and can cause ectropion to regress or improve. Another option is cold coagulation or diathermy to the cervix, however it is likely (around 50% chance) that the ectropion and therefore symptoms will recur and therefore would not be first option of choice. If she opts for treatment and symptoms improve, if irregular bleeding problems recur, it is important she attends her GP to ensure that there is no new cause for this.
		Posted by Sarika N. Fri Feb 19, 2010 12:27 pm
S/N I will ask about the severity of the condition if she is passing blood clots or not , any associated abdominal or pelvic pain. Sexual history including dysparunia, offensive vaginal discharge, any history of previous STI to rule out cases due to infection. Contraception history including current contraception as hormonal methods can lead to menstrual irregularities and IUCD can increase risk of PID. Cervical smear history and date of last cervical smear and any treated previous abnormalities. General enquiry about menopausal symptoms like hot flushing, sweating, vaginal dryness. As well as other associated symptoms easy fatigue, lose of weight or appetite. As well as her parity, smoking. I will assess her generally first as regards to her BMI, pallor, pulse and blood pressure, then abdominal palpation to rule out any abdominal masses or tenderness. Pelvic bimanual examination to rule out any adenxal swellings or tenderness. Speculum examination to rule out any cervical pathology like polyps, ectropion. Any cervical masses or abnormally looking cervix which will be an indication of referral to colposcopy. B) FBC to rule out anaemia from heavy or repeated loss especially if symptomatic. High vaginal and endocervical swab during speculum examination to rule out any infective cause like Gonorrhoea or Chlamydia. Cervical smear only if she is due for one or not having one before. Pipell endometrial biopsy to rule out endometrial pathology. Pelvic USS to rule out uterine pathology as endometrial polyp also to rule out adnexal swellings. Colposcopy if cervical masses or abnormaly looking cervix. C) I will explain the diagnosis and reassure her as cervical ectropion is a benign condition where thin vascular tissue lining cervix is everted outside cervical canal mainly under hormonal effect and usually regress spontaneously. First line treatment is expectant or conservative treatment where condition will improve without treatment and she can be offered another appointment if condition persist or became worse. After ensuring normal cervical smear; Second line will be cryocautry or diathermy if she wishes to have treatment or if condition deteriorate after conservative treatment. .I will explain that cryocautry or freezing of the cervix and it is not painful , can be done in outpatient and she should expect some vaginal spotting and bloody discharge for about 4 weeks while she is refraining from sexual intercourse and use of any vaginal tampons or douches. Or she could be offered Diathermy which can be done under paracervical block in out patient clinic and she will have mild bleeding and discharge 4-6 weeks and mild pelvic and abdominal pain when simple analgesia like paracetamol will be enough to control. She will be instructed to be seen if bleeding persist or she develop offensive vaginal discharge or pyrexia. Change of hormonal contraception if used or removal of IUCD before cervical cautrisation and she will be offered another non hormonal method until bleeding settelled.
		Posted by Green K. Fri Feb 19, 2010 01:35 pm
Green: a) Severity of bleeding and the impact on her quality of life. LMP and regularity of her periods, duration of bleeding and cycle lenght. Features of anaemia such as palpitations, shortness of breath on exertion and lethargy. Constitutional symptoms such as significant loss of weight and loss of appetite to suggest malignancy. Previous pap smear results and treatment done on her cervix if any. Current mode of contraception, duration of use and compliance. Combined oral contraceptive pill use may lead to it cervical ectropion while intrauterine devices may lead to irregular bleeding in the first 6 months of use. Sexual history with regards to recent change in sexual partners may suggest presence of sexually transmitted infection such as chlamydia or gonorrhoea infections. On examination, conjunctiva, nail beds and tongue will be exmined for pallor. BP and pulse rate taken as tachycardia may suggest significant blood loss if present with pallor. Body mass index as obesity is associated with increased risk of endometrial carcinoma. Abdomen examined to detect any palpable pelvic mass to suggest pelvic inflammatory disease. Speculum examination to inspect cervix, vaginal wall for any obvious polyp, growth or abnormal discharge. Bimanual assessment to detect adnexal tenderness and mass to suggest pelvic inflammatory disease. b) Full blood count to determine haemoglobin levels. Platelet levels if reduced and presence of abnormal clotting profile would suggest bleeding diathesis. Endocervical swabs for Chlamydia detection via nucleic acid ampification test. Endocervical swab for gonorrhoea if clinically indicated. Ultrasound pelvis to detect obvious endometrial polyps. Endometrial sampling to detect presence of endometrial carcinoma or hyperplasia. If cervix appears abnormal, a colposcopy would be arranged. c) Explain to patient that cervical ectropion is not a cancer and is not a precancerous lesion. Conservative management if symptoms not affecting quality of life as it would resolve as menopause approaches. If she is taking COCP, to suggest changing to other modes of contarception such as progesterone only pill or long acting reversible contraception. Electrocautery of ectropion under colposcopic guidance. It can be done as out patient in colposcopy clinic. Paracervical block would be required for pain relief. Cryotherapy of ectropion in colposcopy clinic. It can be done as out patient. Expalin to patient that she may experience spotting which may last for a few days. Inform to return if bleeding increasing in nature or presence of foul discharge. Explain to patient to avoid sexual intercourse for 2-3 weeks to allow time to heal. Inform patient to avoid tampons for 2-3 weeks to allow time to heal. Inform patient to continue with regular 3 yearly pap smear regime. Inform patient that there is small risk of recurrence. Patient information leaflet on ectropion to be provided.
		Posted by fluffy F. Fri Feb 19, 2010 09:50 pm
from fluffy a) Menstrual history - prolong menstrual cycles with menorhagia , dysmenorhoea , intermenstrual bleeding would be suggestive of submucosal uterine fibroid. History of dysmenorhoea with intermenstrual bleeding also sugestive of endometriosis . History of weakness, lethargy, palpitations are suggestive of symptomatic anemia due to menorhagia.History of recent cervical smear done, as post coital bleeding is suggestive of cervical lesions and malignancy.History of contraception- oral contraception taken not as per schedule , depo provera injections and recent intrauterine contraception device insertion can cause intermenstrual bleeding and break through bleeding.History of fowl smelling vaginal discharge, feeling unwell , loss of apetite and loss of weight suggests cervical malignancy. examination - for signs of anemia , pallor, tachycardia suggestive of significant menorhagia.Per abdomen ,a suprapubic mass palpable suggestive of uterine fibroid.Per speculum examination of the cervix for growth , ectropion or polyp. B)A full blood count , for her haemoglobin level if she has anemia.A ultrasound abdomen and pelvis for uterine or ovarian mass.A cervical smear if not done recently, and if cervix is suspicious for a colposcopy and biopsy. A pipelle sampling of the endometrium to rule out malignancy. c) I will reassure her that a cervical ectropion is not a malignancy.It can be treated expectantly, and in 50 % of cases the symptoms will subside.Other options available are cryotheraphy of the cervical ectropion. The symptoms will regress however chances of recurence is 20-30 %. A colposcopy and cautery of the ectropion is also an options , however will have risk of bleeding and needs further followup. I will advise her avoid sexual intercourse for 2-3 weeks after the cryotheraphy or cauterization. She is to continue with her cervical screening every 3 yearly. Advise to keep a menstrual calender. If the symptoms recurs to come earlier .
		Posted by M E. Sat Feb 20, 2010 05:02 am
SAM a) Intermenstrual bleed and post coital bleed may be due to malignancy, however most are due to benign conditions. Frequency of intermenstrual bleeding(IMB), if present with every cycle. Timing of IMB in relation to the menstural cycle. Bleeding mid cycle associated with abdominal pain may occur at ovulation. Severity of IMB, whether spotting or heavy bleeding the latter may be due to fibroids or endometrial polyps .Presence of precipitating factors such as exercise. How it has affected her quality of life. Regularity of menstrual cycle, irregular menses seen with PCOS which is a risk factor for endometrial hyperplasia. Her pap smear history, whther she has been up to date or whether any abnormalities detected previous and treatment required. Usage if combined OCP, progesterone pill or Mirena, since these can all cause IMB and PCB. Usage of herbal medications such as St John\'s worth and ginko. History of vaginal discharge , abdominal pain, dyspareunia can be a result of cervicitis. On examination calculation of BMI, since obesity is associated with endometrial cancer. Abdominal examination, presence of abdominal mass may be due to fibroids, adenomyosis or malignancy. Tenderness in iliac fossa may be present with PID. Through vaginal examination should be performed including speculum examination. Contact bleeding, friable tissue from cervix may be present with malignancy. Examination of cervix for polyps or ectropion. Presence of per vaginal discharge or cervical excitation tenderness with cervicitis. Examination for bleeding from lower down the genital tract eg from vaginal malignancy. b) Urine and endocervical swabs should be sent for testing for Chlamydia and Gonorrhea. Pap smear should be done if not uptodate. Colposcopy is required if there is a suspicion of cervical cancer or preinvasive disease. Transvaginal ultrasound to check endometrial thickness and presence of uterine pathology such as uterine fibroids. If endometrial hyperplasia or endometrial polyp suspected hysteroscopic directed biopsy should be performed. c) If the cervical ectropion is associated with the combined oral contraceptive pill, discontinuing the pill cause resolution of symptoms. However if it is not due to COCP and is symptomatic it can be treated by eliminating the superficial layers of cells to facilitate growth of squamous epithelium. Local destructive techniques using silver nitrate, cryocautery or diathermy can be used either under local anaesthesia in the out patient clinic. It is essential to ensure that no associated premalignant condition of the cervix is present before destructive procedure, that may be inadequately treated. She should be counseled that it is not a premalignant or malignant condition and is a common finding in most healthy women. She should be advised that in menopause it will shrink in size due to recession of the squamocolumar junction
		Posted by Mark C. Sat Feb 20, 2010 08:21 am
a) From her history we need to know how heavy the bleeding is, how often it happens and whether it is associated with any pain to identify severity and effect on quality of life. We need to identify any urine or bowel symptoms (dysuria, retention, haematuria, bloody diarrhoea, incontinence) to assess if there is any condition effecting these systems (e.g. stage III cervical ca). Her menstrual history including cycle regularity and periods of amenorrhoea, LMP will help identify risk factor for endometrial hyperplasia. Current contraception may be indicative as progesterone containing contraceptives are assoicated with ectropion and irregular bleeding, and IUD can cause such symptoms associated with chlamydia infection. Sexual history and number of partners would hence be also helpful. Smear test history is also important to identify risk of cervical disease. Any histroy of medical conditons like liver disease and coagulopathy associated with bleeding, hypertension and diabetes associated with hyperplasia. History of pelvic malignancy to assess risk of recurrance. On abdominal examination assess for a mass, tenderness and rebound. Pelvic examination to identify site of bleeding, assess for masses and tenderness, and allow swabs and repeat PAP if indicated. b) Start with a urine test for pregnancy and dipstick, culture and sensitivty. FBC to assess for anaemia. HVS and endocervical swabs to assess for infection. especially chlamydia. TVUS to assess for pelvic masses. If indicated repeat PAP smear. c) Treatment depends on the patient\'s wishes. If this is not bothersome and she is pleased with reassurance then expectant management may be adequate. If she is on progesterone then it may be ideal to stop and change contraception. Otherwise refer for colposcopy to biopsy and do cautery. Inform her that it is possible for the ectropion to recur but should she get these symptoms in the future it would be adviable to have them checked again because there could be another cause of bleeding. Advised to continue cervical screening as per guidelines. Provide information leaflets.
		Posted by K I. Sat Feb 20, 2010 11:50 pm
KI a) Clinical assessment will include smelly vaginal discharge that could be present with infection. Menstrual history including last menstrual period and cycle regularity. Any contraceptive use or hormonal treatment such as HRT that will cause irregular bleeding. Previous abnormal cervical smear should alert suspicion of cervical pathology. Examination includes abdominal palpation for any abdominal or pelvic masses. Speculum examination to visualise the cervix and vagina for any cervical lesion or masses. Bimanul examination to detect any pelvic mass, fixation of cervix and uterus, and adnexal tendeness for suspicion of cervical cancer or cervical exitation for sign of pelvic infection. b) investigations will include cerivcal smear, high vaginal swab, endocervical swabs for gonorrhoea and chlamydia, full blood count, c-reactive protein, urea and electrolyte. Ultrasound of the pelvis if any suspicion of pelvic mass. c) Treatment options include conservative management as this is a benign condition. If left untreated, the lesion will not pogress to become a malignant lesion. unfortunately, the symptoms of intermenstrual bleeding and post coital bleeding may persist, and will lead to further investigation in the future. It can be treated with cryotheraphy. After this treatment, women should be adviced against intercourse or tampon use for about a week post procedure. She should be warned of the heavy vaginal discharge that will be black or brownish in colour. Information leaflet should be given to patient regarding the procedure and post-procedure care. Patient should also be adviced to have regular cervical smear and to return for check-up by the general practitioner if further symptoms.
		Posted by Ida I. Sun Feb 21, 2010 03:05 am
I. a) She should be asked regarding the duration, frequency and amount of bleeding, and if it is affecting her quality of life. Her last menstrual period has be ascertained to exclude the possibility of a pregnancy. Her sexual history has to be obtained, and any presence of foul smelling vaginal discharge could suggest sexually transmitted disease. Any history of combined contraceptive pills or estrogen patches may cause the symptoms. She should be asked regarding the results of her last pap smear. Any history of lethargy, reduced effort tolerance or shortness of breath on exertion may suggest anaemia. Any constitutional symptoms of loss of appetite, loss of weight or feeling generally unwell may suggest underlying malignancy. Any history of bleeding disorders, such as idiopathic thrombocytopenia purpura can be helpful. Examination should include the conjunctivae, nails and tongue to look for pallor, which is suggestive of anaemia. Her BMI needs to be ascertain as obesity is associated with abnormal menstrual bleeding. Her abdomen palpated for masses. Speculum examination is necessary to look for vaginal and cervical pathology, such as polyps or cervical ectropion. A bimanual examination done to assess uterine size, and the presence of any adnexal tenderness that may suggest pelvic inflammatory disease. b) She needs a full blood count to look at her haemoglobin levels to exclude anaemia, and her platlet counts to looks for any possiblity of bleeding disorders. Endocervical and urethral swabs for Chlamydia and Gonorrhea must be taken to exclude pelvic inflammatory disease or sexually transmitted disease. She needs a pap smear to exclude any cervical malignancy. Any gross abnormality of the cervix needs a referral for colposcopy. A pelvic ultrasound, preferably transvaginal, to look for any pelvic masses. c) She should be reassured that it is not a malignant condition, nor is there a possibility of it turning malignant. She can be offered conservative management as the condition can regress. She shold be advised to change her combined contraceptive pills or progesterone only pills or progesterone implants. She can be offered cryotherapy, which can be done as an outpatient basis. Ablative treatment under local or general anaesthesia can also be offered. She should be informed that she may have spotting for a few days after the treatment. She should be advised to refrain from having any sexual intercourse or wear any tampons for 3 to 4 weeks. She should continue with her regular 3 yearly pap smears. She should be given patient information leaflet for better understanding of her condition.
		Posted by Seham S. Sun Feb 21, 2010 05:03 am
SE-SA (a) I would ask her about menstrual cycle ( regularity, menorrhagia,periods of amenorrhea) . Sexual history and presence of more than one partener for sexualy transmitted diseases especialy clamydial infection. contraception history and current method on use.Mirena IUS and Depoprovera injection are associated with spotting. COC may be associated with spotting if the dose is not sufficient or if accompanied with clamydial infection. Cervical smear result as abnormal smears could be due to CIN . History of bleeding disorders or warfarin therapy should be excluded. History of medical disease as Diabetes and hypertention which could be risk factors for endometrial hyperplasia. Examination include BP for hypertention, BMI for obesity and increase risk of Diabetes and decrease effect of COC . Abdominal exam for masses ,uterine size.Bimanual exam for size of uterus, mobility and ovarian masses . Speculum exam for cevical lesion or ectropion. (b) investigations include FBC,liver function tests ,bleeding and clotting time. endocervical swab for clamydial exam by NAAT . Colposcopic exam if abnormal lesion is seen in the cervix and biopsy could be taken for histopathological examination. Vaginal u/s for endometrial thickness and uterine mass. (c) I would inform her that cevical ectopy is benign condition and can be treated conservativly. Follow up is recommended after 6 m if no cause detected. Treatment of clamydial infection by Azithromycin 1 gm single dose.Oflaxacin and clindamycin could be used as alternative option.Follow up after 6 weeks is considered. Cauterization of cevix by elecro-thermal method or cryocautery could be done.Follow up after 4-6 weeks is recommended . patient should be instructed about foul discharge and to avoid sexual intercourse for 2-3 weeks. Laser cauterisation could also be done but more expensive .
		Posted by Dr Dyslexia V. Mon Feb 22, 2010 01:28 am
X a) History of intermenstrual bleeding in terms of quantity as it is excessive enough for usage of sanitary pads or its association with pelvic pain could indicate PID(pelvic inflammatory disease) or endometriosis. It’s association with vaginal discharge could be associated with bacterial vaginosis or candidiasis. Her menstrual history should also be taken as to regularity of her cycles and its association with menorrhagia which could suggest fibroids. Presence of any loss of weight or appetite could suggest malignancy. History of any colposcopic treatment is important as it could indicate CIN or cervical C. History of multiple sexual partner and previous treatment for STD could also suggest pelvic inflammatory disease. Her current usage of contraception is important as COCP could cause cervical ectropian or usage of IUCD which could cause PID. Examination should include general condition such as cachesia could indicate malignancy. Her conjunctiva and tongue to assess for pallor which indicates severity of anemia. Palpation should be done for presence of suprapubic abdominal masses which could indicate fibroid or ovarian masses. A perspeculum examination is most vital examination as it could note any vaginal wall lesion or cervical lesion. It could also note presence of any sore ulcer or fungating mass or polyps seen in the speculum examination. b) Investigation should include a full blood count for presence of anemia and leukocytosis for presence of any infection. A high vaginal swab or endocervical swab should be taken to rule out any PID or infections. A transvaginal scan is done to assess endometrial thickness or presence of any endometrial polyp. If this is suspected I will arrange a hysteroscopy for diagnosis and treatment. A cervical smear should be done if this is not done previously. c) She should be informed that cervical ectropian is a benign condition and it would not lead to malignancy. She should be informed that it will resolve during menopause. She should be informed that a conservative approach could be done in which she could avoid the usage of any COCP if she is on it and change to progesterone based contraception. She should also be given advice for practical measures such as avoidance of tampons usage. If the condition is debilitating, a surgical approach could be done. The lesion could be removed via diatomy or chryotherapy. She should be informed that there could be some bleeding post operatively and it could succumb to infection. She should be advised to refrain from sexual intercourse for up to 2 -3 weeks and she should be advice to come back if there is any discharge or bleeding. There is also chance of this lesion to recur. A patient pamphlet and information should be given to the patient and should be referred to a support group.