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MRCOG PART 2 SBAs and EMQs

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Essay 333 - Inter-menstrual bleeding

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		Posted by Zarin G. Sun Aug 1, 2010 07:13 pm
A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. I would determine if the bleeding was cyclical or sporadic. This would guide whether a hormonal element was involved. I would ask whether the lady was up to date with her smears and that she had a normal smear history, ie, whether she was awaiting colposcopy follow up. An association with dyspareunia might suggest vaginal endometriosis. The lady\'s sexual history would be important to note: whether she is sexually active at present, whether barrier contraception is also being used, whether both partners have had an STI screen, whether she knows she has an STI. Abdominal examination might determine the presence of a pelvic mass consistent with pregnancy or a fibroid uterus. There might be evidence of local trauma/endometriosis to the external genitalia/vagina. Speculum examination might show cervical ectopion/abnormal vaginal discharge/endocervical polps. A urinary bhcg level would determine pregnancy status. (b) Describe how you would investigate her symptoms [4 marks]. Speculum examination of the cervix and procurement of endocervical swabs to check for chlamydia and gonorrhoea, high and low vaginal swabs to check for a full STI screen, eg, trichomonas; also for bacterial vaginosis that could cause intermenstrual bleeding (IMB). I would repeat a smear test if one had not been done in the six month period of IMB. I would request a pelvic ultrasound scan to determine presence of fibroids or intrauterine polyps (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] Conservative management would involve explaining the diagnosis and reassuring that no long term harm is caused by ectropion. If the lady is able to cope with IMB, no treatment may be offered. Medical mangement might involve stopping the oral contraceptive pill (OCP) as ectropion is more commonly found in OCP users. Surgical treatment can involve the use of silver nitrate cautery sticks to the area in clinic or the use of diathermy under local or general anaesthetic. I would ensure that a recent smear test had been sent prior to doing this. (d) Discuss the treatment options is no underlying cause is identified [3 marks]. The progestogen component of the OCP is likely to lead to breakthrough bleeding so the OCP could be changed to one with a higher estrogen content. The OCP could be stopped completely and other contraceptive use could be instituted, educating the woman about irregular bleeding associated with progestogens.
		Posted by sonu P. Sun Aug 1, 2010 08:47 pm
a) S I will take a detailed menstrual history, e.g. if the cycles are otherwise regular,how heavy the periods are and her LMP;any regularity of the intermenstrual bleeding to rule our mid cyclical mittelsmerz/ovulation bleeding; whether it is associated with any pain or postcoital bleeding, dysmenorroea, dyspareunia,excessive/offensive vaginal discharge to evaluate for PID.I will ask her about similar symptoms in the past,any identified caue and response to previous treatments.I would like to know which contraceptive pill, 20 0r 30 ug she is taking.I would also like to establish her compliance with taking the tablet daily and explore her lifestyle with respect to shift working etc. I will ask her if she has any concurrent medical condition and if ahe is on any enzyme inducing medications like anti-epileptics, long term antibiotics etc. I will ask about her last smear and if any abnormality.I will take a sexual history, if she is a long term stable relationship,any change in partner or more than one partner in last year. A past history of STI and treatment, along with partner treatment would be helpful. On examination,I will look for lower abdominal tenderness;On speculum examination, I will look for any obvious vulval, vaginal or cervical lesions like warts, ectropion, foreign body and polyps; and note the amount and type of discharge. I will offer to take a cervical smear if she is due for one.On vaginal examination, I will assess the size and mobility of uterus, any adenaxal masses or tenderness. b) I would like to take triple swabs i.e high vaginal, endocervical for gonococcus and chlamydial swabs.I will request an ultrasound scan to look for endocervical, endometrial polyps, submucosal fibroids and adenaxal masses to rule out PID. In case of normal ultrasound and persistant symptoms, I would consider a diagnostic hysteroscopy. c) If symptoms are minimal and the patient understands the diagnosis, expectant management may be offered as long as all the investigations smear,swabs and pelvic USS are normal. Alternative option is to treat it as an outpatient with chemical cauterization e.g silver nitrate.Ih the ectropion is large,this might not be very beneficial and in that case I will offer her EUA with thermal,cryo or laser cauterization. I will warn her that she will have copious amount of vaginal discharge for few weeks after the treatment and to either avoid sexual intercourse for 4-6 weeks or use condoms till the symptoms have resolved. If the above measures fail, I will discuss with her alternative forms of contraception e.g LARC. d) If no underlying cause is identified, a simple reassurance may be all that is required. She can be offered expectant management with a follow up appointment to see any deterioration or improvement in symptoms. If symptoms are persistant, an alternative form of contraception should be considered.
		Posted by MR R. Sun Aug 1, 2010 08:56 pm
A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. I will take a menstrual history regarding het LMP, age of menarche,cycle regularity and the duration of bleeding.I will ask for any associated post coital bleeding and menorrhagia.I will take a sexual history as to any past STI\'s, recent change of partner or new partner in the last year.I will enquire about her last cervical smaers and any treatment taken for abnormal smears previously. I will ask her about previous contraceptives used and any problems with them.I will gather about gynaecological problems like fibroids,polyps or PID.I will also ask her parity and mode of deliveries if any.I will check her BMI and BP.I will examine her abdomen for any mass arising from the uterus like fibroids.I will do a speculum examination to identify any discharge (STI),visualise the cervix for any ectropion,ulcer,mass or polyps.I will do a bimanual examination to ascertain uterine size and any associated fibroids.I will assess if there is any cervical excitation tenderness or adnexal tenderness(PID). (b) Describe how you would investigate her symptoms [4 marks]. I will do an endocervical swab for gonorrhoea, high vaginal swab and chlamydia swab or urine test for chlamydia. I will do FBC,CRP for raised inflammatory markers suggesting inflammatory process.I will do a transvaginal scan to assess any fibroids. particularly submucous fibroids.I will also assess endometrial thickness,though less useful in premenopausal women can suggest if any endometrial polyp or submucosal fibroids.I will also take an endometrial pipelle biopsy to rule out endometral hyperplasia.Hysteroscopy can be useful in a few cases if suspicious of pulyp and can be therapurtic at the same time.I will take a cervical smear if she has not had one in the last 3 years and refer to colposcopy if the abnormality suggests referral. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] I will reassure the patient that this is a raw area on the cervix due eversion of the inner part of the cervix.This does not suggest cancer.The options for management are 1. No treatment and follow up if required 2.Simple clinic based treatment by using silver nitrate sticks or monsol solution to burn the ectropion.This is effective in small ectropions.3.If the ectropion is large we can arrange diathermy cauterisation as a oupatient procedure.Can be done in colposcopy /DSU under local /paracervical block if required.4.In rare circumstances where the ectropion is resistant to above modalities and giving troublesome symptoms excision with loop diathermy can be performed after careful patient selection.I will advise her in any of the above treatment she can expect small amount of bleeding or black grey discharge for a few days.Avoid intercourse and tampons for 2 weeks.If there is any abnormal smeely discharge will need antibiotics for infection. (d) Discuss the treatment options is no underlying cause is identified [3 marks]. If there are no underlying cause found simply reassurance will help understand her symptoms as this can happen with few COCP\'s.If she wishes an alternative COCP with higher dose progestogen or estrogen can be changed.This might help her bleeding although there is no evidence to support this.An addition of norethisterone(5 mg tds)/provera between D5 - D26 can help in controlling the bleeding.Other alternative will be to stop the COCP and try alternative methods like Depo provera , implant or mirena IUS.They also have ther own pros and cons and should be started after careful counselling.
		Posted by GULSHAN R. Sun Aug 1, 2010 09:04 pm
35 year old women has been reffered to gynaecological clinic because of persistant intermenstrual bleedingfor 6 month.She has been on cocp for 9 month. (a)Discuss your clinical assesment.(8) For clinical assesment of the patient details history & clinical examination is important.details about her bleeding pattern,amount & colour is impotant. history about her sexual activity-for how long she is sexually active? number of partner , parity --help to exlude risk factors of carcinoma cervix. Details of recent paps smear. History of sexually transmitted infections or screening for these done or not--as Chlamydia infection may cause intermenstrual bleeding. Symptom of something coming down per vagina should be ask-polyp may present in this way. Any abdominal mass-to exclude hormone producing ovarian tumor. Now on examination- G/E:anaemia-to assumption about amount of bleeding. P/A/E:any mass P/V/E:any polypoid structure present or not. any features of ectropion-red ring around exturnal os. (b)Discuss how you would investigate her symptoms? Paps smear should be done if not done previously.If present ¬ correspond with cervical examination--repeat cytology or colposcopic refferal should be done. Ultrasound scan -can exlude fibroid, ovarian mass and polyp.Endometrial thickness can also be seen. High vaginal and endocervical swab should be send for infection screen such as Chlamydia & gonorrhoea. Hysteroscopy can be done if suspicion of polyp or endometrial pathology . It has also therapeutic value. (c)Discuss treatment options if cervical ectropion is identify. Cervical ectropion rarely required treatment.But as the patient is symptomatic it required treatment. Treatment options are- Diathermy Cold coagulation Before treatment normal smear result should be obtain. (d)Discuss treatment options if no underlying cause is identify. If no underlying cause is identify reassure the patient.I should inform her that it may be breakthrough bleeding.It is one of the complications of cocp.I should increase the dose of the pill & ask her for follow up.
		Posted by Aruna R. Sun Aug 1, 2010 09:16 pm
aruna A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. (b) Describe how you would investigate her symptoms [4 marks]. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] (d) Discuss the treatment options is no underlying cause is identified [3 marks]. a) clinical assessment :History of details of the presenting symptoms like amount of intermenstrual bleeding(IMB) , associated dysparunia, orany menopausal symptoms like dry vagina ,hotflushes, and vaginal discharge other than bleeding.I would like to ask about her last menstrual bleeding . The cycles are mostly regular because of pills. I would like to ask about the time of last cervical smear taken and is there any abnormality found and past history of treatment to cervix(LLETZ,cone biopsy).I would ask about any history of pelvic infections.The details of the drug intake (apart from oral pills) like anticoagulants, tamoxiphen. Family history of ovarian cancers should alsdo be elicited. I would like tyo whether she is a smoker. Clinical examination include paleness to check anaemia, temperature and lymphadenopathy.abdominal examination to rule out abdomino pelvic mass.speculam examination to rule out atrophic vagina, vulvovaginal ulcers, cervical polyps, ectropian and abnormal vaginal discharge. bimanual examination to rule out uterine or adenexal masses and tenderness. b) Investigation :Vaginal swabs including high vaginal and endocervical swabs for chamydia and gonorrhoea.cervical smear if not taken recently.If any cervical polyps found it should be removed and sent for histology.Colposcopy or biopsy if any suspicious lesion in the cervix, vulva or vagina.Hysteroscopy and endometrial biopsy may be done if all the other causes of bleeding ruled out.full blood count to check the haemoglobin. c)Treatment options for cervical ectropion : Explaining the patient that the oral pills contain hormone( oestrogen) which is responsible for this and change of contraceptives to non hormonal or non oestrogen containing pill is an option. After explannation, no treatment ( wait and watch) is an option but rarely patient accepts this option.cauterisation of the ectropion using silver nitrate sticks,cold coagulation, cryotherapy is an option. d) If no underlying cause is identified the treatment options include notreatment and proper counselling of the patient, changing the pill to non hormonal contraceptives or non oestrogen pills.
		Posted by Brendan M. Sun Aug 1, 2010 10:20 pm
(a) Discuss your clinical assessment [8 marks]. History: - presence post-coital bleeding -timing of bleeding - midcycle, proliferative/secretory phase cycle -nature of bleeding - spotting, heavy, how many pads? -cycle length, number of days, nature of bleeding (ie crescendo - decrescendo pattern). -last pap smear and result, previous abnormal smears, previous Lletz or cone biopsy? -previous history of anovulation/ PCOS. - Medical history - hypothyroidism, bleeding disorders (Von Willebrands) -Sexual history - recent change in partner, prior STDs Examination: - general appearance, goitre -abdominal exam - pelvic masses - Speculum exam - appearance of vulva, vagina and cervix. - Vaginal exam - adnexal masses and abnormalities in cervix and vagina, uterine size. (b) Describe how you would investigate her symptoms [4 marks]. - Pap smear as per local guidelines regarding cervical screening. -Intracervical swabs for chlamydia and gonorrhoea PCR -If abnormal appearance or abnormal pap smears perform colposcopy and biopsy of abnormal areas on cervix. -Send cervical polyps for histology - FBE, TFTs, Coags (if heavy life-long bleeding). -Ultrasound of pelvis assessing endometrial thickness, fibroids and polyps. - If thickened endometrium biopsy of endometrium either by pipelle or hysteroscopy D&C. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] -Expectant management and reassurance of patient. -Change method of contraception as estrogen in OCP can cause ectropion. Depo-provera, Implanon or Mirena may reverse ectropion by making columnar epithelium revert back into cervical os. - Ablative treatments: - serial weekly treatments of silver nitrate will cause metaplasia of columnar epithelium into squamous epithelium of vagina. - alternatively diathermy under local/ sedation or GA may achieve this in one treatment. (d) Discuss the treatment options is no underlying cause is identified [3 marks]. - Expectant management with reassurance and ongoing surveillance for pre-malignant or malignant causes of bleeding - routine pap smears for cervical dysplasia, yearly ultrasound for hyperplasia endometrium. - As cause may be iatrogenic - cease OCP and use alternative forms of contraception or change dose or type of OCP to see if this changes bleeding. - If bleeding is severe and not responsive to ceasing or changing OCP consider managements for dysfunctional uterine bleeding - offer/ trial Mirena, consider Endometrial ablation and if neither of these are effective consider hysterectomy.
		Posted by Syamala H. Sun Aug 1, 2010 10:43 pm
syamalah ans A: initial clinical assesment of the patient who has 6 mnths history of intermenstrual bleeding while on ocs would be to take a detailed history. that would include amount and frequency of bleeding ,associatation with pain and its affect on her quality of life. ask about her complaince with ocs as irregular pill can cause abnormal bleeding and may result in pregnancy which could cause irregular bleeding. also ask about type of oc as low dose pills can cause irregular bleeding.ask about her sexual history such as number of partner or recent change of partner and any history of of sexually transmitted infections (clamydia) or treatment for either of them.also ask about her cervical smear history and any abnormal result as premalignant and malignancy of cervix can be the cause. ask previous menstrual cycles prior to when the problem started and history of fibriod or fibriod polyp. history of bleeding disorder in patient or in family.history of endocrine abnormality like thyriod disorder,hepatic and renal disorder. examination would include general examination like pallor to exclude anemia, thyriod examination.per abdominal examination to see for mass, ascitis to rule out ovarian malignacy.local examination vulval lesion. perspeculum examination to see the condition of vagina and the cervix and any abnormal discharge.look for ectropion.cervical polyp,abnormal lesion. pelvic examination to asses uterine size,mobility tenderness and adnexal mass. ans B: Invetigation will include full blood count anemia and platlet. coagulation screen if suspected coagulopathy. liver and renal fuction test and thyriod according to clinical suspicion cervical smear if not done according to national screening protocol or any suspicious lesion. swab for clamydia and gonococcus. wet mount for tichomoniasis, and gram stain for bacterial vaginosis.pergnancy test to rule out pregnancy complication.office endometrial biopsy for endometrial pathology. tvs for fibriod,endometrial polyp and hyperplasia and adnexal pathology. ansc:reassure the patient that the condition is benign. treatment for cervical ectropion would include conservative managment as ocp can be the cause and stopping ocs will revert the changes. counsel about alternative contraception before stopping. other is chemical cautery , can be done in outpatient setting with either silver nitrate or copper sulphate.. or the patient can undergo electro or cryocautery. repeated session may required to completly treat the lesion. adv regarding increased vaginal discharge and to aviod intercourse till healing is complete. adv regarding risk of reccurence,and difficulty in obtaining adequate cervical pap smear at later date. ans d: if no cause identified either she can be prescribed an oc with higher dose of estrogen. or she can be advised to stop ocs and can be shifted to other medod of contraception like condoms till the symptom subsides.if quality of life not affected she can be reaasured and can continue ocs.
		Posted by Chitra.s M. Sun Aug 1, 2010 11:11 pm
A.The woman is enquired about the pattern of intermenstrual bleed(IMB) and its effect on her quality of life.History of any post coital bleed is enquired.History is taken regarding any associated vaginal discharge and lower abdominal pain.Details of current contraception like dose of estrogen in the pill progestogen componenet,whether compliant,history of missed pills and emergency contraceptive use are noted.Sexual history is taken regarding number of partners,recent change of partner and use of barrier contraception to assess the risk of STIs.Her previous pap smear reports are reviewed.History of treatment taken for IMB if any,is noted. Examination is done to note BMI,pulse and BP.Abdominal examination is done for palpable mass and tenderness.Speculum examination is done to note presence of discharge,cervical polyp/ectropion and contact bleed.Bimanual examination is done for uterine size,tenderness,adnexal mass and tenderness. B.Triple swabs are taken for chlamydia testing( and gonorrhea if indicated.)A cervical smear is taken if she is due and colposcopy arranged if results are abnormal.Pelvic ultrasound examination is done to look for endometrial/submucous fibroid as cause of IMB.Hysterocopy and endometrial biopsy are considered if she has persistent IMB and all investigations are normal .It is also indicated if USS shows evidence of endometrial polyp. C.The woman is reassured and explained that it is a noncancerous change in the cervix .No treatment is required if it is not affecting her quality of life.Chemical cautery using silver nitrate can be offered on an outpatient basis if the lesion is small.Cryocautery of the lesion is another option that can be done of outpatient basis without need for anaesthesia.Electrocautery of the lesion can be done but will require regional/general anaesthesia.Laser ablation of the lesion would also require local/general anaesthesia.The woman is advised that symptoms can recur whatever the treatment modality used.Written information is provided. D.The woman is reassured and asked to continue with current contraception if IMB does not affect her quality of life.If she is on COCPs containing 20mcg of estrogen ,she can be switched to a preparation containing 35mcg of estrogen.COCP with a different progestogen can be tried.Other contraceptive options like copper IUD,barrier methods and DMPA use can be discussed .
		Posted by zara A. Sun Aug 1, 2010 11:49 pm
aASK the patient her concerns ,ask about frequency and amount of bleeding and effect on quality of life .ASK about LMP [possibility of pregnancy] , menstrual loss [heavy] ,duration of bleeding. SHE SHOULD inquired about previous menstrual cycle regular, any other gynaecological problems like fibriods ,pcos, should asked.ASSOCIATED symptoms like dyspareunia ,postcoital bleeding,vaginal discharge ,lower abdominal pain ;dysmennorrhoea [indicate underlying pathology like fibriods ,pid].REVIEW the estrogen dose in pill,and method of use compliance.SExual history taken new partener or more than one partener in previous year.LAST CERVICAL SMEAR Should be reviewed.FAMILY history of malignancies taken[endometrial,breast].MEDICAL HISTORY TAKEN concurrent medical problemslike malabsorption ,diarrhea and epilepsynoted.Medication taken like enzymeinducers[antiepileptic,antibiotics].BP,BMI RECORDED.look for pallor[anaemia]ABDOMINAL EXAMINATION for mass [fibriod ,pregnancy].vULVAL INSPECTION done .SPECULUM EXAMINATION done cervix examined [polyp ,ectropian ,] any abnormal; discharge noted .BIMANUAL examination done size of uterus ,adenexal tenderness noted and adenexal mass.B]INVestigations planned depending on clinical assessment .IF MISSED pills,malabsorption and suspicion of pregnancy pregnancy test done to rule out underlying pregnancy.IF Structural abnormality suspected TVS or hysteroscopy doneto rule out uterine structural abnormality and endometrial biopsy taken if risk factor [family history of endometrial cancer,pcos or patient obese].IF RISK FACTORS of STI refer to STI clinic and endocervical swab and urethral swabs taken for culture for gonorrhea, NATT TESt for chlamydia done and contact tracing.CERVICAL SMEAR TAKEN if due or not participating in NHS CERVICAL SCREENING PROGRAMME.urgent referral for colposcopy if ca cervix suspectedC]IF cervical ectropian found explanation of finding and reassure that most likely due to estrogen in ocps it occurs .OPTIONS FOR HER CONSERVATIVE TO WAIT AND WATCH , if not acceptable as patient bleeding other options chemical cautry WITHAGNO3 under local anaesthesia .CRYOTHERAPY under local .LASER ABLATION or DIATHERMY UNDER LOCAL OR GA.D]IF no cause found then reassure her that nothing is abnormal.Options aRE TO use the ocps with higher dose35micrograms if she is taking 30 micrograms or increase to30 microgram if taking 20microgram. or tricycling with ocps can be done.OTHER OPTION IS TO CHANGE THE TYPE OF PILL BUT EVIDENCE FOR THIS IS BENEFICIAL LACKING.ALTERNATIVE METHODS EXPLAINED .patient wishes taken into account .written information given followup arranged.
		Posted by H H. Mon Aug 2, 2010 12:11 am
I will ask the patient regarding her intermenstrual bleeding( IMB), amount, colour,and if associated with pain,the type of pain,dull aching or colicky (endometrial polyp). Will ask of her obstetric history,her parity and last delivery(placental polyp). Will ask of LMP, menarche, cycle regularity despite the IMB and dysmenorrhea. Will ask of the type of pills she is taking ,how she is taking them,and if she keep forgetting taking them . Will ask of her sexual history,frequency,number of partners,use of barriers as condoms and possibility of sexually transmited infection which can cause IMB.Will ask her of her last cervical smear ,any abnormality and any treatment given including surgery. Will ask of her medical history if has epilepsy,intake of antiepileptic drugs or other medications that induce hepatic enzyme induction ,these lead to lowering of efficiency of COCP and induce IMB. Would consider that the patient might be pregnant. Will ask of personal history of breast, cervical endometrial or ovarian cancer. Will ask of family history of breast,endometrial or ovarian cancer.Will ask of symptoms of malignancy,anorexia,loss of weight,rectal bleeding,hematuria, cogh and hemoptysis. Examination will include BP, BMI, abdominal examination for abdominal mass , local examination ,vaginal speculum exam to see cervical polyps,ectropion or erosion.Rectal examination if rectal bleeding. If has family history of malignancy or suspect malignancy ,urgent investigations within 2wk of referral are needed. Will do a pregnancy test to exclude pregnancy. Will do high vaginal swab ,endocervical swab for chlamydia and gonorrhea. Will do cervical smear if not done and is due for one, with or without colposcopy. Transvaginal ultrasound to show endometrial thickness and can detect polyp though the sensitivity is low.Pipelle suction endometrial biopsy . Out patient hystroscopy and biopsy, this will diagnose polyp,but will not allow removal. In patient hystroscopy and D&C ,is both diagnostic and allow removal of polyp. No treatment and only give assurance. If uncomfortable,will do cautery. Chemical cautery with silver nitrate can be done at out patient clinic,safe and cost effective. Electrocautery can be done under local or general anesthesia . Cryo cautery for 2 minutes is safe ,but require the presense of the equipment. Laser cuterisation lead to evaporisation of lesion ,but need expertise. Patient is told that she will have a bloody discharge for the next 2-3 weeks. She is to avoid sex for 2-3 wk. Will be given follow up appointment. If no under lying cause is identified, the patient is assured. I would advise her to stop the use of the COCP and try another method of contraception that would not involve hormones. If patient insist on taking them, I would tell her to shift to another brand with higher estrogen content. Should she still bleed after both options, would seek 2nd opinion.
		Posted by A A. Mon Aug 2, 2010 12:44 am
AA a, Intermenstrual bleeding (IMB) may signify a potential malignancy , however majority are due to benign causes. I will take menstrual History for LMP, cycle length & menstrual loss,any associated post coital bleeding. Assess severity of IMB, any similar previous episodes & treatment taken &its impact on quality of life. Symptoms like abdominal pain , fever or vaginal discharge may indicate pelvic infection. Detailed contraception history regarding past method of contraception, check her correct use & compliance & Dose of estrogen in pills. Drug history as it might be due to interacting medication like enzyme inducing drugs which reduces the efficacy of pills. Sexual history ,any past STI\'s, recent change of partner or new partner in the last year to assess risk for PID or cervical cancer. I will enquire about her last cervical smear and any treatment taken for abnormal smears previously .I will ask her parity & future fertility plan. Bleeding for non gynaecological origin like urethral or per rectal bleeding need to be excluded .Ask about any recent weight loss, family history of cancer or thrombophilia. Check any contraindication of COCP use like DVT, hypertension,or migraine .Ask Social history about smoking & drug abuse. I will check her BMI and BP.I will examine her abdomen for tenderness or mass. Speculum examination to look for vaginal discharge, assessment of the cervix for evidence of inflammation, polyps, ulceration, and ectropion. Presence of contact bleeding or pelvic mass on bimanual examination (b) . Full blood count for Hb estimation if heavy loss & WBC count & CRP if suspected infection.I will Pregnancy test, to exclude pregnancy I will take High vaginal swab, endocervical swab for Chlamydial & Gonorrhea. If positive , appropriate referral for Screening for other STI . Cervical smear if due, or if not following screening programme. Colposcopy if cervix is abnormal or smear shows dyskaryosis. Trans-vaginal scan for abdominopelvic pathology. Hysteroscopy +/- biopsy if ultrasound evidence of endomertrial polyp or persistent symptoms and other investigations are negative. C) One option is No treatment with reassurance of benign nature of condition. Unlikely to be accepted if symptoms have a significant impact on the woman’s life. Other treatment options are Chemical cautery with AgNO3 which is useful for small lesions. Cryotherapy using liquid nitrogen can be performed in out-patients clinic without anaesthesia . Diathermy cautery or Laser ablation will require local or general anaesthesia .Patient need to avoid sexual intercourse and tampons for 2-3 weeks after these treatments. Expect dark / brown vaginal discharge for 2-3 weeks. Symptoms can even recur. I will Provide written information & respect patient choice. d)I will reassure her. After excluding contraindication to use COCP, estrogen dose adjustment if on Low dose pills upto 35ug can improve cycle control. Use of alternative methods like cupper IUCD or progesterone implants, depoprovera or mireena can be offered. Advice her use condoms for safer sex.I will Provide information leaflets
		Posted by NIRMALA M. Mon Aug 2, 2010 02:02 am
Nirmala a. Elaborating on her present complaint of Intermenstrual bleeding like which part of cycle it is happening and how severe it is. Detailed menstrual history before and after starting COCpills helps to decide on the cause. Regular periods, menorrhagia, dysmenorrhoea with associated IMB point towards fibroid uterus especially submucous fibroids, though menorrhagia and dysmennorrhoea might be suppressed by COC pills. History of any abnormal vaginal discharge which is itchy and foul smelling should be enquired into as PID/ cervicitis might cause IMB. Ask about the COC pill she is taking and the oestrogen dose she is on. Assess her menstrual diary if she has one. Whether any history of post coital bleeding to exclude any cervical pathology like cervicitis or ectropion. Sexual history should be enquired sensitively to note multiple sexual partners, recent change of partners in past six months, any history of PID/STIs in the past, any history of deep dyspareunia as STIs/PID especially Chlamydia can cause IMB. Obstetric history to include parity and any previous vaginal deliveries to note any cervical damage. Smear history whether uptodate and normal so far. General medical conditions like hypertension, diabetes should be excluded as they are high risk for endometrial hyperplasia and carcinoma especially if she is obese, Nulliparous, smoker and a known PCOS. General examination to look for pallor. Abdominal examination to note whether uterus is palpable per abdomen in cases of fibroids and to rule out any other organomagaly like ovarian cyst whether tenderness present. A speculum examination should be carried out to exclude any cervical pathology like ectropion, cervical polyps, pedunculated fibroid polyp through internal os, any abnormal vaginal discharge. Bimanual vaginal examination should be done to note uterine sizeto exclude fibroids, regularity, mobility, adnexal mass, cervical excitation or forniceal tenderness to exclude PID. b. Full blood count should be done to exclude anaemia. During the speculum examination, endocervical swab for Chlamydia and gonorrhea, high vaginal swab should be done. If cervix has ectropion or does not look healthy or she has not uptodate with her smears, cervical smear should be done. Because she has persistent IMB, pipelle biopsy is indicated though she is 35 years old. Transvaginal ultrasound examination preferably post menstruation should be done to note the endometrial thickness, its uniformity and to exclude any intrauterine polyp or submucosal fibroid polyps. If USS is suggestive of any intrauterine pathology or pipelle biopsy is abnormal, diagnostic hysteroscopy should be performed and biopsy or removal of the lesion if any present. c. Usually reassurance is needed as Ectropion it is a normal phenomenon while on COC pills. If smear is normal, she could be given options like changing the contraception method to other methods like POP, Injectables, Mirena. If the patient does not agree, then options of diathermy or cold cauterization should be discussed especially if she has history of post coital bleeding. If the smear result is abnormal, she should be referred to colposcopy for biopsy of abnormal areas. In cases of borderline smear changes, antibiotics can be tried and repeat smear done. d. Reassure her. She could be advised to take tranexamic acid if there is no pain during IMB or mefenamic acid if IMB associated with pain. If she is taking low dose estrogen pill, it could be increased to 30 or 35 micrograms of ethinyl estradiol COC pills.
		Posted by Ir A. Mon Aug 2, 2010 02:10 am
A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. (b) Describe how you would investigate her symptoms [4 marks]. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] (d) Discuss the treatment options is no underlying cause is identified [3 marks]. Ir a) I will take the patient\'s menstrual history including last menstrual period, length and regularity of cycle, postcoital bleeding and dysmenorrhoea. I will ask about the frequency and amount of the intermenstrual bleeding and its impact on her quality of life. I will enquire about her last pap smear. I will ask her about vaginal discharge and itching, lower abdominal pain and dyspareunia. I will take history suggestive of sexually transmitted disease and number of partners in last year. I will enquire which oral contraceptive pill is she taking and whether she takes it regularly. I will enquire whther the onset of IMB coincided witha change in brand of OCP or with any new medication she has started taking, eg enzyme inducing antibiotics. I will also take history of smoking and family history of any gynaecological cancer. On examination, i will document her BMI and look for pallor. I will examine the abdomen for any tenderness or palpable mass. I will do a speculum examination and look for vaginal discharge, cervical erosion or ectropion, any cervical polyp or growth. If her pap smear is due, i will take the pap smear at the same time. I will do a vaginal examination and look for uterine size, mobility, adnexal mass or tenderness and contact bleeding. b) I will take a high vaginal swab for trichomonas, gardenerella vaginalis and candida. I\'ll do an endocervical swab for chlamydia and gonococcus. I\'ll take a pap smear if it is due. I\'ll order a transvaginal scan to rule out endometrial polyp and hyperplasia. If the cervix looks suspicious, a colposcopy may be done. Endometrial sampling with pipelle should be considered keeping in view the long 6 month history. c)The patient should be reassured that its a benign condition. Depending on the impact on her quality of life, she can opt for conservative management. She can be offered chemical cautery using silver nitrate. Other options include cryotherapy in an outpatient setting. Laser ablation or electrocautery can also be done but these methods require local or general anaesthsia. After treatment for ectropin, the patient should be told that she may have some bleeding and brownish vaginal discharge for 2 weeks. She should be advised to abstain from intercourse for 2 to 3 weeks. d) If no underlying cause is identified, the patient should be reassured. If she is taking low dose OCPs, a brand containing 35 or 30 mcg ethinyl estradiol may help. She may consider an alternative method of contraception. She can be prescribed mafenemic acid or tranexemic acid to reduce the amount of bleeding. d)
		Posted by A- N. Mon Aug 2, 2010 03:35 am
A) She should be further evaluated as she has persistant irregular bleeding for more than 3 months after starting COC. I will first take a detailed menustral history to ascertain her menustral pattern including,last menustral period to rule out pregnancy and pregnancy related problems, cycle length, how many days of withdrawal bleeding, weather withdrawal bleeding is regular, I will ask weather what is the frequency, amount of irregular bleeding and its relation to the menustral cycle. The relationship to the menustral cycle will guide as to which harmone doses may have to be altered if no organic pathology found. Association with post coital bleeding may suggest local causes as cervical ectropion, cancer or vaginal causes as vaginitis. Associated causes as presence of white discharge, Dyspaereunea and abdominal pain may suggest pelvic inflamatory disease. History of menorragia, dysmenorrhea preceeding starting of coc\'s will suggest organic causes as submucous polyp/fibroid. I would explore her compliance with taking COC\'s and ask regarding the presence of any medical disorders as epilepsy including medication history example enzyme inducing drugs may enhance catabolism of coc\'s and an increased dose of coc\'s may be required also history of bleeding disorders has to be taken. I would take full sexual history to identify multiple partners which increase risk of pelvic inflamatory disease, History of last cervical smear to identify history of cervical dysplasia. Examination including checking for pallor to identify anaemia. Abdominal examination to check size of uterus which may demonstrate a fibroid uterus. Perspeculum examination to identify local cervical causes like ectropion, cervicitis and obvious cervical cancer. Vaginal examination to check size of the uterus and adnexal masses, cervical excitation which will be positive in case of PID. B) I would first check for presence of pregnancy by performing urine pregnancy test, then, I will do full blood count to check for haemoglobin to identify anaemia. Leucocytosis may suggest PID in which case CRP may also be raised. I would offer to take high vaginal swabs to check for local vaginal infections as bacterial vaginosis and endocervical swabs t identify gonorrhea and chlamydia. I will request pelvic ultrasound to check for size and location of fibroid, posibality of endometrial polyps. I would offer hysteroscopy and endometrial biopsy to identify endometrial pathology as endometrial polyps, endometrial hyperplasia or endometrial cancer. I will repeat cervical smear if last smear is more than 3 years with normal recall. C) If previous cervical smears anr normal, the symptoms are minimal I would reassure that cervical ectropion may be secondary to COC\'s and no further management is needed. If symptoms are profound affecting quality of life, cervical smear history is normal with no previous pathology found then can be treated with cautery or by cold coagulation. If there is a history of cervical dysplasia on smear history I would offer her colposcopy prior to ablative treatment. I would treat with antibiotics if triple swabs show any infection, refer her to GUM clinic for contact tracing. D) I would discuss the options of no further intervention if symptoms are minimal and not affecting quality of life, or change to another form of COC\'s such as triphasic pills which will give different doses of harmones in different phase of cycle. If these are not accetable I would offer to withdraw COC\'s and changing to either non harmonal contraception as condoms, Copper containing IUCD\'s, Or progesterone only harmone contraception as Progesterone only pills, Implanon, Depo-Provera Injections or LNG IUS.
		Posted by L S. Mon Aug 2, 2010 08:59 am
LS: (a) Discuss your clinical assessment [8 marks]. I would ask her about any specific concerns about her symptoms which she might have. I would take a detailed menstrual history with regards to her last menstrual period (LMP), her cycle length and amount of menstrual loss. The frequency and nature of the inter-menstrual bleeding assessed. Presence of post coital bleeding enquired. Effect of her bleeding on her quality of life assessed. Her contraceptive history and relation to the onset of her symptoms asked. Any use of over the counter medications or any recent illness which might have interaction with her contraceptive pill asked. I would assess her risk for sexually transmitted infections (STI) by enquiring details about her sexual history. Her cervical smear history is also asked. Associated symptoms like abnormal vaginal discharge, abdominal pain or pelvic pain are also asked. The possibility of pregnancy enquired. I would then carry out a speculum and vaginal examination to look for any abnormal vaginal discharge. Her cervix would be visualized for evidence of inflammation, polyps, ulceration and ectropion. Presence of contact bleeding would also be documented. (b) Describe how you would investigate her symptoms [4 marks]. Basic blood test checking her full blood count and pregnancy test should be considered if suggestive like missed pill or recent illness. If from her history there is suspicion of STI I would take a high vaginal swab, endocervical swab and Chlamydial swab to look for evidence of an infection. If her cervical smear is due I would also take a cervical smear and carry out colposcopy if during speculum examination her cervix appears abnormal or if her smear result shows dyskaryosis. A trans-vaginal scan is carried out to look for endometrial polyp or other endometrial pathology as her cause of inter-menstrual bleeding. As she has been having persistent symptoms a hysteroscopy with or without biopsy is warranted to be carried if all other investigations are negative. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] Treatment options are firstly no treatment with explanation of its nature and reassurance given. This option is unlikely to be accepted if symptoms have a significant impact on her life. Option of stopping her COCP can be offered as will resolve her ectropion. The next option is chemical cautery with silver nitrate which is useful for small lesions. Cryotherapy using liquid nitrogen of ectropion can be done and can be performed in out-patients clinic without anaesthesia. Diathermy cautery can also be done but this will require local or general anaesthesia. Laser ablation is another treatment option which will also require local or general anaesthesia. The patient should be informed after treatment to avoid sexual intercourse and use of tampons for 2-3 weeks, expect dark brown vaginal discharge for 2-3 weeks, contact their GP if offensive vaginal discharge and that their symptoms can recur after treatment. Written information should be provided on all treatment options. (d) Discuss the treatment options is no underlying cause is identified [3 marks]. She should be reassured that there is no underlying pathology for her symptom and conservative management with regular follow up can be offered. Option to change her COCP with a dose of ethinyl estradiol which can provide the best cycle control can be offered and this might need to increase up to a maximum of 35 microgram. A different COCP can be tried but there is no evidence that one is better than the other in terms of cycle control. Although there is no evidence that changing progestogen dose or type can improve cycle control it may help on an individual basis.
		Posted by millionaire2004 A. Mon Aug 2, 2010 10:03 pm
Ag A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. This problem is associated with considerable patient anxiety, approach her sensitively. Reassure her that in the majority, nothing is wrong. However, malignant pathology of genital tract need to be ruled out. History is important. Enquire about disturbance to her quality of life (ie interference with sexual activity). Ask about frequency of inter-menstrual bleeding(IMB). Ask about her normal menstrual cycle ( age of menarche, cycle length,duration of menses). Ask about last menstrual period as this bleeding could be pregnancy-related. Ask about the relationship between IMB and her normal menses. Ask about relationship of IMB with sexual activity. Ask about associated symptoms such as per vaginal discharge (particularly foul-smelling) and any changes in the pattern of per vaginal discharge. Ask about usage of any other over the counter medications without known contents (could be source of exogenous estrogen). Ask about presence of diabetes mellitus,hypertension (risk factor for endometrial pathology). Ask about presence of bleeding disorder. Ask about usage of any anticoagulant. Ask about past history of similar problems, diagnosis (such as endometrial hyperplasia), treatment given and her response to treatment. Ask about past history of pelvic inflammatory disease and its treatment. Ask about family history of endometrial pathology. Ask about her last cervical smear,when it was done and the results if available. Ask about future pregnancy plan. Do general examination looking for anaemia. Take weight and height and calculate body mass index (weight in kg/ square of height in metre). Palpate abdomen to look for any abdominopelvis mass. Do speculum examination to look at cervical pathology (like ectropion,cervical erosions,cervical mass) and for vaginal discharge. Do pelvic examination to look for uterine size,tenderness,presence of adnexal mass. (b) Describe how you would investigate her symptoms [4 marks]. Do full blood count to detect anaemia. Raised total white count suggest inflammatory cause (PID). Do urine pregnancy test.Take a cervical smear (if no normal smear in last 3 years) and triple swab test ( high vagina swab and 2 endocervical swabs for gonorrhea and chlamydia). Do ultrasound scan of pelvis to detect pelvic pathology such as fibroid uterus, adnexal mass (hydrosalphinx), endometrial thickness.Endometrial thickness/regularity can be better evaluated if use transvaginal scan or with instillation of saline. If suspicious of endometrial pathology, do endometrial sampling using pipelle sampler. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] Reassure women that it is not pathological to have cervical ectropion. She can opt to do nothing and wait. The symptoms may resolve with time. Can consider stopping estrogen based COC if other contraceptive methods acceptable (ie MIRENA) but inform the woman that it may cause irregular bleeding initially. Ablative treatment can be considered depending on her future pregnancy plans. Cryotherapy, diathermy and application of silver nitrate can all can be used. It can be done as out-patient or under local or general anaesthesia. (d) Discuss the treatment options is no underlying cause is identified [3 marks]. Reassure the women. Tell her that no pathology was found and that her symptoms could be due to hormonal imbalance. Discuss about changing to other method (non-hormonal) of contraception if the symptoms are affecting her quality of life. Give her follow up appointment. Give her written information.
		Posted by Dr Dyslexia V. Mon Aug 2, 2010 10:03 pm
X a) History in regards to the quantity and association with clots should be taken. Presence of symptoms of anemia such as weakness, lethargy and palpitation should be taken to assess severity. The history of a menstrual cycle should be ascertain in regards to regularity of her cycle as this should not be mistaken with oligomenorrhea. History of post coital bleeding is of paramount importance as it could point to a local cause. Her history of cervical smears and abnormalities should be taken. Her history of sexual partners, sexually transmitted disease or history of pelvic inflammatory disease should also be taken. Any previous history of gynaecological pathology such as cervical polyp or history of polypectomy should be taken. A general examination to exclude presence of pallor for anemia should be done. Abdominal examination should be done to assess abdominal mass of ovarian or uterine mass which could contribute to this. The most important examination would be a speculum examination to assess for presence of ulcers in the vagina, polyp, cervical ectropian or mass, and vaginal discharge should be noted. Presence of adnexal tenderness or cervical tenderness could point to PID. b) Investigation should include a full blood count to assess hemoglobin level for anemia. A urine pregnancy test should also be done to rule out any presence of miscarriages or ectopic pregnancy. Vaginal endocervical and rectal swab should be taken for Chlamydia and gonorrhea. Cervical smear is also done to assess for any presence of CIN changes or presence of HPV infection. A transvaginal ultrasound should be done to note presence of any small endometrial polyp or pelvic mass. A pipelle should also be done to rule out any endometrial hyperplasia. c) Treatment option include reassurance and inform the patient that this is a benign condition which could resolve spontaneously. She should be also advised to change her other form of contraception such as condoms as the content of progesterone in OCP could cause ectropian. She should also be offered cauterization of the ectropian with silver nitrate. Other option includes diathermy of the ectropian could also be offered. The use of cold cryotherapy could also be offered as well. d) She could be reassured that there is no sinister cause after the extensive investigation and could adopt a wait and see approach. She could also be offered to change her COCP to other preparation such as YAZ.
		Posted by Ida I. Mon Aug 2, 2010 11:19 pm
I. A) Her normal menstrual history, in terms on cycle and duration, has to be ascertained. She should be asked regarding the severity of her bleeding, the amount of pads used and if it has affected her quality of life, in addition if her bleeding is associated with coitus. Any symptoms of anaemia, such as lethargy, reduced effort tolerance or shortness of breath on exertion should be asked. History of foul smelling discharge with chronic pelvic pain would suggest pelvic inflammatory disease. She should be asked regarding her previous cervical smears and the results that could suggest malignancy. A family history of ovarian, endometrium and gastrointestinal malignancy is essential. She should also be asked regarding history of any associated medical disorders, such as hyperthyroidism and diabetes, that could cause irregular menses. She should be examined for pallor, her blood pressure measured and her BMI calculated. Her abdomen is palpated for masses. Speculum examination should be done to asses her cervix for ectropion, polyps or malignant masses. Bimanual examination is done to assess her uterine size and to elicit adnexal tenderness that could suggest pelvic inflammatory disease. B) She needs a full blood count to assess her hemoglobin level, to exclude anaemia. Blood glucose to look for hyperglycaemia. Urethral, endocervical and rectal swabs taken to screen for Chlamydia and Gonorrhea. Pap smear should be taken to exclude cervical malignancy. Ultrasound of her abdomen is done to exclude any masses, particularly ovarian masses. Transvaginal ultrasound done to assess endometrial thickness. Endometrial sampling with Pipelle catheter or Vabra aspirator for tissue biopsy of the endometrial lining. Hysteroscopy with endometrial biopsy and curettage shold be done if Pipelle sampling is inconclusive or inadequate. C) Explain to her that it is a benign lesion that is caused by the estrogen component of the pill. It can be treated conservatively with regular follow up at the clinic to assess her lesion. She should be given the option of stopping her pills or to change her pills to a progestogen only preparation, such as Depo injections, Implanon or progestogen-only pills. Surgical management with cryosurgery or ablation techniques, such as diathermy or cold coagulation can be offered. She would need repeated 3 to 6 monthly cervical smears to ensure there is no other underlying cervical pathology. D) Give her the reassurance that is a benign condition that can regress. Expectant management can be offered with regular surveillance with cervical smears every 3 to 6 months. Advise on alternative progestogen contraceptive methods, such as Implanon, Depo injections or Mirena. Non hormonal treatments with tranexamic acid can be offered to arrest the bleeding.
		Posted by R v P. Tue Aug 3, 2010 12:56 am
RVP A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. What she meant by IMB needs to be explored. It could be mid cycle spotting, luteal phase bleeding (suggestive of hormonal cause) or irregular suggestive of clamydia infection or underlying cervical leision such as ectropean, polyp or rarely cervical cancer. Menstrual history of menarchae, cycle duration and are relevent to establish cycal regularity. Associated post coital bleeding also may poit towards a cervical lesion. Smear history including wether she is up to date with her cervical smear, result of the last smear, previous treatment to cervix including loop exicision help to exclude the possibility of cervical cancer. Low dose COC is associated with IMB. Therefore the type of COC she is on is important. Missed pills may cause irregular bleeding as well as raise the possibility of pregnancy Sexually transmitted infections such as Clamydia and Gonococci can cause irregular bleeding. Sexual history including new partner, unprotected sexual intercourse, results of resent swabs if any needs to be explored. Family history of BRCA 1/2 mutation/ endometrial cancer puts her at risk of early onset endometrial cancer which may present as IMB. Anticoagulation medications such as warfarin may cause IMB if the INR is above the target levels. General examination including BMI and signs of anaemia such as pallor may be present if the bleeding has been heavy. Abdominal examination may reveal a pelvic mass secondary to enlarged uterus. Speculum examination may show the presence of ectropean,polyp or a mass that could be the cause of bleeding. Bimanual examination can exclude an enlarged uterus or adnexal mass. (b) Describe how you would investigate her symptoms [4 marks]. Endocervical swab or urine sample could be used to for NAAT to exclude clamydia. Endocervical swabs can also be used to diagnose gonorrhoea. If NAAT is used for diagnosis, this should be followed by culture and sensitivity. Opportunistic cervical smear should be obtained if she is not up to date. Persistant IMB is an indication for referral to colposcopy in her age group. Pelvic ultrasound may help to exclude endometrial polyps or enlarged uterus. If the history and examination are suggestive of endometrial cancer, Hysteroscoy and endometrial sampling is the gold standard. Pregnancy test shuld be considered if non compliance was revealed in the history (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] Reassuarance may all she need once she is explained ectropean is a benign condition. COC is associated with ectropeans. Changing COC to Mirena IUS or Copper coil may stop IMB and more cost effective. Local treatment such as AgNO3 cautery, laser or diethermy could be used to destroy the extropean but recurrence is a problem. (d) Discuss the treatment options is no underlying cause is identified [3 marks]. Reassurarance is still an option if no cause is found. Changing her to a standard dose of estrogen (35mcg) containing COC if she is on the low dose COC could be tried. No evidence changing to a different COC including phasic preparations (recent cochrane review)may improve bleeding. But may help on an individual basis No evidence changing the type of progestogen improves cycle control. But may help on an individual basis
		Posted by Bee N. Tue Aug 3, 2010 05:08 am
A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. (b) Describe how you would investigate her symptoms [4 marks]. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] (d) Discuss the treatment options is no underlying cause is identified [3 marks]. (bee) A) I will start assessment by analysing her periods. Her LMP will help rule out pregnancy. I will ask forassociation with menorrhagia which can be a pointer to existence of fibroids. I will ask for post coital bleeding which may also be present in vervical pathology. I will ask fro frequency and duration of her symptoms which will help chose appropriate treatment as this may also need to be addressed. I will ask if she is sexually active and also ask for presence of abdominal pain, vaginal discharge and fever which may indicate pelvic inflammatory disease. I will ask when she last had a smear test done and the result to assess need for one. I will ask for amy family history of endometrial, ovarian, cervical or vulvovaginal cancers and if present when they occurred in their relative as this will increase my suspicion of malignancy if present.I will take a past medical history to know if she will be fit for surgery in case one is indicated. I will ask how the symptoms have affected her life and if she has any plans for future conceptions. I will examine her eyes for anaemia since she may be anaemic, her skin for petechiae in cases of bleeding disord and palpate for inguinal lymphadenopathy which may be palpable in reproductive organ cancers. I will then examine her abdomen for any mass which may be present in uterine fibroids. I will inspect her vulva for any lesions and do a speculum examination to rule out vaginal polyp, cervical polyp or fibroid, cervicitis and cervical ectropion or cancer. I will then do a bimanual examination to palpate for the size of the uterus which may be enlarged in fibroids and for any adnexal tenderness( PID) or masses( Ovarian mass) B) I will start by taking bloods for FBC, CRP to assess for anaemia and infection. I will take a smear test if she is due one or refer to colposcopy if suspicious lesion is found. I will take endocervical swabs for chlamydia and gonococcal infection as well as high vaginal swabs. If suspicion of infection is high, I will also take urethral and rectal swabs to increase chances of detection. I will organise a pelvis USS to rule out fibroids and other endometrial pathology such as polyp. If endometrial pathology is suspected, I will arrange for her to have hysteroscopy. C)If cervical ectropion is found, I will explain to her that this is a benign lesion and depending on her choice all she may need is reassurance.She may however continue to experience the symptom though it does not transform to cancer. If she wishes something done, I will inform her that COCP on long term can cause it and she may either choose to change to another COCP with more progestrogen or consider other mode of contraception while discontinuing COCP.The efficacy of this treatment is not proven and symptoms may persist. If the lesions are mild, out patient treatment with silver nitrate can be done. This is usually effective in short term for mild lesions but not usually for more extensive lesion or long term treatment. More extensive lesions may require out patient cryotherapy or cryotherapy/ diathermy as a day case surgery. This is usually very effective though there is risk of scarring the cervix with this treatment which may impact on future pregnancies depending on the severity. patient choice must be considered and respected D) If no cause is found options include reassurrance and follow up. She can be treated with progestrogens such as northisterone or depo provera. The efficacy of this is not proven for this condition. She may be treated with GnRH analogues but this can only be used for short term (6 months)and may cause post menopausal symptoms. If this occurs, add back therapy with HRT can be used. if she has completed her family and is willing to use a very effective long term contraception, endometrial ablation can be done. The indication for this is usually for treatment of menorrhagia but may also be efeective in reducing intermentrual bleeding. In a some women this can actually cause amenorrhoea. Depending on the severity of her symptoms, success in use of other medical and conservative surgical options and the choice of the woman, hysterectomy with conservation of the ovaries will be a very last option. There is evidence that this may bring on menopause sooner than expected and expose her to the risks associated both in the short and long term of such a major surgery.
		Posted by Bgk H. Tue Aug 3, 2010 08:26 am
bgk a. Intermenstrual bleeding need to be given an urgent attention and should be assessed within 2 weeks. I will enquire about the severity of the bleeding such as association with blood clots, flooding and subjectively quantify with number of pads changed if she required to use them. Frequency of the bleeding and the impact of the bleeding to her lifestyle need to be asked and documented. Aggravating factor of the bleeding such as post coital may suggest a cervical ectropian or any cervical growth either polyps or malignancy. I will ask her about the association with vaginal discharge as this may signify an on going vaginal infection. Risk of sexually transmitted disease need to be asked sensitively including number of partner she has and their status. I will ask her detail menstrual history including her cycle length, flow and dysmenorrhoea. Compliance of her oral contraceptive intake need to be checked as poor compliance may cause a breakthrough bleeding in between menstrual flow. Her past cervical smear history need to be asked. b. I will perform a speculum examination and inspect her cervix and look for any cervical polyps, ectropian or growth. At the same time, I will perform high vaginal swab and endocervical sample including chlamydial swab. I will take a cervical smear if she is due to have one. A colposcopic examination may be needed in cases of abnormal appearance of the cervix or highly suspicious of malignancy. Colposcopy is also indicated if the smear result is abnormal. I will arrange an ultrasound of the pelvis to rule out any endometrial pathology such as endometrial polyps or submucosal fibroid. Presence of ovarian pathology or malignancy may cause irregular bleeding. A hysteroscopic examination is needed if any finding of endometrial polyps or abnormally thickened endometrial thickness more than 12 mm on ultrasound examination. c. I will reassure her that this is a benign condition, and it can be treated conservatively without any treatment. However if she is not keen to be treated conservatively, I will inform her the option of destroying the cervical tissue in order to prevent it from bleeding. It can be done by using diathermy, chemical cautery and cryotherapy. If expertise available, it can also be done by laser but she needs to be under GA. d. If no underlying cause identified she should be explained that no identified cause of her bleeding and she can be reassured. She should be informed that if it is not affecting her life, it can be left untreated. An empirical treatment of infection with antibiotic can be considered if she agreeable. If there is persistent bleeding or worsening of the symptoms, a repeat investigation may be needed. A patient information sheet should be given and a support group contact number should be given.
		Posted by Mohamed D. Tue Aug 3, 2010 11:43 am
Mohamed a) History of correct use of pills as incorrect use is a cause of bleeding and pregnacy. Sexual history with number of sexual contacts in the last 12 months for risk of STIs as chlamydia. History of medical disease as bleeding diathesis in haemophillia or thalathemia, or chronic vomitting wich will reduce the pill absorbtion. Any medcations as enzyme inducers as antiepileptics will reduce the effacacy of the pills. History of risk factors for endometrial cancer as treatment with tamoxifen for breast cancer as it could the cause of bleeding. History of updotade cervical screening, and normal smears, to role out cervical causes for the bleeding. General examination for signs of medical disease as bruises in bleeding diathesis, liver disease or anaemia from chronic bleeding. Abdominal examination for organomegaly, and pelviabdominal mass as in fibroid uterus. Speculum examination to role our cervical cause for bleeding as ectropion, napothian follicle, or polyps. Uterine case for bleeding is unlikely with her age, but is suspected, a pippele biopsy can be done and bimanual examination if pelviabdominal mass is suspected. b) FBC to check her anaemia status and to optomize her health by treatment. Cervical swabs and NAAT test for chlamydia at least and gonorrhea if suspected with risks of STIs. Cervical smear should be done if due, not uptodate or not in the screening program yet to role out cervical cytology abnormality as a cause for bleding. Pregnancy test especially with incorrect use of pills or reduced efficacy. Ultrasound if suspected pelviabdominal mass and to check if suspected endometrial polys may be a cause of bleeding. Pipelle biopsy if suspected endometrial abnormality or risk factors for endometrial cancer, with hysteroscopy. c) Conservative management and no treatment if ectropion is not causing any post coital bleeding or she declines treament after counselling. Cauterisation of the ectropion using chemical solutions, cold cautery or diathermy is another option, after normal cervical cytology with uptodate cervical smear. She should be advised that she will experience vaginal discharge after the treatment and advised against intercourse for the next 2 weeks of treatment. Changing the type of pills or contraception and follow up for improvement is another option. d) Changing the type of pills to a lower dose estrogen type and consider increasing the dose up 35mcg for better cycle control. Change type of progesteron in the pills has no evidence for improvement. Change the contraception method with couselling about medical elligability and side effects. Conservative management and reassurance if she declines any further intervention and want to continue on the pills.
		Posted by Kiran J. Wed Aug 4, 2010 10:41 am
A 35 year old woman has been referred to the gynaecology clinic because of persistent inter-menstrual bleeding for 6 months. She has been using the combined oral contraceptive pill for 9 months. (a) Discuss your clinical assessment [8 marks]. (b) Describe how you would investigate her symptoms [4 marks]. (c) Discuss the treatment options if cervical ectropion is identified [5 marks ] (d) Discuss the treatment options is no underlying cause is identified [3 marks]. (Sorry Iam posting this answer a bit late ) I would take a detailed menstrual history i.e her LMP, her cycles length and menstrual loss whether heavy or light .I would ask her the amount of intermenstrual bleeding she has if it is heavy or light and if it is associated with any pain as it cxan be due to an endometrial polyp and how much is it effecting the quality of her life. I would ask about any post coital bleeding and what is the amount and frequency of PCB as it can be a cervical pathology like infection or growths.I would ask if she has been having any intermittent vaginal discharge and if it has been offensive or discoloured.I would enquire regarding her sexual history and if she has any dysparunia assess her for risk of STI(Multiple sexual partners or partner diagnosed with STI).Important to find out if she is on mono,Bi or tri phasic OCP and if she recently changed from one formulation to another.Also if the OCP has 1st generation progesterone as it may give breakthrough bleeding Also if she is compliant with her OCP as non compliance can lead to breakthrough bleeding.I will enquire regarding her last cervical smear and if it was reported normal and she is on normal 3yearly recall.Smoking history is important as it may reduce the estrogen efficacy in the COCP. Examination would entail a speculum examination to inspect the vagina and the cervix.Assess for any vaginal discharge,inspect cervix for any ectropian,infection, cervical growths, polyps or ulcerations.I would also assess the cervix for any contact bleeding. b:Investigation include High vaginal swab,endocervical swab and chalmydia swab.a cervical smear can be taken at this point if due and colposcopy if moderate to severe dyskaryosis is repoted. Transvaginal USS to view intercavitary fibroids or polyps as they can cause IMB. Hysteroscopy and endometrial sampling can be considered if endometrial polyp or if the investigations are negative. c: Treatment includes reassurance if it is an ectropion.If it seriously hampers the patients quality of life than the following option can be considered which are Silver nitrate cautry to cervix if the lesion is small.An out patient cryocautry which can be performed without anesthesia.Diathermy cautry or laser ablation can be done local or general anaesthesia.Give written information in all of these procedure about avoiding intercourse and tampons for at least 2 weeks after the procedure may have brownish discharge for upto 2 weeks.If she has heavy bleeding,offensive discharge or recurrance of symtoms than see her GP. D:I would reassure her,check if she is taking her pill properly and advice on compliance if not or change to a patch/Mirena IUS,Implanon if compliance is poor.Advice her to stop smoking if she is a smoker.If she is on monophasic OCP consider changing it to Biphasic or change the progesterone component to 2nd /3rd generation progesterone(Levonorgesteral)
		Posted by Bobey B. Thu Aug 5, 2010 10:25 am
a) I would ask her about the menstrual history, LMP, cycle length and regularity, whether there are features suggestive of anovulatory bleeding .e.g. painless, irregular menstruation. Any associated postcital bleeding may suggest presence of cervical polyp or CIN. Presence of vaginal discharge may suggest infection. Bleeding after insertion of tampons may be due to cervical ectopy. Sexual history and if she had any sexually transmitted infections , or been investigated for this ?. History of contraception , present and past methods should be asked. Missing pills while taking COCP should be enquired. Drug history and taking any medications which might interfere with COCP ( e.g. antibiotics , enzyme inducers. ) must be asked. Factors affecting absorption of pill e.g. gastroenteritis or ileostomy should be enquired. Bowel symptoms like rectal bleeding and others like hypothyroidism should be asked. The effect on quality of life should be enquired. Abdominal examination should be done to detect the presence or absence of pelvic mass such as pregnancy or fibroid uterus. Vaginal examination ( Speculum and bimanual )should be done . Speculum examination should be done to detect obvious genital tract pathology like cervical ,endometrial polyp , cervicitis, cervical ectopy ( velvet-like appearance ). Bimanual examination should be done to rule out presence of pregnancy , fibroid uterus and also absence of cervical excitation and adenxal tenderness. b) Blood tests ( FBC , clotting studies , thyroid function tests ) if indicated from history. Pregnancy test should be considered. Cervical screen if indicated (PAP smear and/or colposcopy )may be indicated if there is postcoital bleeding to ensure that there is no pre-malignant changes. Infection screen should be performed by endocervical swab for Chlamydia , high vaginal swab for trichomonas or candida. Transvaginal ultrasound should ideally be done immediately postmenstrually ,as the endometrium at its thinnest and polyps and cystic areas tend to be more obvious. An endometrial thickness of 8 mm or less is significantly less likely to be associated with a malignant pathology. Hysteroscopy as out-patient procedure may be done allowing direct visualization of uterine cavity and tissue diagnosis if indicated. c) If cervical ectropion is identified , treatment options are : No treatment needed if it causes no symptoms. It may resolve if COCP stopped . If causes symptoms as vaginal discharge or postcoital bleeding ,thermal cautery ,diathermy , cryosurgery , laser or microwave therapy if treatment desired. d) She should be changed to an alternative contraceptive pill and try phased pill ( biphasic or tri-phasic preparations). Another suitable strategy is the change to a pill containing a higher dose of oestrogen ( 50 ug rather than 30 ug ) . Another option is to change to an alternative progestogen such as third generation progestogen containing desogestorel or gestodene. Change to Medroxyprogestogen acetate injection or levonorgestrel intrauterine system( Mireana).
		Posted by KWASI RICHARD A. Fri Aug 6, 2010 12:40 am
KRA A. I would take a detailed menstrual history, her last menstrual period, cycle length and menstrual loss, frequency and nature of the intermenstrual bleeding. Is there any vaginal discharge which may be suggestive of infection and enquire about the effect of the intermenstrual bleeding on her quality of lift (IMB). I would take a sexual history to assess her risks of sexually transmitted diseases. Any associated post-coital bleeding may be suggestive of a cervical lesion or malignancy. I would find out which type of combined pill she is taking because low dose pills are sometimes associated with IMB. I would take a smear history eliciting whether she is up to date with her smears and results of her last smear any previous treatments to the cervix to exclude the possibility of cervical pathology. General examination including body mass index and signs of anaemia such as pallor may be present if bleeding has been heavy. Abdominal examination may reveal a pelvic mass secondary to enlarged uterus probably fibroid. Speculum and vaginal examination for assessment of cervix for evidence of inflammation, polyps, ulceration and ectropion, vaginal discharge and presence of contact bleeding. B. High vaginal swab, endocervical swab and chlamydial swabs would be taken to screen for infection. Transvaginal ultrasound scan for endometrial polyps as a cause of IMB. Hysteroscopy with or without biopsy of ultrasound evidence of polyp or persistent symptoms and other investigations are negative. Cervical smear if smear is due. C. Reassurance and no treatment, which may not be acceptable to the patient, if it impacts on her quality of life. Chemical cautery with silver nitrate may be useful for small lesions. Cryotherapy using liquid nitrogen can be performed in outpatients clinic without anaesthesia and diathermy cautery would require local or general anaesthesia and laser oblation will also require local or general anaesthesia. D. Reassurance is still an option which may not be acceptable if significant impact on quality of life. Changing the combined pill to different formulation if she is on a low dose pill. Increasing to one of the high dose. Stopping pill and using a different form of contraception like condoms or the partner having a vasectomy if this is an acceptable option.
		Posted by KWASI RICHARD A. Fri Aug 6, 2010 12:43 am
KRA A. I would take a detailed menstrual history, her last menstrual period, cycle length and menstrual loss, frequency and nature of the intermenstrual bleeding. Is there any vaginal discharge which may be suggestive of infection and enquire about the effect of the intermenstrual bleeding on her quality of life (IMB). I would take a sexual history to assess her risks of sexually transmitted diseases. Any associated post-coital bleeding may be suggestive of a cervical lesion or malignancy. I would find out which type of combined pill she is taking because low dose pills are sometimes associated with IMB. I would take a smear history eliciting whether she is up to date with her smears and results of her last smear any previous treatments to the cervix to exclude the possibility of cervical pathology. General examination including body mass index and signs of anaemia such as pallor may be present if bleeding has been heavy. Abdominal examination may reveal a pelvic mass secondary to enlarged uterus probably fibroid. Speculum and vaginal examination for assessment of cervix for evidence of inflammation, polyps, ulceration and ectropion, vaginal discharge and presence of contact bleeding. B. High vaginal swab, endocervical swab and chlamydial swabs would be taken to screen for infection. Transvaginal ultrasound scan for endometrial polyps as a cause of IMB. Hysteroscopy with or without biopsy if no ultrasound evidence of polyp or persistent symptoms and other investigations are negative. Cervical smear if smear is due. C. Reassurance and no treatment, which may not be acceptable to the patient, if it impacts on her quality of life. Chemical cautery with silver nitrate may be useful for small lesions. Cryotherapy using liquid nitrogen can be performed in outpatients clinic without anaesthesia and diathermy cautery would require local or general anaesthesia and laser oblation will also require local or general anaesthesia. D. Reassurance is still an option which may not be acceptable if significant impact on quality of life. Changing the combined pill to different formulation if she is on a low dose pill. Increasing to one of the high dose. Stopping pill and using a different form of contraception like condoms or the partner having a vasectomy if this is an acceptable option.
		Posted by A H. Sat Aug 7, 2010 05:04 pm
AH a) I will take a menstrual history,noting her last menstrual period. Menorrhagia or dysmennorrhoea may be associated with a submucous endometrial polyp or fibroid. I will ask about the about the amount of blood lost,probably using pictoral representation, and its effect on her quality of life. I will also enquire about the timing of the bleed. Mid-cycle bleeding may suggest a hormonal cause..Assoiated post coital bleeding will be asked as this may indicate a cervical lesion. Associated pelvic pain may indicate pelvic inflammatory disease. A history of previous episodes and treatment will be noted. I will take a smear history and enquire about age of coitarche, number of sexual prtners as well as uce of barrier contraception for infection prophylaxis. i will ask about compliance with th oral contraceptive pill. I will examine the mucous membranes for pallor. I will measure pulse and blood pressure. the abdomen will be palpated for tenderness and any mass rising out of the pelvis. A speculum examination will be done lookig for discharge, contact bleeding,cervical ectropion, cervical polyps, prolapsed fibroid or an unhealthy cervix. A bimanual palpation will be done to assess uterine size, and for adnexal masses or tenderness. b) I will do a full blood count to estimate haemoglobin and platelet count. Endocervical swabs for chlamydia and high vaginal swab if there is any discharge. A smear will be taken if this is due.She will be referred for colposcopy if there is contact bleeding. An ultrasound will be requested and outpatient hysteroscopy and biopsy will be done if ultrasound suggests endometrial polyps. c)One option is to counsel and reassure. Ectropion may be due to the combined pill. Another opton is to stop the pill and use another reliable form of contrception for example the LNG-IUS. Cautery of the ectropion using silver nitrate, cryocautery oy electrodiathermy can be offered. She will be counselled and a decision for treatment taken with her input. d)If no cause is found, she can be counselled and reassured, or her pill can be changed to a tricyclic or another form of reliable contraception like Mirena.