Management of Postcoital Bleeding in Primary Care

Total Page：16

File Type：pdf, Size：1020Kb

Management of Postcoital Bleeding in Primary Care

Management of Postcoital Bleeding Underlying causes of post Click for more in Primary Care coital bleeding info Images of normal, benign and malignant cervical pathology RED FLAGS · Suspicious looking cervix Casey et al. Abnormal Cervical Appearance: What to Do, When to Worry?: Mayo Clin Proc. 2011 Feb; History and Examination · Suspicious vulval lesion 86(2): 147–151. https://www.ncbi.nlm.nih.gov/pmc/ Click for · Suspicious Vaginal mass articles/PMC3031439/ more · Post coital haemorrhage info TThhee BBrriittiisshh SSoocciieettyy ffoorr CCoollppoossccooppyy aanndd CCeerrvviiccaall Pathology: https://www.bsccp.org.uk Pathology: https://www.bsccp.org.uk Click for Investigations more info Refer urgently to specialist care on suspected cancer pathway Findings Ectropion Cervical Polyp Positive infection screen Normal cervix and · Can be removed in primary care · · The cause is hormonal Treat based on local sensitivities negative infection screen · May resolve spontaneously if the setting · Contact tracing COCP is stopped or following · Send for histology · Review in 12 weeks pregnancy · If unable to remove in primary · Refer to gynaecology clinic if · Review in 10-12 weeks care refer to gynae clinic persisting despite adequate Review after 6 weeks · If persistent refer to gynae clinic treatment If still bleeding refer to general gynaecology If unresolved - General Gynaecology clinic Back to Underlying causes of post coital bleeding: pathway · Infection · Cervical ectropion - especially in those women taking the combined oral contraceptive pill (COCP) · Cervical or endometrial polyps. · Vaginal cancer · Cervical cancer - usually apparent on speculum examination. · Trauma Post coital bleeding in post-menopausal women should be managed as post-menopausal bleeding. Back to History and Examination pathway The history should aim to determine with the cause is likely benign or malignant. This should include: · Duration, frequency and severity of symptoms · Current contraception · Any current other hormonal treatment (e.g. HRT) · Smear History: regular, irregular, including date and result of last smear · Details of any previous colposcopy, any treatments such as LLETZ/cold coagulation/laser · Sexual History (if appropriate) · Relevant past medical/surgical history (including haematological/ coagulation disorders) · Current regular medication Conduct a bimanual and speculum examination and note the findings (e.g. normal, ectropion, cervicitis, cervical polyp). Refer to online resource below for images of typical examination findings Back to Investigations: pathway Always exclude the possibility of pregnancy and STI as a cause of bleeding: · Pregnancy test · Infection screen – Chlamydia and Gonorrhoeae. Cervical smears should only be taken where a women is due or overdue for her regular screening.

Copy Link

Recommended publications

New Insights Into Human Female Reproductive Tract Development
UCSF UC San Francisco Previously Published Works Title New insights into human female reproductive tract development. Permalink https://escholarship.org/uc/item/7pm5800b Journal Differentiation; research in biological diversity, 97 ISSN 0301-4681 Authors Robboy, Stanley J Kurita, Takeshi Baskin, Laurence et al. Publication Date 2017-09-01 DOI 10.1016/j.diff.2017.08.002 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Differentiation 97 (2017) xxx–xxx Contents lists available at ScienceDirect Differentiation journal homepage: www.elsevier.com/locate/diff New insights into human female reproductive tract development MARK ⁎ Stanley J. Robboya, , Takeshi Kuritab, Laurence Baskinc, Gerald R. Cunhac a Department of Pathology, Duke University, Davison Building, Box 3712, Durham, NC 27710, United States b Department of Cancer Biology and Genetics, The Comprehensive Cancer Center, Ohio State University, 460 W. 12th Avenue, 812 Biomedical Research Tower, Columbus, OH 43210, United States c Department of Urology, University of California, 400 Parnassus Avenue, San Francisco, CA 94143, United States ARTICLE INFO ABSTRACT Keywords: We present a detailed review of the embryonic and fetal development of the human female reproductive tract Human Müllerian duct utilizing specimens from the 5th through the 22nd gestational week. Hematoxylin and eosin (H & E) as well as Urogenital sinus immunohistochemical stains were used to study the development of the human uterine tube, endometrium, Uterovaginal canal myometrium, uterine cervix and vagina. Our study revisits and updates the classical reports of Koff (1933) and Uterus Bulmer (1957) and presents new data on development of human vaginal epithelium. Koff proposed that the Cervix upper 4/5ths of the vagina is derived from Müllerian epithelium and the lower 1/5th derived from urogenital Vagina sinus epithelium, while Bulmer proposed that vaginal epithelium derives solely from urogenital sinus epithelium.
[Show full text]
Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. Leia Mitchell
Himmelfarb Health Sciences Library, The George Washington University Health Sciences Research Commons Obstetrics and Gynecology Faculty Publications Obstetrics and Gynecology 4-28-2017 Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. Leia Mitchell Michelle King Heather Brillhart George Washington University Andrew Goldstein Follow this and additional works at: https://hsrc.himmelfarb.gwu.edu/smhs_obgyn_facpubs Part of the Obstetrics and Gynecology Commons APA Citation Mitchell, L., King, M., Brillhart, H., & Goldstein, A. (2017). Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis.. Sexual Medicine, (). http://dx.doi.org/10.1016/j.esxm.2017.03.001 This Journal Article is brought to you for free and open access by the Obstetrics and Gynecology at Health Sciences Research Commons. It has been accepted for inclusion in Obstetrics and Gynecology Faculty Publications by an authorized administrator of Health Sciences Research Commons. For more information, please contact [email protected]. Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis Leia Mitchell, MSc,1 Michelle King, MSc,1,2 Heather Brillhart, MD,3 and Andrew Goldstein, MD1,3 ABSTRACT Desquamative inflammatory vaginitis is a poorly understood chronic vaginitis with an unknown etiology. Symptoms of desquamative inflammatory vaginitis include copious yellowish discharge, vulvovaginal discomfort, and dyspareunia. Cervical ectropion, the presence of glandular columnar cells on the ectocervix, has not been reported as a cause of desquamative inflammatory vaginitis. Although cervical ectropion can be a normal clinical finding, it has been reported to cause leukorrhea, metrorrhagia, dyspareunia, and vulvovaginal irritation. Patients with cervical ectropion and des- quamative inflammatory vaginitis are frequently misdiagnosed with candidiasis or bacterial vaginosis and repeatedly treated without resolution of symptoms.
[Show full text]
EDUCATION Clinical Challenge
EDUCATION Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality Assurance and Clinical challenge Continuing Professional Development Program and has been allocated 4 CPD points per issue. Answers to this clinical challenge will be published next month, and are available immediately following successful completion online at: www.racgp.org.au/clinicalchallenge. Jenni Parsons SINGLE COMPLETION ITEMS DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer. Case 1 – Donna Watson A. have no treatment until the results of the A. abdominal ultrasound Donna, 23 years of age, has been taking tests come back so that the appropriate B. transvaginal ultrasound the combined oral contraceptive pill antibiotic can be given C. a qualitative urine BHCG (COCP) for many years without problems. B. be treated with azithromycin 1 g stat, doxy- D. a quantitative serum BHCG Over the past 6 weeks she has had cycline 100 mg twice daily for 14 days and E. full blood examination and C reactive protein. intermittent vaginal bleeding on several metronidazole 400 mg twice daily for 14 days days per week despite no missed pills. She Question 6 also noted pain on intercourse during that C. be treated with amoxycillin 500 mg and met- You confirm that Sarah is pregnant. She is time and over the past 2 weeks has had ronidazole 400 mg three times daily haemodynamically stable.
[Show full text]
ASCCP Clinical Practice Statement Evaluation of the Cervix in Patients with Abnormal Vaginal Bleeding Published: February 7, 2017
ASCCP Clinical Practice Statement Evaluation of the Cervix in Patients with Abnormal Vaginal Bleeding Published: February 7, 2017 All women presenting with abnormal vaginal bleeding should receive evaluation of the cervix and vagina, which should include at minimum visual inspection (speculum exam) and palpation (bimanual exam). If cervical or vaginal lesions are noted, appropriate tissue sampling is recommended, which can include Pap testing in addition to biopsy with or without colposcopy. These recommendations concur with those of ACOG Practice Bulletin #128 and Committee Opinion #557.1,2 The purpose of this article is to remind clinicians that Pap testing, as a form of tissue sampling, can be an important part of the workup of abnormal bleeding, and can be performed even if the patient is not due for her next screening test if there is clinical concern for cancer. Due to confusion amongst clinicians that has come to our attention, we wish to highlight the distinction between recommendations for diagnosis of cervical abnormalities including cancer amongst women with abnormal bleeding and recommendations for screening for cervical cancer amongst asymptomatic women. Screening guidelines recommend Pap testing at 3 year intervals for women ages 21-29, and Pap and HPV co-testing at 5 year intervals between the ages of 30-65 (with continued Pap testing at 3 year intervals as an option). These evidence- based guidelines are designed to maximize the detection of pre-cancer and minimize colposcopies. In addition, clinical practice guidelines no longer support routine pelvic examinations for cancer screening in asymptomatic women as this has not been shown to prevent cancer deaths.3,4,5 Consequently, physicians now perform fewer pelvic exams.
[Show full text]
Pregnancy Complicated with a Giant Endocervical Polyp
Pregnancy complicated with a giant endocervical polyp Kirbas A, Biberoglu E, Timur H, Uygur D, Danisman N Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey Objective We report the case of a giant cervical polyp in a primigravid young women that was associated cervical funneling. Methods Case report. Results A 21 year old primigravid woman admitted to our clinic with suspicion of cervical incompetence at 22 weeks of gestation. She complained of light vaginal bleeding and a vaginal mass. She did not have any pain. Her past medical history was uneventful. A detailed abdominal 2D ultrasound scan was performed to verify the presence of the pregnancy and research for associated anomalies. The US scan showed a 22 week viable fetus. Additionally, there was funneling of the cervical canal and the cervical length was 22 mm (Figure 1). On vaginal examination, there was light bleeding and a large fragile mass protruding from the vagina (Figure 2). We detected that the mass originated from the anterior lip of the cervix and it was extending into the cervical canal (Figure 3). We performed simple polypectomy. The funneling of the cervical canal disappeared after the operation and cervical canal length was 31 mm. The final histopathological findings confirmed a benign giant cervical polyp. The pregnancy is progressing well with a normal cervical length and she is currently 34 weeks of gestation. There has been no recurrence. We have planned endometrial and cervical canal evaluation after delivery. Conclusion Cervical polyps less than 2cm are quite common in the female adult population.
[Show full text]
Womena Faqs: Do Menstrual Cups Affect Hymens/Virginity?
WOMENA FAQS: DO MENSTRUAL CUPS AFFECT HYMENS/VIRGINITY? WOMENA SUMMARY AND RECOMMENDATIONS1 Many people believe that - girls are born with a hymen in the form of a solid membrane covering the vaginal opening. - the hymen can be identified through physical or visual examination. - the hymen is always broken at first vaginal sexual intercourse, causing bleeding. - therefore, a lack of blood on the wedding night proves the bride is not a virgin. However, there is increasing evidence and awareness that none of these beliefs are correct. Usually there is no solid membrane covering the vagina. Instead, there is folded mucosal tissue inside the vagina. Some now call it a ‘hymenal ring/rim’ or ‘vaginal corona’. The appearance of the hymen/corona varies among individuals, and may change over time. Hormones make the corona more elastic in puberty. Daily activities (such as cycling, sports, inserting tampons or menstrual cups) may affect appearance. It is impossible to test whether a girl or woman is a virgin by inspecting her corona, either visually, or by inserting two fingers into the vagina (the ‘two-finger test’). The UN strongly recommends against these “virginity tests” as they are inaccurate, and harmful. Bleeding at first vaginal intercourse does not always happen. There are only few studies, but estimates range from around 30% to around 70%. Virginity before marriage is an important value in many religions and cultures. The definition of ‘virginity’ varies between communities and among religious leaders. Many agree that virginity is defined by first vaginal intercourse, not by bleeding. WoMena believes in providing best available evidence, so that women and girls, and their communities, can make informed choice.
[Show full text]
Table of Contents
Problem-Based Clinical Cases Obstetrics and Gynecology Rotation Gyn Cases Updated December 2004 OB Cases Updated June 2005 By Dr. Manisha Patel Table of Contents Section I: General Gynecology Page 4. Breast Disorders..................................................................................................................................... 1 5. Contraception ......................................................................................................................................... 2 7. Dysmenorrhea........................................................................................................................................ 3 8. Dyspareunia ........................................................................................................................................... 5 9. Ectopic Pregnancy.................................................................................................................................. 8 10. Enlarged Uterus...................................................................................................................................... 9 19. Menorrhagia ......................................................................................................................................... 10 23. Pelvic Relaxation .................................................................................................................................. 12 25. Postmenopausal Bleeding...................................................................................................................
[Show full text]
GP Education Series Women's Cancers
GP Education Series Women’s cancers GP Education Day 11 July 2016 The Royal Marsden Current topics in cervical cancers Dr Susan Lalondrelle Consultant Clinical Oncologist The Royal Marsden 3 The Royal Marsden GP study day 11.7.16_SL_cervixcacner Learning objectives – appreciate symptoms of cervical cancer and variations in presentation – Guidelines for referral – Understand the importance of HPV and the role for HPV testing – Appreciate the management choices in early and locally advanced cervix cancer – The GP role in survivorship The Royal Marsden Case study 5 The Royal Marsden GP study day 11.7.16_SL_cervixcacner A 74 year old woman presents with a 3 month history of vaginal discharge and back pain. She should be investigated with: A. Pelvic examination 46% B. TVUSS C. Cervical smear D. CT scan abdo / pelvis E. All of the above 21% 17% F. 1 and 3 G. hysteroscopy 8% 4% 4% 0% TVUSS 1 and 3 Cervical smear hysteroscopy All of the above Pelvic examination CT scan abdo / pelvis 6 The Royal Marsden GP study day 11.7.16_SL_cervixcacner Cervical cancer - presentation – Screening programme – inter-menstrual bleeding (IMB) – post-coital bleeding (PCB) – post-menopausal bleeding (PMB) – abnormal appearance of the cervix (suspicion of malignancy) – vaginal discharge (blood stained) – pelvic pain Although symptoms are associated with later stage cervical cancer up to 32% of women with early stage disease may have symptoms at presentation 7 The Royal Marsden GP study day 11.7.16_SL_cervixcacner Differential diagnosis – Chlamydia infection Friable
[Show full text]
Colposcopy of the Vulva, Perineum and Anal Canal
VESNA KESIC Colposcopy of the vulva, perineum and anal canal CHAPTER 14 Colposcopy of the vulva, perineum and anal canal VESNA KESIC INTRODUCTION of the female reproductive system. The vulva is responsive for Colposcopy of the vulva – vulvoscopy – is an important part the sex steroids. The alterations that are clinically recog- of gynaecological examination. However, it does not provide as nizable in the vulva throughout life and additional cyclic much information about the nature of vulvar lesions as col- changes, occurring during the reproductive period, are the poscopy of the cervix. This is due to the normal histology of this result of sequential variations of ovarian hormone secretion. area, which is covered by a keratinized, stratified squamous Significant changes happen during puberty, sexual inter- epithelium. The multifocal nature of vulvar intraepithelial dis- course, pregnancy, delivery, menopause and the postmeno- ease makes the examination more difficult. Nevertheless, col- pausal period, which alter the external appearance and func- poscopy should be performed in the examination of vulvar pa- tion of the vulva. Knowledge about this cyclical activity is im- thology because of its importance in identifying the individual portant in diagnosis and treatment of vulvar disorders. components of the lesions, both for biopsy and treatment pur- poses. Anatomically, the vulva, the term that designates exter- It should be remembered that the vestibule, as an endodermal nal female genital organs, consists of the mons pubis, the labia derivate, is less sensitive to sex hormones than adjacent struc- majora, the labia minora, the clitoris including frenulum and tures. This should be taken into consideration during the treat- prepuce, the vestibule (the vestibule, the introitus), glandular ment of certain vulvar conditions such as vestibulitis.
[Show full text]
Emergency Department Management of Vaginal Bleeding in the Nonpregnant Patient
August 2013 Emergency Department Volume 15, Number 8 Management Of Vaginal Author Joelle Borhart, MD Assistant Professor of Emergency Medicine, Georgetown Bleeding In The Nonpregnant University School of Medicine, Department of Emergency Medicine, Washington Hospital and Georgetown University Hospital, Washington, DC Patient Peer Reviewers Lauren M. Post, MD, FACEP Abstract Attending Physician, Department of Emergency Medicine, St. Luke’s Cornwall Hospital, Newburgh, NY and Overlook Medical Center, Summit NJ Abnormal uterine bleeding is the most common reason women Leslie V. Simon, DO, FACEP, FAAEM seek gynecologic care, and many of these women present to an Assistant Residency Director, Associate Professor of Emergency Medicine, University of Florida College of Medicine-Jacksonville, emergency department for evaluation. It is essential that emer- Jacksonville, FL gency clinicians have a thorough understanding of the underly- CME Objectives ing physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to Upon completion of this article, you should be able to: 1. Discuss common and serious causes of vaginal bleeding guide the management of nonpregnant patients with abnormal in prepubertal children, nonpregnant adolescents, and bleeding is limited, and recommendations are based mostly on women. expert opinion. This issue reviews common causes of abnormal 2. Describe the ED approach to both the unstable and stable nonpregnant patient with vaginal bleeding. bleeding, including anovulatory, ovulatory, and structural causes 3. Select the common treatments of acute abnormal vaginal in both stable and unstable patients. The approach to abnormal bleeding in nonpregnant patients. bleeding in the prepubertal girl is also discussed. Emergency 4. Discuss the disposition and follow-up needs of the clinicians are encouraged to initiate treatment to temporize an nonpregnant patient with vaginal bleeding.
[Show full text]
The Frequency of Pathology in Women Presenting with Postcoital Bleeding
ORIGINAL ARTICLE The Frequency of Pathology in Women Presenting with Postcoital Bleeding SAMINA ASGHAR* HURRIAT AFZAL**, AYESHA SHAUKAT**, REHANA AYUB* ABSTRACT Objective: The aim of this study is to detect the prevalence of carcinoma cervix amongst women presenting with postcoital bleeding. Design: A cross sectional study. Place and duration of study: Sir Ganga Ram Hospital, from 2006 to 2008; two year study. Patients and methods: We reviewed 283 women with abnormal uterine bleeding out of which 92 women also complained of postcoital bleeding. Their cervical smear, colposcopy and directed biopsy were done .The histopathology records were reviewed. The aim was to detect the frequency of cervical cancer in these patients. Results: 92 patients presented with postcoital bleeding.40 patients out of 92 (43.47%) had normal findings on cervical smear. 15.2% of patients had CIN out of which 11.95% had high grade CIN( CIN II or III). 30.43% of women had inflammatory smear. Cervical polyps were found in 5.43% of patients. Invasive cancer cervix was found in 5.43% of patients. Key words: PCB (postcoital bleeding), cervical cancer, cervical smear, colposcopy, Cervical biopsy. INTRODUCTION Staging of cervical carcinoma PCB is defined as bleeding occurring during or Stage Features immediately after sex independent from O Preinvasive disease menstruation. It can be a symptom in women I Carcinoma confined to cervix (extension to experiencing abnormal uterine bleeding. PCB has corpus should be disregarded) many causes, the most serious of which is cervical Ia Invasive cancer identified only microscopically. cancer2. The main aim of investigating women with All gross lesions are stage Ib cancers.
[Show full text]
· Commonly Used Appendlx Abbreviations in Gyn(Ccology
· Commonly used AppendlX abbreviations in A gyn(Ccology AID Artificial insemination using donor semen. As opposed to AIH which is artificial insemination using husband's or partner's semen. The latter is usually specially prepared and injected high into the uterine cavity (HIUI or high intrauterine insemination). AIS Adenocarcinoma-in-situ. A glandular preinvasive condi tion of the cervix, less common than its squamous coun terpart, CIN (vide below). BSO Bilateral salpingo-oophorectomy. A surgical procedure removing both ovaries and fallopian tubes. BTB Breakthrough bleeding. A term usually applied to the bleeding occasionally noticed by some women using combined oral contraception. The bleeding occurs while the pill is being taken and not in the pill-free week. Bleeding in the pill-free week is normal and is termed withdrawal bleeding. CIN Cervical intra-epithelial neoplasia. A premalignant con dition of the cervix. COC Combined oral contraceptive. This refers to steroid oral contraceptives containing an oestrogen, usually ethinyl oestradiol and a progestogen. POP refers to progesterone only pills. The term OCP means oral contraceptive pills and is a generic term for both combined and progesterone only preparations. D&C Dilatation and curettage. An operative procedure, usually performed under a general anaesthetic. The cervix is ApPENDIX A 281 .................................................................................................................. gradually dilated using a graduated set of dilators to a level where a curette can be introduced into the uterine cavity. This is then used to scrape endometrial or other tissue from the endometrium for histological analysis. The procedure is diagnostic. It is not a treatment for menstrual dysfunction. DUB Dysfunctional uterine bleeding. Excessive (>80 ml) or er ratic menstruation where no recognizable pathology can be found .
[Show full text]