Intermenstrual, Breakthrough, and Post-coital Bleeding

Question 1

What is intermenstrual bleeding (IMB)?

Answer 1

Vaginal bleeding at any time during the menstrual cycle other than during normal menstruation

Question 2

What can IMB be difficult to distinguish from sometimes?

Answer 2

Metrorrhagia

Question 3

What is metrorrhagia?

Answer 3

Irregularly frequent periods

Question 4

What is post-coital bleeding (PCB)?

Answer 4

Non-menstrual bleeding that occurs immediately after sexual intercourse

Question 5

What is breakthrough bleeding?

Answer 5

Irregular bleeding associated with hormonal contraception

Question 6

What are IMB and PCB classified as?

Answer 6

Symptoms

Question 7

What is the result of IMB and PCB being symptoms?

Answer 7

They require further investigation

Question 8

What is the biggest differentiator of causes of abnormal bleeding?

Answer 8

Age

Question 9

What is an uncommon cause of PV bleeding in young women?

Answer 9

Malignancy

Question 10

What happens to the likelihood of uterine polyps and fibroids with age?

Answer 10

Increases

Question 11

What are the possible causes of PCB?

Answer 11

• Infection
• Cervical ectropion
• Cervical or endometrial polyps
• Vaginal cancer
• Cervical cancer
• Trauma or sexual abuse
• Vaginal atrophic change

Question 12

What % of women with PCB have no specific cause found?

Answer 12

50%

Question 13

What are the possible causes of intermenstrual bleeding?

Answer 13

• Pregnancy related
• Physiological
• Vaginal causes
• Cervical causes
• Uterine causes
• Iatrogenic causes

Question 14

What pregnancy related causes can lead to IMB?

Answer 14

• Ectopic pregnancy

- Gestational trophoblastic disease

Question 15

What can be a physiological cause of IMB?

Answer 15

Spotting during ovulation

Question 16

What % of women have spotting during ovulation?

Answer 16

1-2%

Question 17

What are the vaginal causes of IMB?

Answer 17

• Adenosis
• Vaginitis
• Tumours

Question 18

What are the cervical causes of IMB?

Answer 18

• Infection
• Cancer
• Cervical polyps
• Cervical ectropion

Question 19

What infections of the cervix can cause IMB?

Answer 19

• Chlamydia

- Gonorrhoea

Question 20

What are the uterine causes of IMB?

Answer 20

• Fibroids
• Endometrial polyps
• Cancer
• Adenomyosis
• Endometriosis

Question 21

What are the iatrogenic causes of IMB?

Answer 21

• Tamoxifen
• Following smear or cervix treatment
• Missed OCP
• Drugs altering clotting

Question 22

What drugs that alter clotting can cause IMB?

Answer 22

• Anti-coagulants
• SSRIs
• Corticoteroids

Question 23

When is breakthrough bleeding most common?

Answer 23

When a new contraceptive is started, and often settles without intervention

Question 24

What type of hormonal contraceptives are more likely to cause bleeding problems?

Answer 24

Progesterone only

Question 25

What should be asked about when taking a history for abnormal pre-menopausal vaginal bleeding?

Answer 25

- Menstrual history - Obstetric history - Gynaecological history - Sexual history - Medical history - Current medication

Question 26

What should be examined when assess abnormal pre-menopausal vaginal bleeding?

Answer 26

- BMI - Abdomen - Speculum - Bimanual

Question 27

What can be looked for on abdominal examination when a patient presents with abnormal pre-menopausal vaginal bleeding?

Answer 27

Presence of any pelvic masses

Question 28

What should be looked for on vaginal examination in a woman with abnormal pre-menopausal vaginal bleeding?

Answer 28

Any obvious genital tract pathology

Question 29

What are some common findings on vaginal examination in abnormal pre-menopausal vaginal bleeding?

Answer 29

- Cervical ectropion - Cervical polyp - Cervicitis

Question 30

What investigations can be made into women with abnormal pre-menopausal vaginal bleeding?

Answer 30

- Pregnancy test - Infection screen - Blood tests - Transvaginal USS - Endometrial bopisy

Question 31

What blood tests can help identify a cause of abnormal pre-menopausal vaginal bleeding?

Answer 31

- FBC - Clotting - TFTs - FSH/LH

Question 32

What can a transvaginal USS look for in a woman with abnormal vaginal bleeding?

Answer 32

Structural abnormalities

Question 33

What does management of abnormal pre-menopausal vaginal bleeding depend on?

Answer 33

The type and cause of the bleeding

Question 34

What is the first management step if cancer is the suspected cause of abnormal pre-menopausal vaginal bleeding?

Answer 34

Urgent referral for further investigation

Question 35

What are the management steps if infection is the suspected cause of abnormal pre-menopausal vaginal bleeding?

Answer 35

Antibiotics (if appropriate) and contact tracing

Question 36

What is the management if hormonal contraception is considered to be the cause of abnormal pre-menopausal vaginal bleeding?

Answer 36

Advise that it is normal in the first 3 months but can swap if persistent

Question 37

How can cervical ectropion be treated?

Answer 37

- Conservatively | - Cauterisation

Question 38

How is cervical ectropion cauterised?

Answer 38

With silver nitrate

Question 39

How should cervical polyps be managed?

Answer 39

Evulsed and sent for histology

Question 40

How can fibroids be managed?

Answer 40

- Hysteroscopic removal for small fibroids - Uterine artery embolisation - Medical management with oestrogen reducing drugs