intermenstrual bleeding
Doctor Information
Claire Jefferies, age 19
PMH:
Tonsillectomy 2008
Current Medication:
Microgynon 30
No known allergies
PMH:
Tonsillectomy 2008
Current Medication:
Microgynon 30
No known allergies
Patient Information
Claire Jefferies, age 19
Opening line: I’d like to change my pill
History: You have been on microgynon for 2 years and at first it was great - you had a really light period in the pill free week. But in the last couple of months, it hasn't worked very well, you get spotting of blood at random times, outside of the pill free week. No urinary or bowel symptoms, no abdominal pain or sickness. No fever.
If asked only: You have a boyfriend, Adam, and have been going out for 12 months. You have had one other boyfriend in the past but didn't have sex with him. You don't use condoms with Adam because he says the sensation is less, and you don't bleed after sex. You have not been unfaithful to Adam, and have no reason to believe he has been unfaithful to you. You have noticed slightly more discharge from down below but haven’t really payed much attention to it. You have no itching, no urinary and no bowel symptoms. A few times you have had a really deep pain on sex, and once it lasted for a few hours afterwards too. You have not had any other sexual partner in the last 6 months.
You thought you could be pregnant but you've done a test and it's negative.
Past History
Apart from your tonsils out when you were 12, nothing else
Medication:
Microgynon
Social History
You are a student at Liverpool University, doing Business Studies
You live with three other girls, and Adam lives two streets away.
You have smoked occasionally but nothing regular, and you drink on nights out - a bottle of wine or a few cocktails once a week.
No allergies
Ideas: Your pill isn't working anymore
Concerns: You were worried that you could be pregnant but you did a test and it was negative
Expectation: You need a stronger pill, you've heard of dianette, and that sounds like a good option to you.
If a sexually transmitted infection is mentioned, start to get defensive, because you nor your boyfriend have been unfaithful. You will relax and cooperate if the doctor is nice and sympathetic towards you, or says that infection could always have been from previous partners.
Opening line: I’d like to change my pill
History: You have been on microgynon for 2 years and at first it was great - you had a really light period in the pill free week. But in the last couple of months, it hasn't worked very well, you get spotting of blood at random times, outside of the pill free week. No urinary or bowel symptoms, no abdominal pain or sickness. No fever.
If asked only: You have a boyfriend, Adam, and have been going out for 12 months. You have had one other boyfriend in the past but didn't have sex with him. You don't use condoms with Adam because he says the sensation is less, and you don't bleed after sex. You have not been unfaithful to Adam, and have no reason to believe he has been unfaithful to you. You have noticed slightly more discharge from down below but haven’t really payed much attention to it. You have no itching, no urinary and no bowel symptoms. A few times you have had a really deep pain on sex, and once it lasted for a few hours afterwards too. You have not had any other sexual partner in the last 6 months.
You thought you could be pregnant but you've done a test and it's negative.
Past History
Apart from your tonsils out when you were 12, nothing else
Medication:
Microgynon
Social History
You are a student at Liverpool University, doing Business Studies
You live with three other girls, and Adam lives two streets away.
You have smoked occasionally but nothing regular, and you drink on nights out - a bottle of wine or a few cocktails once a week.
No allergies
Ideas: Your pill isn't working anymore
Concerns: You were worried that you could be pregnant but you did a test and it was negative
Expectation: You need a stronger pill, you've heard of dianette, and that sounds like a good option to you.
If a sexually transmitted infection is mentioned, start to get defensive, because you nor your boyfriend have been unfaithful. You will relax and cooperate if the doctor is nice and sympathetic towards you, or says that infection could always have been from previous partners.
Examination Findings
Pulse 98
Blood pressure 117/67
Temperature 36.9 degrees
Abdomen soft and non tender
Pelvic Examination - normal external genitalia, anteverted uterus, healthy looking cervix, no adnexal tenderness, no cervical excitation. Discharge in the the posterior fornix.
Urine dipstick NAD
Blood pressure 117/67
Temperature 36.9 degrees
Abdomen soft and non tender
Pelvic Examination - normal external genitalia, anteverted uterus, healthy looking cervix, no adnexal tenderness, no cervical excitation. Discharge in the the posterior fornix.
Urine dipstick NAD
Mark scheme
Data Gathering
|
Positive Indicators
Systematic approach to the history Takes a through sexual history Offers to examine patient and take swabs for infection |
Negative Indicators
Non-systematic approach to history Fails to take, or takes incomplete sexual history Does not examine patient or take swabs (unless offers full sexual health screen at GUM clinic same day) |
Clinical Management Skills
|
Positive indicators
Identifies intermenstrual bleeding as opposed to irregular cycles Explains diagnosis avoiding jargon Discusses and shares management options, makes reasonable management plan |
Negative indicators
Fails to diagnose intermenstrual bleeding Fails to explain diagnosis, or uses jargon Makes assumptions or decisions about management without involving patient |
Inter Personal Skills
|
Positive indictors
Offers chaperone Open and non judgemental approach to sexual history Builds up good rapport Explores ICE and health understanding |
Negative indicators
Fails to offer chaperone Judgemental or awkward taking sexual history Poor rapport Fails to establish ICE or explore health understanding |
Management
Both intermenstrual and postcoital bleeding require further investigation.
Possible Causes:
Cervical ectropion
Pelvic infection
Cervical/endometrial polyps
Cervical/vaginal cancers
Trauma Vaginitis
Ectopic pregnancy
Ovulation spotting
In a woman who has just started hormone-based contraception, breakthrough bleeding is common and usually settles within a few weeks. Remember you are more likely to get breakthrough bleeding with progesterone only methods, but even so, you should still check for pregnancy and infection.
History: LMP, usual cycle length and any associated symptoms (abdominal pain/vaginal discharge/fever). Pregnancy history and any contraception used, as well as smear reports, and don't forge to take a full sexual history as well.
Examination: check the bleeding is vaginal and not urethral or rectal. Perform basic observations (temperature/pulse) as well as abdominal and pelvic examination including high vaginal and endocervical swabs. Note contact bleeding, cervical excitation and adnexal tenderness. Cervical ectropion looks like a red ring around the cervix.
Always do a pregnancy test and a urine dipstick analysis.
A transvaginal ultrasound is useful to look for pelvic structural abnormalities, but usually better to wait for swab results first.
Possible Causes:
Cervical ectropion
Pelvic infection
Cervical/endometrial polyps
Cervical/vaginal cancers
Trauma Vaginitis
Ectopic pregnancy
Ovulation spotting
In a woman who has just started hormone-based contraception, breakthrough bleeding is common and usually settles within a few weeks. Remember you are more likely to get breakthrough bleeding with progesterone only methods, but even so, you should still check for pregnancy and infection.
History: LMP, usual cycle length and any associated symptoms (abdominal pain/vaginal discharge/fever). Pregnancy history and any contraception used, as well as smear reports, and don't forge to take a full sexual history as well.
Examination: check the bleeding is vaginal and not urethral or rectal. Perform basic observations (temperature/pulse) as well as abdominal and pelvic examination including high vaginal and endocervical swabs. Note contact bleeding, cervical excitation and adnexal tenderness. Cervical ectropion looks like a red ring around the cervix.
Always do a pregnancy test and a urine dipstick analysis.
A transvaginal ultrasound is useful to look for pelvic structural abnormalities, but usually better to wait for swab results first.
