Post Coital Bleeding

Transcription

1 Gillian Baird, University f Dundee, 5 th Year Medical Student Pst Cital Bleeding What is Pst Cital Bleeding Pst Cital Bleeding (PCB) is defined as nnmenstrual bleeding, which ccurs immediately after sexual intercurse. 1 Epidemilgy Within General Practice apprximately 6% f patients will present with pst cital bleeding. PCB ccurs in 0.739% f wmen with cervical cancer. 2 The incidence f finding a wman in the cmmunity presenting with PCB wh has cervical cancer is 1 in 44,00 f 2024 year lds and 1 in 2,400 f year lds. 2 What are the main causes f Pst Cital Bleeding 1,2,3,4,5

2 Gillian Baird, University f Dundee, 5 th Year Medical Student Cervical Carcinm a Plyps Ectrpin /Ersin Cervicitis (due t infectin) Trauma Endmetr isis Vaginal Vaginitis Atrphic Infective Carinma (rare) Endmetrial Plyps Carcinm a

3 Gillian Baird, University f Dundee, 5 th Year Medical Student Imprtant questins t ask in the histry Presenting Cmplaint Pst Cital Bleeding Histry f Presenting Cmplaint Hw lng has it been ging n fr? When did the bleeding start? Hw heavy is the bleeding? Any pain assciated with the bleeding? (abdminal pain, dyspareunia [superficial r deep]) Any urinary symptms? Has this happened befre? Gynaeclgical Histry Menstrual Last menstrual perid (LMP) when was it Length and duratin f nrmal cycle Age f menarche/menpause Any menrrhagia and/r dysmenrrhea Sexual Currently sexually active? Frequency Libid Regular partner r multiple partners? Use f cntraceptin? If yes what kind and is it always used? Any vaginal discharge? If yes clur/dur/character, vulval irritatin Previus histry f sexually transmitted infectins Cervical Smear histry

4 Gillian Baird, University f Dundee, 5 th Year Medical Student Date f last smear? Any previus abnrmal smear result Any previus treatment fr abnrmal result Any previus gynaeclgical histry Any previus gynaeclgical surgery Obstetric Histry Parity Chrnlgical rder: year, gestatin, mde f delivery (SVD,caesarean) Any prblems antenatal/intrapartum/pstnatal Systemic Enquiry Past Medical and Surgical Histry Drug Histry Use f ral cntraceptin pill (OCP) Family Histry Scial Histry Smking quantity per day Alchl units per week Occupatin Investigatins ALWAYS exclude the pssibility f the patient being pregnant. If this is psitive then the patient requires urgent referral t early pregnancy clinic fr an ultrasund +/ serial serum βhcg. This will help t exclude an ectpic pregnancy. 1,4,5 Screening fr STIs This can be perfrmed by a selfbtained lw vaginal swab. This swab will allw fr yu the patient t be tested fr Chlamydia and Gnrrhea. 1,4,5 Cervical Smear A speculum examinatin will allw fr yu t have a lk at the vaginal wall fr any evidence f vaginitis, an abnrmal cervix, an ectrpin r any bvius mass. A smear is nt rutinely perfrmed

5 Gillian Baird, University f Dundee, 5 th Year Medical Student unless the patient is due fr a smear. A negative smear, with persistent pst cital bleeding shuld be referred. 5,6,7,8 Bimanual examinatin Feeling fr a palpable mass cnsistent with a plyp r carcinma, r cervical excitatin/tenderness, which wuld indicate pelvic inflammatry disease. 1 Blds may nt be rutinely perfrmed but yu can perfrm FBCs (lking fr infectin and anaemia), Cltting, Thyrid functin and FSH/LH levels (if yu suspect the nset f menpause). 1 Management KEY POINTS fr urgent referral: 8,9,10,11 >35 years with persistent PCB fr mre than 4 weeks require URGENT referral t be seen within 2 weeks Any features suggestive f cervical cancer must be referred urgently A patient with persistent intermenstrual bleeding with a negative pelvic exam shuld be referred urgently Unexplained vulval lump Vulval bleeding due t ulceratin POST MENOPAUSAL BLEEDING IS ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE! Management f certain causes f Pst Cital Bleeding CERVICAL Cervical Carcinma Cervical Plyps: treatment is remval, which can be dne in the GP surgery r gynaeclgy clinic simply by twisting the plyp. This can nly be dne if the patient has a small cervical plyp. Larger mre persistent plyps shuld be remved by the Gynaeclgist. 4,12 Cervical Ectrpin/Ersin These are cmmnly seen in teenagers and patients taking the OCP. Treatment can be with crycautery. 4 Cervicitis Treatment shuld be tailred twards the results f the swab taken.

6 Gillian Baird, University f Dundee, 5 th Year Medical Student Chlamydia (1g Azithrmycin as a single dse r 100mg dxycycline twice daily fr seven days) 13 Gnrrhea (500mg ceftriaxne 500mg IM stat plus azithrmycin 1g rally) 14 Bacterial vaginsis (Metrnidazle 400mg BD fr 7 days) VAGINAL Atrphic vaginitis 1 This is ften due t lw levels f estrgen resulting in thinning f the vaginal wall and decreased lubricatin. There are multiple management ptins fr this including: Encuraging the patient t use a watersluble lubricant during intercurse Vaginal misturising cream Avidance f scented saps, ltins and perfuse Tpical estrgen fr the vaginal wall Be aware that this can cause psychsexual prblems in the patients relatinship. Infective vaginitis 1,4 Management is against the rganism. The cmmn causes f infective vaginitis include: Candida Albicans (thrush) Tpical cltrimazle 500mg pessary plus vulval cream r 150mg ral Flucnazle nce nly dse. Bacterial Vaginsis Metrnidazle 2g rally nce nly dse Trichmniasis Vaginalis Metrnidazle 2g rally nce nly dse ENDOMETRIUM Endmetrial Plyps 4 These will require referral t the gynaeclgist fr surgical remval during a hysterscpy r with curettage. Endmetrial Carcinma Management is dependent upn staging and surgical excisin is the main stay management. 1

7 Gillian Baird, University f Dundee, 5 th Year Medical Student References 1. Pstcital bleeding, accessed 20/02/13 2. Shapley M, Jrdan J, Crft Pr, A systematic review f pstcital bleeding and risk f cervical cancer, Br J Gen Practice, 2006; 56(527): Red Flag symptms Pstcital bleeding, Pstcitalbleeding/, accessed 20/02/13 4. Cllier J, Lngmre M, Turmezei T, Mafi A, Oxfrd Handbk f Clinical Specialties, Eighth Editin, Oxfrd University Press, SelOjeme D, FreemanWang T, Khan NH, Pstcital bleeding: a rare and unusual presentatin f cervical endmetrisis, Arch Gynecl Obstet, 2006, 273(6): Seval MM, Cavkaytar S, Atak Z, Guresci S, Pstcital bleeding due t cervical endmetrisis, BMJ Case Rep, 2013;2013.pii:bcr Persistent pstcital bleedingquery bank, 20/02/13 8. Tze Ann See Alexandriia, Havenga S, Outcmes f wmen with pstcital bleeding, Internatinal Jurnal f Gynaeclgy and Obstetrics 120,2013, Natinal Institute f Clinical Excellence, Guidelines fr Suspected Cancer, NHS Cancer Screening Prgramme. Clpscpy and Prgramme Management, Secnd Editin, Scttish Executive, Scttish Referral Guidelines fr Suspected Cancer, Stamatells I, Stamatpuls P, Bntis J, The rle f hysterscpy in the current management f the cervical plyps. Arch Gynaecl Obstet, 2007, 276(4):299303

8 Gillian Baird, University f Dundee, 5 th Year Medical Student 13. Scttish Intercllegiate Guidelines Netwrk, Management f genital Chlamydia Trachmatis Infectin, Guidelines N 109, British Assciatin fr Sexual Health and HIV, UK Natinal Guideline fr the Management f Gnrrhea in Adults, 2011