1. Abnormal Vaginal Bleeding in a 56 year old Max Brinsmead PhD FRANZCOG May 2015

2. Mrs. JP Age 56 Para 1 Complains of a period that has been “going on for 2 weeks” with pain WHAT ARE THE POSSIBLE CAUSES?

3. Mrs. JP Differential Diagnosis Endometrial Pathology Carcinoma Benign eg Polyp Cervical Pathology Other genital tract pathology Ovarian Ca Trauma Dysfunctional Uterine Bleeding Blood dyscrasia

4. Mrs. JP Age 56 Para 1 Complains of a period that has been “going on for 2 weeks” with pain WHAT ADDITIONAL INFORMATION DO YOU REQUIRE?

5. Mrs. JP Additional History Required Usual menstrual pattern Recent menstrual cycles and LNMP Estimate of blood loss Description of the pain Use of hormones - COC or HRT Pap & Gynae History Risk factors for endometrial Ca Sexual, contraception & social history

6. Mrs. JP Additional History Usual cycle Recent cycles & LNMP Estimate of blood loss Description of the pain Use of hormones - COC or HRT Pap & Gynae History Risk factors for endometrial Ca Sexual history etc. Monthly until 6m ago Some early and some late. Skipped one month. This period 3w late Has used 3 packets pads, some 3’’ clots. “Flooding” “Like labour” Nil Regular Paps – NAD. One CS and postpartum curette. Took pill for 10 yrs then separated Infertility. Hypertension. Obese Celibate since separation

7. Mrs. JP Age 56 Para 1 Complains of a period that has been “going on for 2 weeks” with pain DO YOU EXAMINE THIS PATIENT? WHAT DO YOU LOOK FOR?

8. Mrs. JP Physical Exam Required Signs of anaemia Signs of endocrinopathy Thyroid Androgen excess Examine the cervix ?Pap or ThinPrep Look for cervical mucous Is the cervix open? Uterine size and regularity Pelvic tenderness or adnexal mass?

9. Mrs. JP Physical Exam Signs of anaemia Signs of endocrinopathy Thyroid Androgen excess Examine the cervix ?Pap or ThinPrep Look for cervical mucous Is the cervix open? Uterine size and regularity Pelvic tenderness or adnexal mass? Pale. PR 96/min Male type hair distribution Intact but patulous with abundant clear mucous NAD

10. Mrs. JP Age 56 Para 1 Complains of a period that has been “going on for 2 weeks” with pain DO YOU SEND THIS PATIENT FOR SCAN?

11. Mrs. JP Scan Report “Thank you for referring this patient with menorrhagia. Abdominal and transvaginal scans were performed. The uterus is enlarged by multiple fibroids the largest of which measures 2.5 cm in diameter. However, there is no distortion of the endometrial cavity which measures 17 mm. This is at the upper limit of normal and reevaluation at another stage of the menstrual cycle may be desirable. The right ovary is mildly enlarged with a volume of 40 cc and the left ovary contains a cyst measuring 2.8 x 2.7 cm. This was evaluated with colour Doppler and no abnormal vascularity noted.”

12. Mrs. JP Age 56 Para 1 Complains of a period that has been “going on for 2 weeks” with pain DO YOU SEND THIS PATIENT FOR BLOOD TESTS? WHAT TESTS WOULD YOU ORDER?

13. Mrs. JP Pathology Results HB 90 Microcytic and hypochromic film S. Ferritin – 5 Pap smear + ThinPrep NAD “but only scanty squamous cells are present TSH - normal

14. Mrs. JP Age 56 Para 1 Complains of a period that has been “going on for 2 weeks” with pain DO YOU PRESCRIBE FOR THIS PATIENT? WHAT WOULD YOU Rx?

15. Mrs. JP Treatment Complains of a period that has been “going on for 2 weeks” with pain Rx Tabs Primolut 5 mg TDS for 10 days Ferro-gradumet – one daily Maybe Nurofen 1-2 Q4-6H

16. Mrs. JP Age 56 Para 1 DOES THIS PATIENT REQUIRE? Abdominal CT scan? Immediate D&C? Hysteroscopy? Saline sonography? Endometrial biopsy? Hysterectomy?

17. Mrs. JP Next Steps Abdominal CT scan? Immediate D&C? Hysteroscopy? Saline sonography? Endometrial biopsy? Hysterectomy? No There are better options This is one that can be performed as an outpatient Maybe – but best for delineating polyps Pipelle endometrial sampling is the best option Only required if cancer of the endometrium is diagnosed