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OSCE question 7. |
Marks |
A
52 year old patient presents with a complaint of post-menopausal bleeding.
1. What is the definition of post-menopausal bleeding?
| Genital tract bleeding occurring after 12 months after the menopause. |
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2. What issues will you particularly cover in taking the history? List 4.
| When did the bleeding start?
How often has it occurred? How long has it lasted? Have there been any
associated symptoms e.g. discharge? Has there been any obvious explanation
e.g. trauma or using a ring pessary for prolapse control? Is she taking
any drugs that might cause bleeding e.g. HRT & anticoagulants? Is
there any factor that might increase the risk of malignancy e.g. taking
Tamoxifen, previous genital tract cancer or pre-cancer, family history of
genital tract cancer? |
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3. What will you look for on pelvic examination? List 3 things.
| Benign or malignant
conditions causing the bleeding. Vulval ulceration. Atrophic vaginal
changes. Vaginal ulceration. Foreign body in the vagina: pessary, inserted
object. Cervical polyps, “erosions” or possible malignancy. Pelvic
masses - ? ovarian tumour. Vaginal infection, e.g. trichomonal or candidal,
is mentioned in some books, but I must say that it rarely, if ever, occurs
in my experience. Up to 15% of ovarian cancer presents with postmenopausal
bleeding, so the ovaries must never be overlooked. |
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4. What further investigations might be appropriate? List 3.
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Cervical
smear. This will help exclude cervical cancer, though if the cervix looks
at all odd, colposcopy and biopsy are indicated. Occasionally atypical
glandular cells are found arising from the endocervix, endometrium, ovary
or even the tube, though the latter two are rare. Ultrasound, usually
transvaginal, to measure endometrial thickness and exclude pelvic tumours.
If the endometrium is < 4mm., the risk of hyperplasia or malignancy is
small. (Lots of patients present with a single scanty bleed. The
associated risk of malignancy is tiny. If the scan shows the endometrium
to be thin, I usually give them the option of no further investigation
unless the bleeding recurs. They all take it!) The scan may also suggest
benign endometrial pathology such as submucous fibroids or polyps that
could explain the bleeding. |
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5. If clinical examination is normal, what advice will you give her about possible serious pathology?
| The College quotes a 9% risk
of malignancy associated with postmenopausal bleeding. I think this is on
the high side, but you can still reassure the patient that the risk of
serious disease is <10%. In addition, most of the serious conditions,
such as endometrial hyperplasia and cancer are treatable though you cannot
offer guarantees of cure. |
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