Case 4: Vaginal bleeding

Opening scenario

Elaine Hill, a 50-year-old female; , comes to the physician because of vaginal bleeding.

Vital signs

• Temperature: 98.7°F (37°C)
• Blood pressure: 118/79 mm Hg
• Heart rate: 85/min
• Respirations: 17/min
• BMI: 32 kg/m²

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You are distrustful of medicine and doctors, and you treat the examinee with some suspicion.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “My doctor told me I had finally gone through menopause. Does this mean that is not the case?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I got my period again last week, but I thought I already went through menopause.
• Onset
• 5 days ago.
• Constant/intermittent
• It started out with some spots in my underwear. It has been as heavy as a normal period the past 2 days, though.
  • Exact amount of bleeding for last 2 days
  • I had to use 3 pads per day.
• Precipitating events
• None.
• Progression
• Like I told you. Spotting until 2 days ago. Now it is like a period.
• Previous episodes
• None.
• Frequency
• This is the first time I have had this in 2 years.
• Alleviating factors
• No.
• Aggravating factors
• No.
• Associated symptoms
• I have been feeling fine otherwise.

Review of systems specific to vaginal bleeding in a postmenopausal woman

• Trauma (to the pelvis)
• No, nothing like that.
• Swelling of the ankles
• No.
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• Not really.
• Urinary problems
• No.
• Bowel problems
• No.
  • Abdominal pain
  • No.
• Appetite
• Normal.
• Weight changes
• No. I am still on the heavier end of the scale.

Past medical history, family history, and social history

• Past medical history
• I was diagnosed with diabetes; 5 years ago and with hypertension 2 years ago.
• Allergies
• No.
• Medications
• Metformin, metoprolol.
• Hospitalizations
• Just to have my kids.
• Past surgical history
• None.
• Family history
• My dad has heart disease.
• Work
• I sell cosmetics from home.
• Home
• My kids are gone and I live alone, except for when I have someone over.
• Alcohol
• When I go out on the weekends, I have a drink or two.
• Recreational drugs
• No.
• Tobacco
• I have smoked a pack a day since I was 15 years old.

Sexual history, OB/Gyn

• Sexually active
• Yes.
• With whom
• Guys I meet at bars or online.
• Number of partners over the past year
• I have had about 10 different partners this year.
• Protection
• Sometimes I do not bother. I have gone through menopause anyway.
  • Sexually transmitted infection(s) in the past
  • I had chlamydia about 7 years ago and was given some antibiotics for it.
  • HPV infection
  • No; , I do not have an infection, but I was also never tested.
• Last menstrual period
• 2 years ago.
  • Age menopause started
  • 45.
  • Any symptoms of menopause now
  • No, that is all over, thank goodness.
• Menarche
• I was 9 years old.
• Vaginal discharge
• No, it is about the same as always, except for the blood.
• Vaginal itching
• No.
• Vaginal dryness
• No.
• Pregnancies
• I have 4 kids.
• Abortions/miscarriages
• No.
• Last Pap smear
• Maybe 7 years ago when I had chlamydia? I did not get one in the past few years and I forgot what the results were last time.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the conjunctivae
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
• Extremities
  • Examination for pitting edema

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on safer sex practices.
• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Hill, I understand your concern about your symptoms. By definition, if you have not had a menstrual period for 12 months, you are in menopause, so we have to look for another cause of your vaginal bleeding. I would like to run a few tests today, do a pelvic exam, and get some imaging of your lower abdomen done. Once the results are back, you and I can talk about what to do next. What do you think about that?”

Patient note

Differential diagnoses

1. Cervical cancer: Postmenopausal vaginal bleeding in a woman around 50 years of age should always raise suspicion for malignancy. This patient has a number of risk factors for cervical cancer (multiple sexual partners, history of a sexually transmitted infection, high parity, smoking history, last Pap smear was 8 years ago, no history of HPV testing), which makes it the most likely diagnosis in this case.
2. Endometrial cancer: Postmenopausal bleeding, a history of early menarche, and metabolic syndrome should prompt evaluation for endometrial cancer. Although it is the most common gynecological malignancy in the United States, this patient has a history of multiple pregnancies, which is a protective factor against endometrial cancer. Additionally, she has more risk factors for cervical cancer, making it the more likely diagnosis.
3. Endometrial polyp: Postmenopausal bleeding is often caused by endometrial polyps. Risk factors for the condition include hypertension and obesity, which are both present in this patient. However, the other two differential diagnoses are can't-miss diagnoses and should therefore be considered first.

Diagnostic studies

• Pelvic examination: mandatory in all cases of postmenopausal vaginal bleeding
• Rectal examination: to rule out a rectal cause of bleeding that was mistaken as vaginal bleeding
• Pap smear, HPV testing: In patients 30–65 years of age, a Pap smear every 3 years OR a Pap smear with HPV testing (co-testing) every 5 years is recommended.
• CBC: to assess for possible anemia due to chronic blood loss
• Transvaginal ultrasound: to assess for endometrial polyps and endometrial thickening, which is a sign of endometrial cancer
• Endometrial biopsy: to assess for endometrial cancer

Other differential diagnoses to consider

• See also painless vaginal bleeding.