Managing Intermenstrual & postcoital bleeding
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Take a good history including:
hormone therapy including OCP
recurrence of bleeding
previous abnormal pap smears
Do a detailed gynaecological examination including a pap smear and bimanual exam.
look for cervical or vaginal abnormalities eg polyps, ectropion
assess uterine size
assess for adnexal masses
take a pap smear
If examination is normal do a transvaginal ultrasound to assess the thickness of the endometrium. the size of the uterus and adnexae.
If the endometrium is thickened or polypoid they will need a biopsy.
Recurrent intermenstrual bleeding without an obvious cause needs referral even though they are most likely normal. Organise an ultrasound and pap smear before referral.
Repeat the pap smear even if there was a normal one performed within recommended times.
The presence of a fibroid on US scan does not exclude malignancy. Fibroids are more likely to cause menorrhagia and dysmenorrhoea rather than intermenstrual bleeding.
If there is a cervical abnormality the specialist with perform a graded curette, or cervical biopsy and a uterine curette. If adnexal or uterine disease is suspected, then they may also need a laparoscopy.
Endometrial biopsy in the rooms without need for anaesthesia is possible but as it has a false negative rate, if the problem persists, then full hysteroscopy and curettage is needed.