Obstetrics/gynecology
Obstetrics
Vaginal Bleeding, Excessive/irregular/abnormal

Vaginal Bleeding: Excessive, Irregular, and Abnormal

Introduction

Abnormal uterine bleeding (AUB) is a common gynecological complaint encountered in Canadian clinical practice. Understanding its causes, evaluation, and management is crucial for success in the MCCQE1 exam and future medical practice in Canada.

💡

For MCCQE1 preparation, focus on the PALM-COEIN classification system, which is widely used in Canadian gynecology to categorize causes of AUB.

PALM-COEIN Classification

The PALM-COEIN system categorizes causes of AUB into structural and non-structural factors:

  • Polyps
  • Adenomyosis
  • Leiomyoma (fibroids)
  • Malignancy and hyperplasia

Clinical Presentation

Patients with AUB may present with:

  • Heavy menstrual bleeding (menorrhagia)
  • Prolonged bleeding (>7 days)
  • Intermenstrual bleeding
  • Postmenopausal bleeding
🇨🇦

In the Canadian healthcare context, it's important to consider the patient's cultural background and potential barriers to seeking care, as these factors can influence presentation and management.

Diagnostic Approach

Step 1: History

  • Menstrual history
  • Associated symptoms
  • Risk factors for endometrial cancer

Step 2: Physical Examination

  • General examination
  • Abdominal examination
  • Pelvic examination

Step 3: Investigations

  • Complete blood count (CBC)
  • Thyroid-stimulating hormone (TSH)
  • Pelvic ultrasound
  • Endometrial biopsy (if indicated)

Canadian Guidelines for AUB Management

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides guidelines for managing AUB:

  1. Initial Assessment: Thorough history and physical examination
  2. Investigations: CBC, ferritin, TSH, and pelvic ultrasound
  3. Endometrial Sampling: For women >40 years or with risk factors for endometrial cancer
  4. Treatment: Based on underlying cause and patient preferences

MCCQE1 Tip

Remember that Canadian guidelines may differ from international ones. Always prioritize Canadian recommendations in your MCCQE1 preparation.

Management Options

Medical Management

  1. Hormonal Options:

    • Combined oral contraceptives
    • Progestin-only pills
    • Levonorgestrel intrauterine system (LNG-IUS)

  2. Non-hormonal Options:

    • Tranexamic acid
    • NSAIDs

Surgical Management

  • Endometrial ablation
  • Myomectomy
  • Hysterectomy
🇨🇦

In the Canadian healthcare system, consider the availability and wait times for surgical procedures when discussing management options with patients.

Special Considerations in Canadian Practice

  1. Rural Healthcare: Access to specialists may be limited in remote areas.
  2. Indigenous Health: Consider cultural practices and beliefs when managing AUB in Indigenous patients.
  3. Immigrant Health: Be aware of cultural sensitivities and potential language barriers.

Key Points to Remember for MCCQE1

  1. Know the PALM-COEIN classification system thoroughly.
  2. Understand the SOGC guidelines for AUB management.
  3. Be familiar with both medical and surgical management options.
  4. Consider patient age and risk factors when deciding on investigations.
  5. Recognize the importance of endometrial sampling in women >40 years.
  6. Be aware of the unique aspects of the Canadian healthcare system in managing AUB.

Sample Question

A 45-year-old woman presents with heavy menstrual bleeding for the past 6 months. She reports no intermenstrual bleeding or postcoital bleeding. Her medical history is unremarkable, and she has no known risk factors for endometrial cancer. Physical examination is normal. Which one of the following is the most appropriate next step in management?

  • A. Prescribe combined oral contraceptives
  • B. Perform endometrial biopsy
  • C. Order pelvic ultrasound
  • D. Recommend hysterectomy
  • E. Start tranexamic acid

Explanation

The correct answer is:

  • C. Order pelvic ultrasound

According to Canadian guidelines, the initial workup for abnormal uterine bleeding in a 45-year-old woman should include a pelvic ultrasound. This non-invasive imaging study can help identify structural causes of AUB, such as fibroids or polyps, and assess endometrial thickness.

While endometrial biopsy is important in women over 40, it is not the first-line investigation in the absence of risk factors for endometrial cancer. Medical management (options A and E) or surgical intervention (option D) should only be considered after appropriate investigations have been completed.

References

  1. Singh, S., et al. (2018). Abnormal Uterine Bleeding in Pre-Menopausal Women. Journal of Obstetrics and Gynaecology Canada, 40(5), e391-e415.

  2. Munro, M. G., et al. (2011). FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology & Obstetrics, 113(1), 3-13.

  3. Society of Obstetricians and Gynaecologists of Canada. (2018). Management of Abnormal Uterine Bleeding. SOGC Clinical Practice Guideline No. 292.

  4. Canadian Task Force on Preventive Health Care. (2016). Recommendations on screening for cervical cancer. CMAJ, 188(1), 14-25.

  5. Health Canada. (2021). Canada's Health Care System. Retrieved from https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html (opens in a new tab)

InfertilityContraception