Rationale

Vaginal bleeding is considered abnormal when it occurs at an unexpected time (before menarche or after menopause) or when it varies from the normal expected amount or pattern. It may be associated with significant morbidity, and mortality, depending upon the underlying cause.

Causal Conditions

(list not exhaustive)

1. Pre-menarchal (e.g., trauma, sexual abuse)

2. Pre-menopausal

   1. Ovulatory

      • Inter-menstrual (e.g., oral contraceptive, benign growths)

      • Menorrhagia

      • Neoplasms-coagulation disorders

      • Other (e.g., endometritis, hypothyroidism)

   2. Anovulatory

      • Age related-endocrine/metabolic (e.g., thyroid)

      • Neoplasms (e.g., prolactinoma, ovarian tumor)

      • Other (e.g., polycystic ovary, weight loss/exercise/stress, structural disease)

   3. Pregnancy-related

3. Post-menopausal-structural/systemic

   1. Genital tract disease (exclude trauma)

   2. Neoplastic systemic disease

   3. Drugs (e.g., hormone replacement therapy, anticoagulants)

Key Objectives

Given a patient who presents with abnormal, irregular or excessive vaginal bleeding, the candidate will diagnose the cause, severity, and complications, and will initiate an appropriate management plan.

Enabling Objectives

Given the patient who presents with abnormal, irregular, or excessive vaginal bleeding, the candidate will

1. list and interpret critical clinical findings, including those based on

   1. first and foremost, determining whether the patient is hemodynamically stable;

   2. differentiating between bleeding related to or unrelated to pregnancy;

   3. information gathered to determine the underlying cause (e.g., other bleeding, medications) if pregnancy has been ruled out;

   4. results of an appropriate physical examination, including a pelvic examination unless contraindicated (e.g., placenta previa);

2. list and interpret critical clinical investigations, including

   1. complete blood count, pregnancy test and, in women with recent pregnancy, qualitative and quantitative beta HCG;

   2. determining ovulatory status and order clinically-indicated diagnostic tests;

   3. determining whether a referral for investigation is required;

3. construct an effective initial management plan, including

   1. determining if the patient requires urgent or specialized care;

   2. resuscitating patient if hemodynamically unstable;

   3. initiating first-line medical therapy, as appropriate, for control of abnormal vaginal bleeding and referring the patient for specialized surgical care;

   4. outlining legal responsibilities (e.g., mandatory reporting obligations) if sexual abuse is suspected;

   5. recognizing the potential need for counselling and support in case of sexual abuse.