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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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388 SYMPTOM SORTER
Do not accept too readily the claim that there is ‘no chance of pregnancy’; if in any doubt,
arrange a pregnancy test.
Consider anorexia – an emaciated body may be well hidden under baggy clothing, and the
disease oen presents with the absence of periods.
Early morning headache and visual disturbance associated with amenorrhoea suggest
possible intracranial pathology – refer urgently.
Before attributing amenorrhoea to weight loss, make sure that the weight loss itself hasn’t
been caused by thyrotoxicosis.
NOTES:
https://t.me/med1917
389
HEAVY PERIODS
The GP overview
is is a common presenting complaint. e average GP can expect about 100 women to
consult each year for menstrual problems (female GPs rather more) and many of these will be
for menorrhagia. Normal menstrual blood loss is 20–80 mL. In practice, measurement is not
feasible, so the denition rests on what the woman reports, although some eorts can be made
to establish whether or not the bleeding is ‘excessive’.
Differential diagnosis
COMMON
dysfunctional uterine bleeding (DUB)
cervical or endometrial polyps
endometriosis
broids
puberty and perimenopause
OCCASIONAL
hypothyroidism (and hyperthryoidism)
IUCD
iatrogenic (contraceptives, HRT)
cystic glandular hyperplasia (metropathia haemorrhagica)
chronic PID
RARE
adrenal disorders and hyperprolactinaemia
liver disease, especially alcoholic
clotting disorder
endometrial carcinoma
tuberculous endometritis
https://t.me/med1917
390 SYMPTOM SORTER
Ready reckoner
DUB Polyps Endometriosis Fibroids Puberty/perimenopause
Long history Possible Possible Possible Possible No
Long cycle Possible No No No Possible
PVE: Tender No No Yes No No
Very painful periods No Possible Ye s No Possible
PVE: Enlarged uterus No No Possible Ye s No
Possible investigations
LI KE LY: FBC.
POSSIBLE: TFT, ESR/CRP, transvaginal ultrasound and, aer referral, endometrial sampling
and hysteroscopy.
SMALL PRINT: LFT, HVS, clotting studies, endocrine assays.
FBC to check for anaemia and thrombocytopenia. WCC may be elevated in PID.
Check possible thyroid dysfunction with TFT.
ESR/CRP: Elevated in PID.
LFT: If clinical suspicion of liver disease.
Clotting studies: If other history of abnormal bleeding or bruising.
Transvaginal ultrasound useful for conrming broids and suggesting endometrial
pathology.
HVS very occasionally useful in chronic PID with discharge.
Endocrine assays: For hyperprolactinaemia or adrenal disorders.
Investigation aer referral is likely to include endometrial sampling and/or hysteroscopy.
TOP TIPS
Self-reporting of the heaviness of the menstrual ow is notoriously unreliable. Attempt an
objective assessment by enquiring about the number of pads or tampons used, ooding and
the presence of clots, and by checking an FBC for iron-deciency anaemia.
Establish the woman’s agenda. is presentation may be the passport to a prescription (e.g.
the contraceptive pill in a young woman) or to discussion of a specic anxiety (e.g. fears about
possible cancer or a need for hysterectomy).
Don’t forget to enquire about a ‘long-forgotten’ coil.
In a young woman who has painless heavy periods, is otherwise well and has no other
relevant symptoms (such as intermenstrual bleeding or pelvic pain), it is reasonable to make
a presumptive diagnosis of DUB and treat empirically.
https://t.me/med1917
HEAVY PERIODS 391
Establish whether the problem really is simply ‘heavy periods’; if the bleeding is chaotic, or
there is also intermenstrual or post-coital bleeding, the chances of a structural lesion are
much higher – ensure the patient is appropriately investigated.
Blood clots suggest signicant bleeding; do not forget to arrange an FBC.
Menorrhagia with secondary dysmenorrhoea, dyspareunia and pelvic tenderness on
examination suggest endometriosis or chronic PID.
NOTES:
https://t.me/med1917
392
IRREGULAR VAGINAL
BLEEDING
The GP overview
Irregular vaginal bleeding presents commonly in primary care – particularly to female GPs,
as the patient will oen anticipate a pelvic examination. is chapter covers all causes of this
symptom throughout life including prepubertal, causes in early pregnancy and post-menopausal
(causes in late pregnancy are not covered as they constitute a quite dierent clinical scenario).
e key to appropriate management usually lies in a careful history.
Differential diagnosis
COMMON
dysfunctional uterine bleeding (DUB)
breakt hrough bleed ing (BTB) on contrac eptive pill s and long-acti ng reversible contra ception;
also HRT
cervical polyp or erosion
cervicitis and PID
post-menopausal atrophic vaginitis
OCCASIONAL
endometrial polyps
ovulatory bleeding (associated with mittelschmerz)
hypothyroidism (and less commonly hyperthyroidism)
perimenopause
bleeding during early pregnancy (20% of all pregnancies in rst trimester); also miscarriage,
ectopic pregnancy
RARE
uterine bleeding in the newborn
carcinoma (ovary, fallopian tube, uterus, cervix and vagina)
cystic glandular hyperplasia (metropathia haemorrhagica)
pyometra
hydatidiform mole (5% go on to chorionic carcinoma)
https://t.me/med1917
IRREGULAR VAGINAL BLEEDING 393
Ready reckoner
DUB BTB Polyp/erosion Cervicitis/PID Atrophic vaginitis
Profuse bleeding Possible No No Possible No
Painful periods Possible No No Yes No
Discharge No No Possible Yes Possible
Discomfort PV No No No Possible Ye s
Post-coital bleeding No No Ye s Possible Possible
Possible investigations
LI KE LY: FBC, specialised gynaecologica l investigation (see the following list) for post-menopausal
or intermenstrual bleeding.
POSSIBLE: HVS and endocervical swab, colposcopy, transvaginal ultrasound.
SMALL PRINT: TFT.
FBC to check for anaemia in heavy bleeding. Raised WCC in PID.
TFT: To check for possible thyroid dysfunction.
HVS and endocervical swab: To attempt to establish pathogen in cervicitis and PID.
Transvaginal ultrasound: To detect uterine and ovarian pathology, hydatidiform mole and
to establish nature of problem in early pregnancy.
Colposcopy: If signicant cervical pathology suspected.
Specialised gynaecological investigation (e.g. hysteroscopy and endometrial sampling):
Performed in secondary care, particularly for intermenstrual and post-menopausal bleeding.
TOP TIPS
Try to distinguish between intermenstrual bleeding and irreg ular periods, as the likely causes
are dierent (the former suggests a structural lesion, the latter is likely to be DUB). Simply
asking the patient if the bleed feels like a period, with associated period-type symptoms,
may help.
Consider asking the patient to keep a menstrual diary. Very slight bleeding occurring
consistently in mid-cycle with a slight pain and with no other worrying features suggests
an ovulatory bleed.
Remember that missed doses, diarrhoea and vomiting, and the rst few months of treatment
can cause breakthrough bleeding when using oral hormonal preparations. It is worth waiting
a few more cycles before changing treatment.
https://t.me/med1917
394 SYMPTOM SORTER
Post-menopausal bleeding is always abnormal. Even if atrophic vaginitis is present, do not
assume this is the cause – this symptom requires a full assessment.
A very inamed-looking cervix with a purulent discharge is likely to be caused by Chlamydia
infection – consider referral to the local GUM clinic for further investigation and contact
tracing.
A ‘recent’ normal cervical smear can provide false reassurance; if the cervix looks suspicious,
do not take another smear – remember, this is a screening, rather than diagnostic, test.
Instead, refer urgently for colposcopy.
Beware of ‘breakthrough bleeding’ in patients on hormonal contraception or HRT. If it
persists, consider other causes and investigate or refer.
Unilateral pelvic pain with vaginal bleeding within a fortnight of a missed period suggests
an ectopic pregnancy. Admit urgently.
NOTES:
https://t.me/med1917
395
PAINFUL PERIODS
The GP overview
Painful periods are extremely common: 50% of women in the UK complain of moderate pain,
and 12% suer severe, disabling pain. Primary dysmenorrhoea is pain with no organic pathology,
usually starting when ovulatory cycles begin. Secondary dysmenorrhoea is associated with pelvic
pathology, and appears later in life.
Differential diagnosis
COMMON
primary dysmenorrhoea
endometriosis
chronic PID
IUCD
pelvic pain syndrome (‘venous congestion’)
OCCASIONAL
retroverted uterus
cervicitis
chocolate cyst of ovary
endometrial polyp
RARE
uterine malformation
imperforate hymen
uterine hypoplasia
cervical stenosis
psychogenic
https://t.me/med1917
396 SYMPTOM SORTER
Ready reckoner
Primary Endometriosis PID Pelvic congestion IUCD
During rst few days
of period only
Ye s No No No No
Deep dyspareunia No Yes Ye s Ye s No
Colicky pain Yes No No No Ye s
Begins in adulthood No Ye s Ye s Ye s Ye s
Enlarged uterus O/E No Possible No Possible No
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, HVS and endocervical swab, ultrasound, laparoscopy.
SMALL PRINT: None.
FBC for anaemia if periods also heavy. WCC and ESR/CRP raised in PID.
HVS and endocervical swab for Chlamydia if vaginal discharge present: May help establish
pathogen in chronic PID.
Ultrasound helpful to dene uterine enlargement or other abnormalities and to detect
ovarian cysts.
Laparoscopy is the usual investigation aer referral to secondary care: Will make diagnosis
of PID and endometriosis.
TOP TIPS
Explore the patient’s agenda: Young adolescents may use the symptom of painful periods as
a passport symptom to obtain a prescription for the contraceptive pill.
Beware of the diagnosis of endometriosis. Even if detected laparoscopically, this may not
be the actual cause of the patient’s pain (endometriosis is oen asymptomatic). Unless it is
explained that the treatment oered is not necessarily a panacea, the patient is likely to get
frustrated at the apparent lack of progress.
A long-forgotten IUCD can be a cause of dysmenorrhoea. Enquire specically about this
possibility – and check the notes too.
Explain to patients early on in your management that a precise organic diagnosis isn’t always
possible; this will help maintain a good doctor–patient relationship, which wil l facilitate the
subsequent unravelling of any signicant underlying psychological problems.
https://t.me/med1917
PAINFUL PERIODS 397
e chances of organic pathology are greater if the patient has secondary dysmenorrhoea
which is severe enough to disturb sleep.
Half of women who undergo laparoscopy for secondary dysmenorrhoea have no obvious
organic pathology. Consider psychological problems and avoid over-investigating and over-
referring – a number of these women end up having surgery (e.g. TAH) but even then
continue to have pain.
Consider other pathologies if the patient presents acutely with a self-diagnosis of ‘severe
period pain’ – non-gynaecological causes of pelvic pain such as appendicitis, renal colic or
UTI may occur at the expected time of the period.
While painful periods are depressing, true clinical depression may lower the pain threshold
of an otherwise normal woman and should not be missed.
NOTES:
https://t.me/med1917
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