Irregular periods/vaginal bleeding :: PLAB 2 Symptomatic Differential Stations

• Vulval cancer

  • Other presenting symptoms- 

    • Lump or ulcer on vulva

    • Painless, itching/burning/bleeding

    • FLAWS

  • Past history and PMAFTOSA- 

    • P questions

    • Smoking

  • Social-

    • Day-to-day life, relationships

  • Exam and Invs

    • GPE, vitals

    • Routine bloods

    • Lymph node examination

    • Chest, abdomen and PV examination

    • Speculum for pap smear

    • Urine dipstick

  • Referral 

    • Cancer pathway

  • Treatment 

    • Symptomatic management

    • Surgery 

  • Warning signs- 

    • About appointment

    • Worsening symptoms

    • Bleeding

• Endometriosis

  • Other presenting symptoms- 

    • Dysmenorrhea

    • Dysuria

    • Dyspareunia

    • Dyschezia

    • Pelvic pain

    • Infertility/subfertility

  • Past history and PMAFTOSA- 

    • P questions

  • Social-

    • Day-to-day life, relationships

    • Plans to have kids

  • Exam and Invs

    • GPE, vitals

    • BMI

    • Chest, abdomen and PV examination

    • LH, FSH

    • Urine dipstick, pregnancy test

    • Transvaginal ultrasound

  • Referral 

    • Gyne referral

    • Diagnostic work-up including laparoscopy

  • Treatment 

    • Involve seniors

    • Symptomatic management:

      • Mefenamic acid

      • Tranexamic acid

    • Definitive management:

      • Laparoscopy

      • COCP

  • Warning signs- 

    • Worsening symptoms 

    • Anemia symptoms 

    • Support groups

• Pelvic floor prolapse

  • Other presenting symptoms- 

    • 
      

  • Past history and PMAFTOSA- 

    • 
      

  • Social-

    • 
      

  • Exam and Invs

    • GPE,

  • Referral 

    • 
      

  • Treatment 

    • 
      

  • Warning signs- 

    • 
      

• PCOS

  • Other presenting symptoms- 

    • Oligo/amenorrhea

    • Subfertility/infertility

    • Acne, hirsutism

    • Obesity/weight gain, acanthosis nigricans (dark velvety patches in armpits, neck, groin)

  • Past history and PMAFTOSA- 

    • P questions

    • Rule out diabetes, steroid/androgenic drug intake

  • Social-

    • Confidence and self-esteem

    • Plans to have kids

  • Exam and Invs

    • GPE, vitals

    • BMI

    • Glucometer

    • Chest, and abdomen and PV examination

    • LH, FSH, prolactin, TSH, testosterone

    • USG abdomen

  • Referral 

    • Routine OG referral

  • Treatment 

    • Weight management

    • COCP, topical creams for acne

    • Shaving, and waxing for hirsutism

  • Warning signs- 

    • CVS disease

    • DM

• Premature Ovarian Insufficiency

  • Other presenting symptoms- 

    • Young patient

    • Amenorrhea

    • Risk factors:

      • Stress, strenuous exercise, weight loss

      • Prolactinoma:

        • Headache, visual disturbance, white discharge from nipples

  • Past history and PMAFTOSA- 

    • Family history

    • Rule out PCOS

  • Social-

    • Self esteem, confidence 

    • Plans to have kids

  • Exam and Invs

    • GPE, vitals

    • BMI

    • Thyroid

    • USG

    • Prolactin level

    • Testosterone level

  • Referral 

    • Gynecologist

    • Endocrinologist if prolactinoma

  • Treatment 

    • Involve senior 

    • Specialist treatment: HRT may be offered

  • Warning signs- 

    • Headache, blurring of vision, FLAWS

• Perimenopause/Menopause

  • Other presenting symptoms- 

    • Age 45-55 or higher

    • Hot flushes, night sweats, triggers

    • Mood swings, anxiety, depression

    • Vaginal dryness, dyspareunia, low libido

    • Perimenopause (all these symptoms + irregular periods)

    • Menopause (All these symptoms + 12 months of amenorrhea)

  • Past history and PMAFTOSA- 

    • P questions

    • Rule out suicidal thoughts

  • Social-

    • Day-to-day life, relationships

  • Exam and Invs

    • GPE, vitals

    • BMI

    • Chest, abdomen and PV examination

    • LH, FSH

  • Referral 

    • None

  • Treatment 

    • Reassurance

    • Offer HRT

    • General measures

      • Avoid exercise late in the day for sleep disturbance

      • Avoiding triggers, cool showers etc.. for hot flashes

      • Adequate sleep, CBT and exercise for mood problems

      • Vaginal estrogen or lubricants for vaginal problems

  • Warning signs- 

    • Post-coital bleeding

    • Symptoms worsening

• Atrophic vaginitis

  • Other presenting symptoms- 

    • Age >45

    • Post-menopausal bleeding

    • Post-coital bleeding

    • Hot flushes, night sweats, triggers

    • Mood swings, anxiety, depression

    • Vaginal dryness, dyspareunia, low libido

  • Past history and PMAFTOSA- 

    • P questions

    • Rule out FLAWS

    • Rule out suicidal thoughts

  • Social-

    • Day-to-day life, relationships

  • Exam and Invs

    • GPE, vitals

    • BMI

    • Chest, abdomen and PV examination

    • LH, FSH

    • Urine dipstick

  • Referral 

    • None

  • Treatment 

    • Reassurance

    • Offer HRT

    • General measures

      • Avoid exercise late in the day for sleep disturbance

      • Avoiding triggers, cool showers etc.. for hot flashes

      • Adequate sleep, CBT and exercise for mood problems

      • Vaginal estrogen or lubricants for vaginal problems

  • Warning signs- 

    • Continued bleeding

    • Symptoms worsening

    • FLAWS

    • Pelvic pain

• Fibroids

  • Other presenting symptoms- 

    • Dysmenorrhea

    • Menorrhagia

    • Abdominal fullness/discomfort

    • Subfertility/infertility

  • Past history and PMAFTOSA- 

    • P questions

    • Rule out FLAWS, anemia symptoms

  • Social-

    • Plans to have kids

  • Exam and Invs

    • GPE, vitals

    • Routine bloods

    • Chest, abdomen and PV examination

    • USG

    • Urine dipstick, pregnancy test

  • Referral 

    • Gyne referral routine

  • Treatment 

    • Symptomatic:

      • Mefenamic acid 

      • Tranexamic acid

    • Definitive(specialist): based on plans to have kids

      • COCP, progesterone, GnRH analogues

      • Uterine artery embolisation

      • Surgical options

  • Warning signs

    • Excess bleeding

    • Symptoms worsening

    • FLAWS