GuidelinesOther guideline
Clinical Assessment
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Important points on history
- Duration of bleeding
- Last menstruation (LMP), including the possibility of pregnancy
- Regularity of menstrual cycle
- Number of days of bleeding
- Amount of bleeding – presence of clots, or increase in number of pads or tampons needed
- Progressive increase in amount of bleeding for that patient or not
- Post-coital bleeding, intermenstrual bleeding
- Associated vaginal discharge – offensive or not
- Presence & nature of pain or discomfort
- Full gynaecological history – parity, contraception, sexually active etc.
- History of a bleeding disorder
- Use of medicines or contraceptives
Examination
- Check general condition, i.e. wasted, ill-looking etc.
- Look for bruising or petechiae
- Look for pallor
- Assess haemodynamic status, i.e. heart rate & blood pressure
- Palpate for any abdominal mass or uterine enlargement
- Palpate for abdominal tenderness
- A speculum & bimanual examination are mandatory
Investigations
- No blood tests required if the patient is well, has no pallor
- Hb - if there is pallor, or an FBC and Group & Hold or Crossmatch - if there is pallor & haemodynamic compromise.
- Blood microscopy, differential, & B12 are essential before transfusion If the Hb <6 or if there is bicytopenia or pancytopenia
- If miscarriage, ectopic pregnancy or molar pregnancy is suspected do a pregnancy test
- Ultrasound scan to assess size and position of fibroids & to assess masses that may not be fibroids
- Cervical smear must be done, but can be deferred for 2 weeks if bleeding is heavy.
- Biopsy rather than Pap smear any cervical lesion that appears malignant
- Endometrial biopsy, e.g. Z-sample, for:
- Women over 40 years, especially with irregular bleeding & risk factors for endometrial cancer - hypertension, obesity and diabetes
- Failed conservative management
- Transvaginal scan for endometrial thickness is only of value in postmenopausal women
Treatment
- Explain the problem to the patient
- If an organic cause is found, e.g. fibroids, carcinoma, PID, pregnancy, etc. this must be dealt with specifically
- Give iron if there is anaemia e.g. ferrous sulphate 200 mg po tds with meals. Advise it may nauseate, faeces will be black
- Transfuse patients who have bled heavily only where clinically indicated
- Tranexamic acid may be given for acute bleeding (dosage below)
- Many drugs are useful for dysfunctional uterine bleeding (discussed below) but may also be effective in the presence of organic disease e.g. fibroids, adenomyosis, or in women on contraception
- Discovered medical conditions should be managed appropriately