Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Abnormal Vaginal Bleeding

 

Abnormal vaginal bleeding is one of the most commonly encountered problems in caring for the female patient. Abnormal vaginal bleeding is a common symptom that may result from a variety of causes, including congenital anomalies, pathology of the uterus, tubes, or ovaries, as well as systemic illness and emotional conditions.

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Prerequisites

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Describe and discuss:

  • anatomy of the uterus, tubes, and ovaries, as well as the GU, and GI systems
  • pathogenesis and pathophysiology of diseases and conditions that contribute to abnormal uterine bleeding
  • pharmacology of drugs used to treat abnormal uterine bleeding
  • epidemiology of abnormal uterine bleeding

Demonstrate:

  • ability to take a medical history and perform a physical exam
  • ability to perform  a pelvic exam
  • basic communication skills, especially as they relate to the pelvic exam
     

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe the clinical features that help to differentiate one etiology from another:

  •           gynecologic
  •           urinary
  •         gastrointestinal
  •          endocrine
  •          emotional

2.     Describe the signs and symptoms that suggest gynecological etiology.

3.     Describe signs and symptoms due to other disease and conditions:

  • gastrointestinal
  • urinary
  • endocrine
  • emotional

4.     Describe associated risk factors. 

5.     Describe how lab studies would help in the evaluation, including their indications, limitations, and cost.

6.     Describe how imaging studies would help in the evaluation of vaginal bleeding, including their indications, limitations, and cost.

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Diagnose

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1.    Obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease.

2.    Perform a physical exam, including a pelvic exam, to establish the diagnosis and severity of disease.

3.    Generate a differential diagnosis recognizing specific history and physical exam findings that distinguish causes (GI, urinary, endocrine, and emotional as well as gynecological conditions).

 

4.    Recommend when to order imaging and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering and include consideration of test cost and performance characteristics as well as patient preferences.

5.    Define the indications for and interpret (with consultation) the significance of the results of appropriate clinical tests.

6.    Perform relevant basic clinical diagnostic procedures.

7.    Record, present, research, critique, and manage clinical information.

 

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Develop a Management Plan

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1.    Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with abnormal vaginal bleeding.

2.    Describe and discuss the indications, benefits and disadvantages of interventions and surgical therapy.

3.    Describe and compare the cost-effectiveness of:

  • various agents within each class of medications
  • interventional strategies
  • surgical approaches

4.    Select an approach to treatment for the patient with abnormal vaginal bleeding based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences. 

5.    Formulate a prognosis for the patient based on the diagnosis, treatment plan, and patient's characteristics.

6.    Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of a diagnosis related to abnormal vaginal bleeding and its potential effect on lifestyle (work performance, sexual functioning, etc.).

7.    Provide education for the patient about the treatment plan.

8.    Provide counseling to patients when indicated about issues related to prevention.

9.    Refer for psychological support if indicated.

10. Access and utilize appropriate information systems to ascertain information about health system and community resources.

11. Plan for follow-up.

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Differential Diagnosis

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Pregnancy Related

  • Ectopic
  • Spontaneous abortion
  • Cervical insufficiency
  • Gestational trophoblastic disease
  • Abruption
  • Placenta previa
  • Preterm labor
  • Labor

Gynecologic – Uterine Causes

  • Uterine fibroids
  • Uterine polyps
  • Uterine cancer
  • Endometritis

Gynecologic – Ovarian Causes

  • Ovarian cancer
  • Ovarian torsion
  • Functional ovarian cyst
  • Ovarian failure

Gynecologic – Cervical Causes

  • Cervical cancer
  • Cervical polyp
  • Ectropion
  • Cervicitis

Gynecologic – Vaginal Causes

  • Vaginitis
  • Atrophy
  • Trauma

Gynecologic – Vulvar Causes

  • Vulvar cancer
  • Atrophy
  • Trauma

Endocrine

  • Hyper or hypothyroidism
  • Prolactinoma

Hematologic

  • Bleeding diasthesis
  • Anticoagualtion

Systemic Disease

  • Renal failure
  • Autoimmune disorders