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Vanderbilt Core Clinical Curriculum

Abnormal Vaginal Bleeding and/or Discharge

Abnormal vaginal bleeding and discharge are most commonly encountered problems in caring for the female patient. Abnormal vaginal bleeding and discharge are common symptoms 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.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with ABNORMAL VAGINAL BLEEDING can include:

Medical Knowledge Learning Topics related to ABNORMAL VAGINAL BLEEDING

1. Clinical features that help to differentiate one etiology from another, including gynecologic, urinary, gastrointestinal, endocrine, and emotional
2. Signs and symptoms that suggest gynecological etiology
3. Signs and symptoms due to other disease and conditions, including gastrointestinal, urinary, endocrine, and emotional
4. Associated risk factors
5. Utility of lab studies to help in the evaluation, including their indications, limitations, and cost
6. Utility of imaging studies to help in the evaluation of vaginal bleeding, including their indications, limitations, and cost

Diagnostic Evaluation Learning Topics related to ABNORMAL VAGINAL BLEEDING

1. Age-appropriate medical history that differentiates among etiologies of disease
2. Physical exam, including a pelvic exam, to establish the diagnosis and severity of disease
3. Differential diagnosis recognizing specific history and physical exam findings that distinguish causes (GI, urinary, endocrine, and emotional as well as gynecological conditions)
4. Diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Consideration of test cost and performance characteristics, as well as patient preferences
5. Indications for and interpretation of the significance of the results of appropriate clinical tests
6. Relevant basic clinical diagnostic procedures

Management Plan Learning Topics related to ABNORMAL VAGINAL BLEEDING

1. Indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with abnormal vaginal bleeding
2. Indications, benefits and disadvantages of interventions and surgical therapy
3. Comparison of the cost-effectiveness various agents within each class of medications, interventional strategies, and surgical approaches
4. Approach to treatment for the patient with abnormal vaginal bleeding based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences
5. Prognosis for the patient based on the diagnosis, treatment plan, and patient’s characteristics
6. Communication of 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. Patient education about their treatment plan, including counseling to patients when indicated about issues related to prevention
9. Referral for psychological support if indicated
10. Utilization of appropriate information systems to ascertain information about health system and community resources
11. Follow-up planning

Potential Differential Diagnosis Topics Include:

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 diathesis
  • Anticoagulation

Systemic Disease

  • Renal failure
  • Autoimmune disorders

Abnormal Vaginal Discharge

Learning Topics during encounters with a patient with ABNORMAL VAGINAL DISCHARGE can include:

Medical Knowledge Learning Topics related to ABNORMAL VAGINAL DISCHARGE

1. Clinical features that help to differentiate one etiology from another, including gastrointestinal, urinary, emotional, and gynecological
2. Signs and symptoms that suggest gynecological etiology
3. Signs and symptoms associated with abnormal vaginal discharge due to other disease and conditions, including gastrointestinal, urinary, and emotional.
4. Risk factors associated with acquisition of abnormal vaginal discharge
5. Utility of laboratory studies to help in the evaluation of abnormal vaginal discharge, including their indications, limitations, and cost
6. Utility of imaging studies to help in the evaluation of abnormal vaginal discharge, including their indications, limitations, and cost

Diagnostic Evaluation Learning Topics related to ABNORMAL VAGINAL DISCHARGE

1. Age-appropriate medical history that differentiates among etiologies of disease
2. Physical exam, including a pelvic exam, to establish the diagnosis and severity of disease
3. Differential diagnosis recognizing specific history and physical exam findings that distinguish causes of abnormal vaginal discharge (GI, urinary and emotional as well as gynecological conditions)
4. Diagnostic imaging and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics, as well as patient preferences
5. Indications for and interpretation of the significance of the results of appropriate clinical tests
6. Basic clinical diagnostic procedures

Management Plan Learning Topics related to ABNORMAL VAGINAL DISCHARGE

1. Indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with abnormal vaginal discharge
2. Indications, benefits and disadvantages of the interventional therapy
3. Cost-effectiveness of various agents within each class of medications, and interventional strategies
4. Approach to treatment for the patient with abnormal vaginal discharge based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences
5. Prognosis for the patient with abnormal vaginal discharge based on the diagnosis, treatment plan, and patient’s characteristics
6. Communication of 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 discharge and its potential effect on lifestyle (partner status, sexual functioning, etc.)
7. Patient education about the treatment plan
8. Patient counseling, when indicated about issues related to prevention
9. Referral for psychological support, if indicated
10. Utilization of appropriate information systems to ascertain information about health system and community resources
11. Follow-up planning

Potential Differential Diagnosis Topics Includes:

  • Bacterial vaginosis
  • Candida
  • GC and chlamydia
  • Physiologic