Family medicine
Intermenstrual Bleeding
Intermenstrual bleeding is vaginal bleeding that occurs between expected menstrual periods, indicating possible cervical pathology, hormonal imbalance, infection, or structural uterine abnormalities.
Murtagh Diagnostic Strategy
GC/CFB lecture key point: Intermenstrual bleeding has a different set of differential diagnoses from heavy regular bleeding (menorrhagia). [2][3]
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Cervical ectropion / erosion | Young woman, OCP user, painless PCB/IMB | 「你有冇食避孕藥？行房後有冇出血？」 |
| Endocervical / endometrial polyp | Painless irregular IMB, may have PCB | Speculum: visible polyp at os | |
| Breakthrough bleeding from OCP / POP / IUCD | Temporal link to starting/changing contraception | 「你幾時開始食藥/擺環？出血係咪之後先開始？」 | |
| Serious Not To Miss | Cervical carcinoma | PCB, foul discharge, abnormal Pap smear, visible cervical lesion | 「有冇行房後出血？白帶有冇臭味？柏氏抹片幾時做？」 |
| Endometrial carcinoma | Perimenopausal/PMB, obesity, unopposed oestrogen, nulliparity, FHx [1] | 「收咗經之後有冇再出血？有冇食雌激素？」 | |
| Ectopic pregnancy / Miscarriage | Positive pregnancy test, pain, missed period | 「有冇機會懷孕？M有冇遲咗？有冇肚痛？」 | |
| Gestational trophoblastic disease | Markedly elevated β-hCG, "snowstorm" USS | As above pregnancy screening | |
| Pitfalls | Chlamydia / Gonorrhoea cervicitis | Young, new partner, mucopurulent discharge | 「最近有冇新嘅性伴侶？有冇用安全套？」 |
| Cervical intraepithelial neoplasia (CIN) | Abnormal Pap; may be asymptomatic | Check Pap smear history | |
| Caesarean scar defect (isthmocele) | Post-menstrual spotting/IMB after prior C-section [3] | 「你之前開刀生BB之後有冇一直有啲啲出血？」 | |
| Uterine fibroid (submucosal) | Usually HMB but can cause IMB; bulky uterus on exam | Bimanual: enlarged, irregular uterus | |
| Masquerades | Hypothyroidism | Fatigue, weight gain, menstrual irregularity | 「有冇成日攰、怕凍、肥咗？」 |
| Coagulopathy / Anticoagulant use | Easy bruising, gum bleeding, warfarin/DOAC use | 「你有冇食薄血藥？容唔容易瘀？」 | |
| Depression → somatisation | Low mood, poor sleep, loss of interest | 「心情點呀？有冇開心唔到？」 | |
| Trying to Tell Me Something? | Fear of cancer | Anxiety about cervical/uterine cancer | 「你係咪擔心會唔會係cancer？」 |
| Relationship/sexual concerns | PCB affecting intimacy | 「出血有冇影響到你同伴侶嘅關係？」 | |
| Fertility worry | Wants to conceive; worried bleeding = infertility | 「你有冇計劃生BB？擔唔擔心會影響生育？」 |
Intermenstrual Bleeding (IMB) — Family Medicine Clinical Test Notes
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, build rapport | 「你好呀，我係XXX醫生，今日由我同你傾吓，可以點稱呼你呀？」 (Hello, I'm Dr XXX, how should I address you?) | Scores interpersonal marks; warm, patient-centred opening |
| 0:30–1:30 | Elicit chief complaint & HPI — open question first, then focused symptom analysis | 「你今日嚟有咩嘢想睇吓？」→「可唔可以同我講多啲嗰個出血嘅情況？幾時開始㗎？」→「出血嘅量大概有幾多？要唔要成日換M巾？有冇血塊？」 | Captures CC + HPI accurately; shows systematic symptom analysis |
| 1:30–2:30 | Red flags & targeted history — PCB, PMB, pain, discharge, weight loss, contraception, sexual history, Pap smear | 「有冇行房之後出血呀？」「有冇肚痛或者白帶有味？」「你而家有冇食避孕藥或者擺環？」「最近一次做子宮頸抹片係幾時？」 | Red flags screen for cervical/endometrial Ca; contraception guides DDx |
| 2:30–3:30 | PMH, DHx, FHx, Allergy, OBS/GYN hx | 「以前有冇咩大病或者做過手術？食緊咩藥？有冇藥物敏感？屋企人有冇人試過生cancer？你有幾多個仔女呀？」 | Completeness marks; FHx endometrial/breast Ca is high-yield [1] |
| 3:30–4:30 | ICE — Ideas, Concerns, Expectations | 「你自己覺得呢個出血可能係咩原因？」「你最擔心嘅係咩嘢呀？」「你嚟睇呢次，最希望我幫到你咩？」 | ICE is a mandatory CRF field; hidden agenda often here |
| 4:30–5:15 | Social history & psychosocial impact | 「你做咩工嘅？出血有冇影響到你返工或者日常生活？」「心情點呀？會唔會好擔心？」 | Biopsychosocial problem scoring; uncovers functional impact |
| 5:15–6:00 | Summarise, safety-net, close | 「等我總結返：你係兩個月前開始經期之間出血⋯⋯我有冇漏咗啲咩？」→「我建議你做吓檢查⋯⋯如果出血突然增加或者好痛，就要即刻返急症睇。」→「今日仲有冇嘢想問？」 | Summarising + checking understanding + safety-net = high interpersonal marks |
Uncovering the hidden agenda: The patient may present with "bleeding" but the real reason for consultation is fear of cancer, worry about fertility, relationship stress from PCB, or side effects of contraception. Always ask 「你最擔心嘅係咩？」 and 「點解揀咗今日嚟睇？」 (Why did you choose to come today?)
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did the IMB start? How often? | 「經期之間嘅出血幾時開始？大概隔幾耐出一次？」 | Acute vs chronic; guides urgency | Chronic → structural; acute → iatrogenic/infection |
| Amount/Pattern | How heavy? Clots? Spotting vs flow? | 「出幾多血？有冇血塊？係少少啲定好似嚟M咁？」 | Severity; anaemia risk | Heavy + clots → fibroid/polyp; spotting → cervical ectropion, pill |
| Timing | Mid-cycle? Random? Related to pills? | 「係唔係每個月中間出？定冇固定時間？食緊藥嗰段時間有冇出？」 | Mid-cycle → ovulatory; random → structural/neoplastic | Mid-cycle spotting → physiological; breakthrough bleeding → OCP |
| Post-coital bleeding (PCB) | Any bleeding after intercourse? | 「有冇行房之後出血？」 | Red flag for cervical pathology [1][2] | Cervical Ca, cervical ectropion, cervical polyp, chlamydia cervicitis |
| Post-menopausal | Have your periods stopped? Any bleeding after menopause? | 「你收咗經未呀？收咗之後有冇再出血？」 | PMB = endometrial Ca until proven otherwise [1] | Endometrial Ca, endometrial polyp, atrophic vaginitis |
| Pain | Any pelvic pain or dysmenorrhoea? | 「有冇肚痛？嚟M嗰陣痛唔痛？」 | Pain → PID, endometriosis, adenomyosis | Adenomyosis, PID, ectopic |
| Vaginal discharge | Any abnormal discharge, smell? | 「有冇白帶異常、有冇臭味？」 | STI screen | Chlamydia/gonorrhoea cervicitis, PID |
| Contraception/Drugs | Current contraception? HRT? Anticoagulants? | 「而家有冇食避孕藥、擺環、或者食薄血丸？」 | Iatrogenic is a common cause of IMB [2][3] | Breakthrough bleeding (OCP/POP), IUCD, anticoagulants, HRT |
| Sexual history | New partner? Unprotected sex? | 「最近有冇新嘅性伴侶？有冇用安全套？」 | STI risk; pregnancy risk | Chlamydia cervicitis, pregnancy complications |
| Pregnancy possible? | Any chance of pregnancy? LMP? | 「有冇可能懷孕？上一次嚟M係幾時？」 | Must exclude pregnancy-related bleeding | Ectopic, miscarriage, trophoblastic disease |
| Cervical screening | When was last Pap smear? | 「最近一次做柏氏抹片係幾時？結果正唔正常？」 | Cervical Ca screening status | Cervical intraepithelial neoplasia, cervical Ca |
| Menstrual history | Age of menarche, regularity, duration, LMP, PMP | 「幾歲開始嚟M？週期準唔準？嚟幾多日？」 | Baseline cycle for comparison [3] | Anovulatory bleeding if irregular |
| Red flags — weight loss, appetite | Any weight loss? | 「最近有冇瘦咗？食嘢點呀？」 | Malignancy screen | Gynaecological cancer |
| FHx | Family history of gynae/breast cancer? | 「屋企人有冇人試過生子宮癌、乳癌？」 | Endometrial Ca risk factors [1] | Hereditary (Lynch syndrome), endometrial Ca |
| OBS history | Gravidity, parity, mode of delivery | 「你有冇生過BB？順產定開刀？」 | Caesarean scar defect can cause IMB [3] | C/S scar defect (isthmocele) |
| Impact on life | How does it affect daily life/work/mood? | 「呢個出血有冇影響到你返工、瞓覺、或者心情？」 | Biopsychosocial scoring | Psychological distress, functional impairment |
| ICE | What do you think it is? What worries you most? What do you hope for today? | 「你自己覺得係咩事？最擔心咩？今日最想點？」 | Mandatory CRF field | Hidden agenda: cancer fear, fertility worry |
Case Report Form Answer Builder
- CC: Intermenstrual bleeding × [duration]
- HPI high-yield points to capture:
- Onset, duration, frequency, amount (spotting vs flow), clots
- Relationship to cycle (mid-cycle / random), PCB, PMB
- Associated: pain, discharge, fever
- LMP, menstrual cycle regularity, pregnancy possibility
- Contraception / HRT / medications
- Cervical screening history
- Red flags: weight loss, PMB, foul discharge
- Anaemic symptoms
| Likely RFC Examples | How to Phrase |
|---|---|
| Worried the bleeding is due to cancer | "Patient is concerned that intermenstrual bleeding may indicate cervical or uterine cancer" |
| Wants investigation / referral | "Patient requests investigation to find the cause of abnormal bleeding" |
| Bleeding affecting relationship/intimacy | "Patient is distressed as post-coital bleeding is affecting her relationship" |
| Wants to know if contraception is the cause | "Patient wants to know if her IUD/OCP is causing the bleeding" |
Pick the ONE that the simulated patient emphasises — usually revealed through ICE questions.
| Likely Content | Example Wording for CRF | |
|---|---|---|
| Ideas | "I think my IUD might be causing it" / "Maybe it's hormonal" / "Could it be cancer?" | "Patient thinks the bleeding may be related to her contraceptive device" |
| Concerns | Fear of cervical/uterine cancer; worry about fertility; embarrassment about PCB | "Patient is worried the bleeding could be a sign of cancer" |
| Expectations | Wants reassurance / ultrasound / referral / Pap smear / change contraception | "Patient hopes to have an ultrasound and be referred to a gynaecologist" |
Depends on the stem, but in a young reproductive-age woman on OCP → Breakthrough bleeding (iatrogenic) or cervical ectropion
In a perimenopausal woman → endometrial polyp or dysfunctional/anovulatory uterine bleeding
Minimum supporting evidence: Temporal relationship to contraception + no red flags + normal examination → breakthrough bleeding. Visible ectropion on speculum → cervical ectropion.
| DDx | Key Discriminator |
|---|---|
| 1. Cervical polyp | Visible polyp on speculum; painless IMB/PCB |
| 2. Chlamydia cervicitis | Young, new partner, mucopurulent discharge, contact history |
| 3. Endometrial carcinoma (if perimenopausal/PMB) | PMB, risk factors (obesity, nulliparity, unopposed oestrogen, FHx) [1] |
(Adjust based on patient age and context in the station.)
| Domain | Problem |
|---|---|
| Biological | Iron-deficiency anaemia secondary to prolonged IMB |
| Psychological | Anxiety / fear of cancer causing sleep disturbance |
| Social | IMB/PCB affecting intimate relationship and work attendance |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Cervical ectropion (most likely if young + OCP) | Red, granular area around external os on speculum | Cusco speculum exam; ectropion bleeds on contact | Characteristic visible finding; explains painless IMB/PCB |
| Cervical polyp | Polyp visible at cervical os | Speculum examination | Direct visualisation = diagnostic |
| Cervical carcinoma | Irregular, friable, bleeding cervical mass | Speculum examination | Visible tumour; contact bleeding |
| Chlamydia cervicitis | Mucopurulent endocervical discharge, contact bleeding of cervix | Speculum + endocervical swab | Inflammation at cervix causing IMB/PCB |
| Endometrial carcinoma | Bulky uterus on bimanual exam (may be normal) | Bimanual pelvic examination | No reliable single physical sign in brief FM station — best clue is PMB + risk factors; investigation: TVUSS + endometrial biopsy [1] |
| Uterine fibroid | Enlarged, irregular, firm, non-tender uterus | Bimanual pelvic examination | Palpable fibroid supports structural cause |
| Hypothyroidism | Slow-relaxing ankle reflexes, dry skin, bradycardia | Ankle jerk reflex, vitals | Suggests thyroid masquerade |
Must-Not-Miss Red Flags for Urgent Referral
- Post-menopausal bleeding (PMB) = endometrial carcinoma until proven otherwise → urgent TVUSS + endometrial biopsy [1]
- Post-coital bleeding (PCB) with visible cervical lesion → urgent colposcopy referral for ?cervical Ca
- Positive pregnancy test + IMB + pain → exclude ectopic pregnancy (emergency)
- Haemodynamic instability (tachycardia, hypotension) → resuscitate and refer
Common Exam Traps
- Forgetting to ask about pregnancy — always check LMP and pregnancy possibility in any woman of reproductive age with vaginal bleeding
- Not asking about contraception — breakthrough bleeding from OCP/IUD is the most common "easy" diagnosis in a young woman
- Confusing IMB with HMB — they have different differential diagnoses [2][3]; the question is about bleeding BETWEEN periods, not heavy periods
- Missing cervical screening history — a Pap smear question is almost always expected
- Writing "dysfunctional uterine bleeding" as diagnosis — this is a diagnosis of exclusion; examiners want you to consider structural and infective causes first
- Ignoring psychosocial impact — always ask about mood, relationship, and functional impact for biopsychosocial marks
Shortest safe management/safety-net line:
「如果出血突然增加好多、頭暈企唔穩、或者好痛，就要即刻去急症室。我哋會安排你做吓檢查，之後再跟進。」 (If bleeding suddenly increases, you feel dizzy/faint, or severe pain — go to A&E immediately. We will arrange tests and follow up.)
High Yield Summary
What to ASK:
- LMP, pregnancy possibility, contraception/HRT, PCB, PMB, sexual history, cervical screening history, FHx of gynae cancer, anaemic symptoms, ICE
What to WRITE on CRF:
- CC: "Intermenstrual bleeding × [duration]"
- RFC: Usually cancer fear, desire for investigation, or contraception concern
- Most likely Dx: Match to age + context (young + OCP → breakthrough bleeding / ectropion; peri/postmenopausal → polyp / endometrial Ca)
- DDx: Cervical polyp, cervicitis (STI), endometrial Ca (if risk factors)
- BPS: Anaemia (Bio), cancer anxiety (Psych), impact on relationship/work (Social)
- Physical sign: Speculum finding (ectropion / polyp / cervical lesion)
What NOT to MISS:
Active Recall - Family Medicine Clinical Test
[1] 2020 Fourth Summative Minicases.pdf (Case Three, Sections 1–2: IMB in 55-year-old, endometrial Ca risk factors, DDx, investigations) [2] CFB (OG04) Menstrual Disorders.pdf (p58: Intermenstrual bleeding) [3] Adrian Lui Gynecology Notes.pdf (p13: HMB vs IMB different DDx, structural vs non-structural causes, history-taking framework, C/S scar defect)
Hoarseness
Hoarseness is an abnormal change in voice quality, typically characterized by a rough, breathy, or strained sound, resulting from disorders affecting the vocal folds or laryngeal function.
Irregular Or Frequent Cycles
Menstrual cycle irregularity refers to variations in cycle length (oligomenorrhea >35 days, polymenorrhea <21 days) or unpredictable timing of menses, often reflecting underlying ovulatory dysfunction or hormonal imbalance.