Others (In Murtagh)
Postcoital Bleeding
Postcoital bleeding is vaginal bleeding that occurs during or after sexual intercourse, most commonly caused by cervical pathology such as ectropion, cervicitis, polyps, or cervical carcinoma.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Cervical ectropion (erosion) | Young, on OCP, small amount, painless | 「你有冇食避孕藥？出血量多唔多？」 | ~30% |
| Cervicitis (Chlamydia/GC) | Mucopurulent discharge, new sexual partner | 「最近有冇新嘅性伴侶？有冇異常分泌物？」 | ~20% | |
| Cervical polyp | Painless PCB, visible polyp on speculum | Speculum: smooth, pedunculated growth at os | ~10% | |
| Serious Not To Miss | Cervical cancer | PCB is the classic bleeding pattern; risk: HPV, smoking, early sex, multiple partners [1] | 「柏氏抹片幾時做過？有冇消瘦、腰痛、腳腫？」 | ~2% |
| Endometrial cancer | PMB, IMB, obesity, older age | 「收咗經之後有冇出血？」 | < 1% | |
| Vaginal cancer | Rare; bloody discharge, visible lesion | Speculum: ulcerative/exophytic vaginal mass | < 1% | |
| Pitfalls | Atrophic vaginitis | Postmenopausal, dryness, dyspareunia | 「有冇覺得陰道乾燥或者痛？」 | ~15% |
| Trauma/foreign body | History of vigorous intercourse, retained object | 「做親密行為之後有冇受傷？有冇用任何物品？」 | ~5% | |
| Endometriosis | Deep dyspareunia, dysmenorrhoea, cyclical pain | 「經痛嚴重唔嚴重？做嘢嗰陣入面痛唔痛？」 | ~2% | |
| Masquerades | Anticoagulant/drug-induced bleeding | On warfarin, DOACs, aspirin | 「有冇食薄血藥？」 | ~2% |
| Pregnancy complication | Amenorrhoea, positive pregnancy test | 「月經有冇遲嚟？有冇可能懷孕？」 | ~1% | |
| Trying to Tell Me Something? | Fear of cancer / STI / relationship problem | Anxiety, avoidance, partner infidelity concern | 「你最擔心嘅係咩？你同伴侶關係點呀？」 | ~30% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好，我係X醫生。今日有咩嘢可以幫到你呀？」(Hello, I'm Dr X. How can I help you today?) | Friendly opening, patient-centred start; scores interpersonal marks |
| 0:30–2:00 | HPI & symptom analysis – onset, frequency, amount, relation to intercourse, associated symptoms, last menstrual period, pregnancies | 「你幾時開始發現做完親密行為之後有出血呀？」「出幾多血？有冇血塊？」「每次都有定係間唔中先有？」 | Thorough HPI captures the bulk of written-section marks |
| 2:00–3:00 | Red flags & targeted ROS – weight loss, back pain, leg swelling, abnormal discharge, dyspareunia, IMB, PMB | 「有冇覺得消瘦咗？有冇腰痛或者腳腫？有冇異味嘅分泌物？」 | Rules out cervical cancer, STI; shows systematic approach |
| 3:00–4:00 | PMH, drug Hx, allergy, FHx, O&G Hx – Pap smear, HPV vaccine, OCP, STI, parity, contraception | 「你上一次做柏氏抹片係幾時？結果正唔正常？有冇打過HPV疫苗？」「食緊咩藥？有冇藥物敏感？」 | Direct discriminators for cervical pathology; drug history for anticoagulants/OCP |
| 4:00–4:30 | Sexual & social history – number of partners, condom use, smoking, occupation, relationship, stress | 「可唔可以了解下你嘅性生活同伴侶情況？」「你有冇食煙？」 | Scores for tact; smoking & multiple partners = cervical CA risk factors [1] |
| 4:30–5:15 | ICE – Ideas, Concerns, Expectations | 「你自己覺得可能係咩原因呢？」「你最擔心嘅係咩？」「你嚟睇醫生最希望我幫你做啲咩？」 | ICE is a dedicated section on the CRF; must ask explicitly |
| 5:15–5:45 | Summarise & check understanding | 「等我總結一下：你最近幾個月做完親密行為之後有少量出血，冇痛冇異味，你擔心會唔會係嚴重問題。我講得啱唔啱？」 | Shows active listening; scores interpersonal marks |
| 5:45–6:00 | Safety-net & close | 「我會安排你做柏氏抹片同婦科檢查。如果出血突然好大量或者好痛，記得即刻去急症。」「你仲有冇嘢想問？」 | Closes safely; demonstrates responsible FM care |
Uncovering the hidden agenda: The patient may have come because she is worried about cancer or an STI, or there may be relationship/sexual concerns. Always ask the open ICE questions. "Why did you come today rather than before?" (「點解揀今日嚟睇呢？」) often reveals the trigger.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/duration | When did postcoital bleeding start? | 「幾時開始做完親密行為之後有出血？」 | Acute vs chronic narrows DDx | Chronic → cervical ectropion/polyp; new → infection/cancer |
| Frequency | Does it happen every time or occasionally? | 「每次都有定係間唔中先有？」 | Consistent = structural; intermittent = functional/infective | Every time → ectropion, polyp, cancer |
| Amount/colour | How much? Bright or dark red? | 「出幾多血？鮮紅色定係啡色？」 | Large amount = more concern for cancer or trauma | Heavy bright red → malignancy, trauma |
| Associated discharge | Any abnormal vaginal discharge or smell? | 「有冇異味或者唔正常嘅分泌物？」 | Purulent/malodorous = STI or advanced cancer | Cervicitis (Chlamydia, gonorrhoea), CA cervix |
| Dyspareunia | Pain during intercourse? | 「做親密行為嗰陣有冇痛？」 | Deep dyspareunia → endometriosis; superficial → vaginitis/atrophy | Endometriosis, atrophic vaginitis |
| IMB/PMB | Any bleeding between periods or after menopause? | 「月經之間有冇出血？收咗經之後有冇出血？」 | IMB/PMB = red flag for endometrial/cervical pathology [1] | Endometrial cancer, cervical cancer |
| LMP & cycle | When was your last period? Regular? | 「你上一次月經幾時嚟？月經準唔準？」 | Rule out pregnancy; assess menstrual pattern | Pregnancy complication |
| Pregnancy test | Any chance of pregnancy? | 「有冇可能懷孕？」 | Pregnancy test is first-line investigation [2] | Ectopic, threatened miscarriage |
| Cervical screening | Last Pap smear? Result? HPV vaccine? | 「上一次柏氏抹片幾時做？結果正常嗎？有冇打HPV針？」 | Overdue Pap = higher risk missed CIN/cancer [1] | CIN, cervical cancer |
| Contraception | What contraception do you use? OCP? IUD? | 「你用咩避孕方法？有冇食避孕藥或者用環？」 | OCP is a risk factor for cervical cancer [1]; IUD can cause bleeding | Breakthrough bleeding, cervical ectropion |
| Sexual history | Number of partners? Condom use? New partner? | 「可唔可以了解吓你嘅性伴侶情況？有冇用安全套？」 | Multiple partners & early sex = cervical CA risk [1] | HPV-related disease, STI |
| Smoking | Do you smoke? | 「你有冇食煙？」 | Smoking is a risk factor for cervical cancer [1] | Cervical cancer |
| Drug history | Anticoagulants? Hormones? | 「有冇食薄血藥或者荷爾蒙藥？」 | Drug-induced bleeding | Anticoagulant effect |
| PMH | Any gynaecological surgery or STI? | 「以前有冇婦科手術或者性病？」 | Previous treatment → recurrence | Recurrent cervicitis, cervical stenosis |
| FHx | Family history of cervical/uterine cancer? | 「屋企人有冇試過生子宮頸癌或者子宮癌？」 | Genetic risk | Gynaecological malignancy |
| Red flags | Weight loss? Back pain? Leg swelling? | 「有冇消瘦？腰痛？腳腫？」 | Late cervical cancer = back pain / leg oedema [1] | Advanced cervical cancer |
| Impact | How does this affect your daily life/relationship? | 「呢個問題對你日常生活或者同伴侶關係有冇影響？」 | Functional impact → psychosocial problem for CRF | Anxiety, relationship strain |
Case Report Form Answer Builder
- CC: Postcoital bleeding × [duration]
- HPI points to capture:
- Onset, duration, frequency (every time vs intermittent)
- Amount (spotting vs moderate), colour
- Associated: vaginal discharge (character, odour), dyspareunia, IMB, PMB
- LMP, cycle regularity, possibility of pregnancy
- Cervical screening history (last Pap smear date and result)
- Sexual history: number of partners, contraception, condom use
- Red flags: weight loss, back pain, leg oedema
- Risk factors: smoking, OCP, early coitarche, HPV vaccine status
- "Worried about the cause of bleeding after intercourse" or
- "Concerned the bleeding may indicate cervical cancer" or
- "Wants investigation/reassurance about postcoital bleeding"
- Phrase as a single sentence linking the patient's concern to the visit trigger.
| Example Wording | |
|---|---|
| Ideas | "Patient thinks bleeding may be caused by infection or cancer" |
| Concerns | "Patient is worried it could be cervical cancer; afraid it may affect her fertility/relationship" |
| Expectations | "Patient wants a Pap smear / gynaecological check-up / referral to a specialist" |
- Cervical ectropion (if young, on OCP, small painless PCB, no red flags)
- Cervicitis (if discharge, new partner, young)
- Cervical cancer (if older, risk factors, weight loss, irregular Pap)
- Choose based on the stem: age, risk factor profile, associated symptoms. Support with ≥2 history features.
| DDx | Key Discriminator |
|---|---|
| 1. Cervical polyp | Painless PCB; visible pedunculated lesion on speculum |
| 2. Cervicitis (Chlamydia) | Mucopurulent discharge; new sexual partner; endocervical swab for Chlamydia [2] |
| 3. Cervical cancer | PCB + weight loss + back pain + abnormal Pap; risk factors: HPV, smoking, early sex, multiple partners [1] |
| Domain | Problem |
|---|---|
| Biological | Postcoital bleeding requiring investigation to exclude cervical pathology |
| Psychological | Anxiety / fear of cancer or serious disease |
| Social | Impact on sexual relationship / intimacy with partner; avoidance of intercourse |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Cervical ectropion | Red, granular area around external os on speculum exam | Cusco speculum examination of cervix | Columnar epithelium visible around os; bleeds on contact; benign |
| Cervical polyp | Smooth, pedunculated mass protruding from cervical os | Speculum examination | Visible polyp explains contact bleeding |
| Cervicitis | Mucopurulent discharge from cervical os; cervix erythematous, friable | Speculum + endocervical swab | Inflamed cervix bleeds easily; swab confirms Chlamydia/GC |
| Cervical cancer | Irregular, friable, ulcerated, or exophytic cervical mass | Speculum examination ± biopsy | Visible lesion with contact bleeding is highly suspicious; refer for colposcopy [1] |
| Atrophic vaginitis | Pale, dry, thin vaginal mucosa with petechiae | Speculum exam in postmenopausal patient | Oestrogen deficiency causes fragile epithelium |
Must-Not-Miss Red Flags
- Postcoital bleeding is the hallmark bleeding pattern of cervical cancer [1] — always ask about Pap smear history, HPV, and cancer risk factors.
- Late-stage cervical cancer signs: back pain, leg oedema, weight loss [1] → urgent gynaecology referral.
- Postmenopausal bleeding in addition to PCB → rule out endometrial cancer (refer for USS + endometrial sampling).
- Never assume PCB is benign without adequate cervical screening history.
Top Traps That Lose Marks:
- Forgetting to ask about last Pap smear — this is the single most important discriminator.
- Not asking sexual history — students lose marks for skipping partners, condom use, or doing it insensitively.
- Missing pregnancy — always do a pregnancy test first [2].
- Writing "AUB" as the chief complaint instead of the specific "postcoital bleeding."
- Omitting ICE — this is a dedicated CRF section; you must ask all three explicitly.
- Not exploring the hidden agenda — the patient may be worried about partner infidelity/STI, or fertility impact.
- Forgetting smoking in social history — it is a key cervical cancer risk factor examined on GC slides [1].
Key investigation to remember from GC/CFB slides: endocervical swab for Chlamydia in postcoital/intermenstrual bleeding [2]
Safety-net line for closing: 「如果突然大量出血、好痛、或者頭暈，要即刻去急症室。我會盡快安排柏氏抹片同婦科檢查。」
High Yield Summary
What to ASK: Onset/frequency/amount of PCB; associated discharge & dyspareunia; LMP & pregnancy; last Pap smear & result; sexual history (partners, condoms); contraception (OCP); smoking; red flags (weight loss, back pain, leg oedema); ICE explicitly.
What to WRITE: CC = "Postcoital bleeding × duration"; RFC = patient's specific concern (e.g., fear of cancer); ICE with exact wording; Most likely Dx supported by ≥2 features; DDx with discriminators; biopsychosocial problems; physical sign = speculum finding of cervix.
What NOT to MISS: Cervical cancer (PCB is its classic presentation); pregnancy; Chlamydia cervicitis; ask Pap smear history in EVERY case of PCB; smoking status.
Active Recall - Family Medicine Clinical Test
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