Family medicine
Vaginal Bleeding (non-menstrual)
Non-menstrual vaginal bleeding is abnormal bleeding from the vaginal or uterine tract occurring outside of normal menses, caused by conditions such as pregnancy complications, infection, hormonal imbalances, trauma, or neoplasia.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Dysfunctional uterine bleeding (anovulatory) | Reproductive age, irregular cycles, no structural lesion | 「你月經準唔準時？有冇試過成個月都冇嚟？」(Are your periods regular? Ever missed a whole month?) |
| Cervical ectropion / polyp | Postcoital bleeding, visible on speculum | Speculum: visible red area / polyp at cervix | |
| Atrophic vaginitis (if postmenopausal) | PMB, vaginal dryness, thin pale mucosa | 「有冇覺得陰道乾、痕或者痛？」(Vaginal dryness, itch or pain?) | |
| Serious Not To Miss | Endometrial cancer | PMB, age > 40, unopposed oestrogen, obesity, nulliparity, family Hx [1][2] | 「收咗經之後有冇再出過血？」(Any bleeding after menopause?) |
| Cervical cancer | Postcoital bleeding, irregular bleeding, abnormal Pap smear | 「行房之後有冇流血？上次抹片結果點？」(Bleeding after intercourse? Last Pap result?) | |
| Ectopic pregnancy | Sexually active, missed period, unilateral pain, +ve pregnancy test [4] | 「月經有冇遲咗？有冇一邊肚痛？」(Period late? One-sided pain?) | |
| Incomplete miscarriage | Pregnancy + bleeding + cramping + tissue passed | 「有冇排出啲組織或者血塊？」(Passed any tissue or clots?) | |
| Pitfalls | Cervicitis (Chlamydia/gonorrhoea) | Intermenstrual/postcoital bleeding, purulent discharge | 「有冇黃綠色分泌物？有冇新嘅性伴侶？」(Yellow-green discharge? New partner?) |
| Endometrial polyp | Intermenstrual bleeding, normal-sized uterus, diagnosed on USS/hysteroscopy | 「超聲波有冇發現子宮入面有瘜肉？」(Any polyp found on ultrasound?) | |
| Uterine fibroid (submucosal) | Heavy/prolonged bleeding, enlarged uterus on exam | Bimanual exam: irregularly enlarged uterus | |
| Masquerades | Hypothyroidism | Menorrhagia, fatigue, weight gain, cold intolerance | 「有冇特別怕凍、便秘、攰？」(Cold intolerance, constipation, fatigue?) |
| Anticoagulant / HRT use | Drug-induced bleeding | 「有冇食薄血丸或者荷爾蒙藥？」 | |
| Coagulopathy (vWD) | HMB since menarche, family Hx of bleeding | 「由第一次嚟月經開始係咪已經好多血？屋企人有冇容易流血嘅問題？」 [3] | |
| Trying to Tell Me Something? | Fear of cancer | Anxiety, repeated visits, family member with cancer | 「你最擔心嘅係咩嘢？」(What worries you most?) |
| Domestic violence / sexual assault | Evasive about Hx, injuries, mood changes | 「你喺屋企安唔安全？」(Do you feel safe at home?) | |
| Unwanted pregnancy | Young, anxious, vague about LMP | 「有冇可能係懷咗孕？」 |
Minute-by-Minute 6-Minute Consultation
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduction, set agenda | 「你好呀，我係X醫生，今日由我同你傾下。請問點稱呼？」「今日嚟睇醫生，最主要想傾啲咩呢？」 | Rapport, identifies chief complaint early. Interpersonal marks. |
| 0:30–1:30 | HPI: Characterise the bleeding — onset, duration, amount, timing in relation to menses, associated Sx, triggers | 「呢次流血係幾時開始㗎？」「同月經有冇關係？」「流咗幾多血？有冇血塊？」「有冇肚痛？」 | Establishes it is non-menstrual bleeding — intermenstrual / postcoital / postmenopausal. Marks for completeness. |
| 1:30–2:30 | Red flags + serious DDx screening — pregnancy, postmenopausal status, weight loss, postcoital bleeding, vaginal discharge | 「有冇可能懷孕？上一次月經幾時？」「收咗經未？」「行房之後有冇出血？」「有冇唔正常嘅分泌物？」 | Rules out ectopic pregnancy, gynaecological cancer. "Must not miss" marks. |
| 2:30–3:30 | Targeted Hx: menstrual / obstetric / sexual / gynaecological — LMP, cycle regularity, parity, contraception, Pap smear, STI | 「你月經平時幾時嚟、幾日一個cycle？」「有冇做過子宮頸抹片檢查？」「有冇用避孕方法？」 | Exam expects thorough sexual/menstrual Hx. High-yield for CRF. |
| 3:30–4:15 | PMHx, Drug Hx, FHx, Social Hx — thyroid disease, bleeding disorder, anticoagulants, HRT, family Ca, smoking, BMI | 「有冇食緊薄血丸或者荷爾蒙藥？」「屋企人有冇試過生癌？」「有冇食煙飲酒？」 | Drug Hx (HRT, anticoagulants) and FHx (endometrial/breast Ca) are discriminators. Past paper tested this directly [1]. |
| 4:15–5:00 | ICE + Hidden agenda — Ideas, Concerns, Expectations | 「你自己覺得呢次流血會唔會係咩原因？」「最擔心嘅係咩嘢？」「今日嚟睇醫生，你最希望我幫到你啲咩？」 | Directly scores ICE marks on CRF. Uncovers hidden agenda (e.g., fear of cancer, fertility concern). |
| 5:00–5:45 | Summarise, check understanding | 「等我總結一下…你係XX歲，出現咗唔正常嘅陰道出血，持續咗X日…有冇講漏咗啲咩？」 | Demonstrates active listening. Interpersonal marks. |
| 5:45–6:00 | Signpost next steps, safety net, close | 「我建議幫你做個婦科檢查同安排幾樣化驗。如果出血突然加多、頭暈或者劇烈腹痛，要即刻去急症室。」 | Safe closure + safety-net = marks for professionalism. |
Uncovering the hidden agenda: The patient may present with "a bit of bleeding" but actually be terrified of cervical or endometrial cancer, or worried about infertility, or hiding a pregnancy/miscarriage concern. Ask: 「你最擔心嘅係咩嘢？」(What worries you most?) — this single question often reveals the real reason for consultation.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Bleeding characterisation | When did the bleeding start? How much? Any clots? | 「幾時開始流血？流咗幾多？有冇血塊？」 | Quantifies severity; heavy + clots → structural cause | Fibroid, endometrial pathology |
| Timing vs menses | Is the bleeding between periods, after sex, or after menopause? | 「係經期之間流、定行房之後流、定收咗經之後先流？」 | Postmenopausal bleeding (PMB) must be investigated to exclude endometrial cancer [2] | PMB → endometrial Ca; postcoital → cervical pathology |
| Pregnancy | Could you be pregnant? When was your LMP? | 「有冇可能有咗BB？上次月經幾時嚟？」 | Must exclude pregnancy first — ectopic is life-threatening | Ectopic pregnancy, threatened/incomplete miscarriage |
| Contraception | Are you using any contraception? Which type? | 「有冇用避孕方法？用邊種？」 | IUD → irregular bleeding; OCP breakthrough bleeding | IUCD-related bleeding, hormonal BTB |
| Sexual Hx | Are you sexually active? Any new partners? | 「有冇性生活？最近有冇新嘅伴侶？」 | STI screening; cervicitis causes intermenstrual/postcoital bleeding | Chlamydia cervicitis, PID |
| Vaginal discharge | Any unusual discharge — colour, smell? | 「有冇唔正常嘅分泌物？咩顏色？有冇異味？」 | Purulent discharge → PID/cervicitis | PID, cervicitis, cervical Ca |
| Pain | Any abdominal or pelvic pain? | 「有冇肚痛或者下腹痛？」 | Acute pain + bleeding → ectopic; chronic → endometriosis/PID | Ectopic, PID, endometriosis |
| Systemic / red flags | Any weight loss, night sweats, fatigue? | 「有冇消瘦、夜晚出汗、攰？」 | B symptoms → malignancy | Gynaecological cancer |
| Menstrual Hx | What is your usual cycle length / duration? Age at menarche? | 「你月經平時幾日嚟一次、嚟幾多日？幾歲嚟第一次月經？」 | Establishes baseline; early menarche = risk factor for endometrial Ca [1] | Anovulatory DUB, endometrial Ca |
| Menopausal Sx | Any hot flushes, night sweats, vaginal dryness? | 「有冇潮熱、陰道乾、瞓得唔好？」 | Confirms menopausal status | Atrophic vaginitis, PMB evaluation |
| Drug Hx | Taking any hormones, blood thinners, herbal meds? | 「有冇食緊荷爾蒙藥、薄血丸、或者中藥？」 | Unopposed oestrogen is a major risk factor for endometrial cancer [1][2] | Drug-induced bleeding, endometrial hyperplasia/Ca |
| Cervical screening | Have you had a Pap smear? When was the last one? | 「有冇做過子宮頸抹片？幾時做㗎？」 | Screening status critical for cervical Ca risk assessment | Cervical Ca/CIN |
| PMHx | Any thyroid problems, bleeding disorders, liver/kidney disease? | 「有冇甲狀腺問題、凝血問題、肝腎病？」 | Hypothyroidism → menorrhagia; coagulopathy → abnormal bleeding [3] | Hypothyroidism, vWD, liver disease |
| FHx | Family history of gynaecological or breast cancer? | 「屋企人有冇試過生子宮癌、卵巢癌或者乳癌？」 | Lynch syndrome / HNPCC → endometrial cancer risk [1] | Endometrial Ca |
| Obstetric Hx | How many pregnancies? Any miscarriages? | 「懷過幾多次孕？有冇試過小產？」 | Nulliparity = risk factor for endometrial Ca | Endometrial Ca |
| Social / functional | How is this affecting your daily life / work / mood? | 「呢個問題影唔影響到你日常生活、返工或者心情？」 | Biopsychosocial assessment; functional impact for CRF | Anxiety, depression, work impairment |
Case Report Form Answer Builder
Template: "[Age]/F presenting with [intermenstrual / postcoital / postmenopausal] vaginal bleeding for [duration]."
High-yield HPI points:
- Onset, duration, amount (soaking how many pads/day), colour, clots
- Timing relative to menstrual cycle / menopause
- Associated symptoms: pain, discharge, systemic symptoms
- Sexual activity, contraception, LMP
- Pregnancy test result
- Risk factors: age, parity, obesity, HRT use, smoking, Pap smear status, family Hx of gynaecological cancer
| Likely RFC | Phrasing |
|---|---|
| Concern about the cause of abnormal bleeding | "To find out the cause of her vaginal bleeding outside her normal period" |
| Fear of cancer | "To exclude cancer as the cause of postmenopausal bleeding" |
| Desire for treatment | "To seek treatment for her persistent abnormal vaginal bleeding" |
Tip: The RFC is often the patient's worry, not just the symptom. Use ICE to find it.
| Component | Likely Content | Exact Wording for CRF |
|---|---|---|
| Ideas | "I wonder if it's hormonal" or "Maybe something is wrong with my womb" | Patient thinks the bleeding may be due to hormonal imbalance / a growth in the uterus |
| Concerns | "I'm worried it could be cancer" / "Will I still be able to have children?" | Patient is worried that the bleeding may indicate cancer / affect fertility |
| Expectations | "I want an ultrasound / blood test to check" / "I want referral to a specialist" | Patient expects investigation (ultrasound / biopsy) and specialist referral to rule out serious pathology |
How to choose: Use age and clinical context:
- Reproductive age + irregular cycles, no pregnancy: Anovulatory dysfunctional uterine bleeding
- Reproductive age + positive pregnancy test + bleeding: Threatened miscarriage / ectopic pregnancy
- Perimenopausal + intermenstrual bleeding: Endometrial polyp / anovulatory bleeding / must exclude endometrial cancer if age > 40 [2]
- Postmenopausal bleeding: Atrophic vaginitis is most common, but must exclude endometrial cancer [1][2]
- Postcoital bleeding: Cervical ectropion / cervicitis / must exclude cervical cancer [2]
Minimum supporting evidence for endometrial Ca: Age > 40 (or postmenopausal), PMB, risk factors (obesity, unopposed oestrogen, nulliparity, FHx), bulky uterus on exam.
| DDx | One Key Discriminator |
|---|---|
| Endometrial cancer | Age > 40, PMB, unopposed oestrogen exposure, obesity, abnormal endometrial thickness on TVUSS ≥ 5mm [2] |
| Cervical cancer/CIN | Postcoital bleeding, abnormal Pap smear, visible cervical lesion on speculum [2] |
| Ectopic pregnancy | Positive pregnancy test, unilateral pelvic pain, adnexal tenderness, empty uterus on TVUSS [4] |
(Adjust based on the specific case stem — swap in cervical polyp, fibroid, atrophic vaginitis, PID, or coagulopathy as appropriate.)
| Domain | Problem |
|---|---|
| Biological | Anaemia secondary to chronic abnormal vaginal bleeding |
| Psychological | Anxiety / fear of cancer diagnosis |
| Social | Impact on work attendance and daily activities; impact on sexual relationship / intimacy |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Endometrial cancer | Bulky, irregularly enlarged uterus on bimanual palpation | Bimanual examination: left hand on abdomen, right hand two fingers in vagina, palpate uterus for size and regularity [5] | Enlarged uterus suggests endometrial mass; combined with PMB, high suspicion for endometrial Ca |
| Cervical cancer | Visible friable/irregular cervical mass or ulcer on speculum | Cusco speculum exam: visualise cervix | Irregular, friable, bleeding-on-touch cervical lesion strongly suggests invasive cervical cancer |
| Ectopic pregnancy | Adnexal tenderness + cervical excitation (Chandelier sign) on bimanual exam | Bimanual: gently move cervix — severe pain = positive cervical excitation [4][6] | Cervical excitation + adnexal tenderness with +ve pregnancy test = ectopic until proven otherwise |
| Uterine fibroid | Irregularly enlarged, firm, non-tender uterus on bimanual palpation | Bimanual palpation | Bosselated (lumpy) enlargement typical of fibroids |
| Atrophic vaginitis | Thin, pale, dry vaginal mucosa ± petechiae on speculum exam | Speculum examination | Atrophic changes in a postmenopausal woman explain contact/PMB bleeding |
| Cervicitis | Mucopurulent discharge from cervical os on speculum | Speculum exam | Purulent discharge supports infective cervicitis (Chlamydia/gonorrhoea) |
| Coagulopathy (e.g., vWD) | No reliable sign in brief FM station — best clue is petechiae/bruising on skin survey; confirm with clotting profile + vWF assay | Inspect skin for bruising, petechiae | Mucocutaneous bleeding pattern supports platelet/vWF disorder |
Must Not Miss Red Flags
- Postmenopausal bleeding = endometrial cancer until proven otherwise — always needs endometrial sampling if age > 40 or TVUSS endometrial thickness ≥ 5mm [2]
- Positive pregnancy test + vaginal bleeding + unilateral pain → Ectopic pregnancy — urgent referral
- Postcoital bleeding + cervical lesion → Cervical cancer — urgent referral for colposcopy/biopsy
- Hemodynamic instability (tachycardia, hypotension, pallor, syncope) with vaginal bleeding → ruptured ectopic / heavy haemorrhage → A&E immediately
- Unopposed oestrogen use (e.g., HRT without progesterone, tamoxifen) → significantly ↑ risk of endometrial hyperplasia/cancer [1][2]
Top Traps That Lose Marks:
| Trap | How to Avoid |
|---|---|
| Forgetting to ask about pregnancy | Always ask LMP and pregnancy test in ANY woman of reproductive age — even if chief complaint seems unrelated |
| Not asking about cervical screening (Pap smear) | Ask every time — a common exam expectation |
| Assuming PMB = atrophic vaginitis without investigating | PMB must have endometrial assessment [2] |
| Forgetting drug history (HRT, anticoagulants, OCP) | Directly relevant — drugs are a masquerade |
| Missing ICE → losing easy marks | Always ask the three ICE questions explicitly |
| Not asking about sexual history | Required to assess for STI/cervicitis, postcoital bleeding, and ectopic risk |
| Forgetting family history of gynaecological cancer | Lynch syndrome / HNPCC is a high-yield exam point [1] |
Safety-net closing line: 「如果突然間流好多血、頭暈眼花、或者劇烈腹痛，要即刻去急症室。我哋會盡快安排超聲波同進一步檢查。」 (If sudden heavy bleeding, dizziness, or severe abdominal pain → go to A&E immediately. We will arrange USS and further investigations as soon as possible.)
Key GC lecture point [2]: For age over 40 with abnormal bleeding — need endometrial sampling (e.g., Pipelle). For postmenopausal bleeding — transvaginal USS (endometrial thickness ≥ 5mm triggers biopsy). Gold standard = hysteroscopy and biopsy.
Key GC lecture point [3]: Investigations for abnormal uterine bleeding include pregnancy test, CBC, cervical screening, endocervical swab for Chlamydia (if postcoital/intermenstrual bleeding), and endometrial assessment (aspiration / pelvic USS / hysteroscopy).
High Yield Summary
What to ASK:
- Pregnancy test / LMP — ALWAYS first
- Timing: intermenstrual vs postcoital vs postmenopausal
- Amount, duration, associated pain/discharge
- Cervical screening (Pap smear) status
- Contraception, sexual history, STI risk
- Drug Hx: HRT (unopposed oestrogen!), anticoagulants, OCP
- FHx: gynaecological/breast cancer
- ICE — explicitly
What to WRITE on CRF:
- Chief complaint: specify the type of non-menstrual bleeding (IMB/PCB/PMB) and duration
- RFC: the patient's real worry (often fear of cancer)
- Most likely Dx: match to age group + clinical context
- DDx: always include endometrial Ca and cervical Ca if age-appropriate
- Biopsychosocial: anaemia (bio), cancer anxiety (psych), impact on work/relationships (social)
- Physical sign: speculum finding or bimanual palpation finding
What NOT to MISS:
- PMB = endometrial cancer until proven otherwise
- Positive pregnancy test + bleeding = ectopic until proven otherwise
- Unopposed oestrogen / nulliparity / obesity / FHx = endometrial Ca risk factors
Active Recall - Family Medicine Clinical Test
[1] Past paper: 2020 Fourth Summative Minicases.pdf (Case Three, Sections 1–2, pp. 25–26) [2] Lecture slides: GC 112. Abnormal vaginal bleeding Gynaecological cancer.pdf (pp. 39–40) [3] Lecture slides: CFB (OG04) Menstrual Disorders.pdf (p. 31 — Investigations) [4] Senior notes: Ryan Ho Radiology.pdf (p. 36 — Ectopic pregnancy) [5] Senior notes: Ryan Ho Fundamentals.pdf (p. 197 — Bimanual examination) [6] Senior notes: Ryan Ho GI.pdf (p. 99 — PID / Chandelier sign)
Urinary Urgency / Frequency
Urinary urgency and frequency refer to the sudden, compelling need to urinate and an abnormally increased number of voidings, often resulting from bladder irritation, detrusor overactivity, or underlying urologic or neurologic conditions.
Vaginal Dryness Or Atrophy
Vaginal dryness or atrophy is a condition characterized by thinning, drying, and inflammation of the vaginal walls due to decreased estrogen levels, most commonly occurring during menopause.