Case 4: Vaginal bleeding

Last updated: September 14, 2023

Examinee instructionstoggle arrow icon

Opening scenario

Elaine Hill, a 50-year-old female; , comes to the physician because of vaginal bleeding.

Vital signs

  • Temperature: 98.7°F (37°C)
  • Blood pressure: 118/79 mm Hg
  • Heart rate: 85/min
  • Respirations: 17/min
  • BMI: 32 kg/m2

Examinee tasks

Patient encountertoggle arrow icon

Patient instructions

  • You are distrustful of medicine and doctors, and you treat the examinee with some suspicion.
  • You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
  • Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “My doctor told me I had finally gone through menopause. Does this mean that is not the case?”

Focused historytoggle arrow icon

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

  • Chief complaint
  • I got my period again last week, but I thought I already went through menopause.
  • Onset
  • 5 days ago.
  • Constant/intermittent
  • It started out with some spots in my underwear. It has been as heavy as a normal period the past 2 days, though.
    • Exact amount of bleeding for last 2 days
    • I had to use 3 pads per day.
  • Precipitating events
  • None.
  • Progression
  • Like I told you. Spotting until 2 days ago. Now it is like a period.
  • Previous episodes
  • None.
  • Frequency
  • This is the first time I have had this in 2 years.
  • Alleviating factors
  • No.
  • Aggravating factors
  • No.
  • Associated symptoms
  • I have been feeling fine otherwise.

Review of systems specific to vaginal bleeding in a postmenopausal woman

  • Trauma (to the pelvis)
  • No, nothing like that.
  • Swelling of the ankles
  • No.
  • Fever/chills
  • No.
  • Night sweats
  • No.
  • Fatigue
  • Not really.
  • Urinary problems
  • No.
  • Bowel problems
  • No.
    • Abdominal pain
    • No.
  • Appetite
  • Normal.
  • Weight changes
  • No. I am still on the heavier end of the scale.

Past medical history, family history, and social history

Sexual history, OB/Gyn

Communication and interpersonal skillstoggle arrow icon

Patient interaction

  • Examinee knocked on the door.
  • Examinee introduced him- or herself and identified his/her role.
  • Examinee correctly used the patient's name.
  • Examinee asked open-ended questions.
  • Examinee listened attentively (did not interrupt the patient).
  • Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
  • Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
  • Examinee discussed initial diagnostic impressions with the patient.
  • Examinee explained the management plan.
  • Examinee used non-medical terms and provided reasons for planned steps in management.
  • Examinee evaluated the patient's agreement with the next diagnostic steps.
  • Examinee asked about concerns or questions.

Counseling and challenge

Suggested response to challenge: “Ms. Hill, I understand your concern about your symptoms. By definition, if you have not had a menstrual period for 12 months, you are in menopause, so we have to look for another cause of your vaginal bleeding. I would like to run a few tests today, do a pelvic exam, and get some imaging of your lower abdomen done. Once the results are back, you and I can talk about what to do next. What do you think about that?”

Patient notetoggle arrow icon

Further discussiontoggle arrow icon

Patient note

Differential diagnoses

  1. Cervical cancer: Postmenopausal vaginal bleeding in a woman around 50 years of age should always raise suspicion for malignancy. This patient has a number of risk factors for cervical cancer (multiple sexual partners, history of a sexually transmitted infection, high parity, smoking history, last Pap smear was 8 years ago, no history of HPV testing), which makes it the most likely diagnosis in this case.
  2. Endometrial cancer: Postmenopausal bleeding, a history of early menarche, and metabolic syndrome should prompt evaluation for endometrial cancer. Although it is the most common gynecological malignancy in the United States, this patient has a history of multiple pregnancies, which is a protective factor against endometrial cancer. Additionally, she has more risk factors for cervical cancer, making it the more likely diagnosis.
  3. Endometrial polyp: Postmenopausal bleeding is often caused by endometrial polyps. Risk factors for the condition include hypertension and obesity, which are both present in this patient. However, the other two differential diagnoses are can't-miss diagnoses and should therefore be considered first.

Diagnostic studies

Other differential diagnoses to consider

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