Wednesday, January 25, 2012

Question time for Dr Graham Tronc Obstetrician and Gynaecologist on "How to manage intermenstrual bleeding?"

Dr Graham Tronc
  • Gynaecologist
  • Fertility Specialist
  • Director of Brisbane Endometriosis Clinic
  • Obstetrician

Intermenstrual Bleeding
I personally tackle this problem from an anatomical perspective first. Most causes are benign but cancer (especially of the cervix) should be excluded. As always, detailed history, including that of pain, dyspareunia, and amount of bleeding, is important. There are five common causes of benign intermenstrual bleeding.

  1. Intrauterine Polyps 
  • Polyps usually occur in the 30 plus age group
  • Ultrasound Scan (using a vaginal probe) …… almost always suggestive of a polyp being present
  • Polyp should be visualised and removed hysteroscopically. Also do a D and C at the same time to send Endometrium off.
  • Always send for Histology
  • Very small chance of malignancy in post-menopausal women with Polyps

  1. Cervical Polyps
  • Usually visualized at time of speculum examination
  • Can be twisted off (in most cases in the surgery, using sponge holding forceps)
  • Grasp the polyp, twist many times without pulling on the stalk and the polyp will “come away”. Don’t just pull, or it will bleed. Send for Histology
  • More often Cervical Polyps will cause post coital bleeding. Once twisted off, wait for healing and repeat the smear.

  1. Cervical “Erosions”
  • Most Cervical Erosions are NOT erosions at all, but eversions of the Cervical Columnar Epithelium, exposed when a speculum is inserted and opened
  • Cervicitis, on the other hand, almost always causes bleeding when the pap smear is taken (differential diagnosis of Cancer of the Cervix). Cervicitis may also cause post-coital bleeding
  • Very often the smear is too blood-stained to interpret and if this is the case take a high vaginal swab (Microscopy Culture Sensitivity (MCS)) as well. Vaginosis is often the diagnosis. If bleeding occurs at time of smear, treat for Cervicitis with Dalacin V 2% (clindamycin cream) vaginal cream, once a day for a week. Then, repeat the pap smear. Always test for chlamydia and gonococcus
  • If bleeding recurs, it is of vital importance to refer for Colposcopy (3% acetic acid) even in the presence of a normal smear. This is a specialist referral for biopsy of any suspicious areas. Do not of course “observe” patients who have recurrent bleeding, Intermenstrual bleeding, or Post-coital bleeding. This is pertinent even in the presence of repeated normal smears!

  1. Sub-mucous Fibroids
  • Bleeding from small sub-mucous fibroids may be difficult to distinguish from Polyps. Ultrasound diagnosis may also be difficult to differentiate from Polyps. However, the investigation and treatment is the same, hysteroscopic removal (always do a curette at the same time)
  • It is of paramount importance that continued intermenstrual bleeding must not be observed!

  1. Endometriosis
  • Endometriosis is a common cause of intermenstrual bleeding on the pill in young women.
  • Often the bleeding may be premenstrual, brown, prune juice coloured spotting. Consider other symptoms of pain, dyspareunia, pain with defecation, time off work, time off school, and REFER FOR A LAPAROSCOPY if there is any chance of Endometriosis.

FOR ADVICE on referrals, please do not hesitate to contact Dr Graham Tronc on 3870 5602

Dr. Graham Tronc
Obstetrics; Gynaecology ;Infertility; Endometriosis
Suite 15, Wesley Medical Centre, 40 Chasely Street, Auchenflower Brisbane Q  4006
Telephone: (07) 3870 5602, Facsimile: (07) 3217 8758, Email:

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