History-taking
CPSA · Focused history · Obstetrics & gynaecology
Vaginal bleeding
Characterise the bleeding and place it in the reproductive context. The first split is pregnant vs not — always establish pregnancy status (β-hCG) and exclude an ectopic.
Focused questions
Characterise
- Amount (clots, flooding, pads/hour), timing (intermenstrual, postcoital, postmenopausal), duration, pain, associated discharge
Reproductive context
- LMP, cycle regularity, pregnancy possibility / contraception, smear history, parity
- Postmenopausal bleeding = endometrial cancer until proven otherwise
Screen
- If pregnant: ectopic (unilateral pain, shoulder-tip), miscarriage, molar
- If not: fibroids, polyps, PCOS, bleeding disorder, cervical/endometrial pathology
Differentials to screen
Ectopic pregnancyPositive β-hCG, unilateral pain, amenorrhoea then bleeding — emergency
Miscarriage / threatened miscarriagePregnant, bleeding ± cramping, os open/closed
Endometrial carcinomaPostmenopausal bleeding — 2-week-wait referral
Fibroids / polypsHeavy/prolonged menstrual bleeding, bulk symptoms
Cervical pathologyPostcoital/intermenstrual bleeding, smear history
Red flags — exclude these
- Postmenopausal bleeding (endometrial cancer)
- Positive pregnancy test with pain (ectopic)
- Haemodynamic instability (heavy bleeding)
- Postcoital bleeding with an abnormal cervix
OSCE tips
- Establish pregnancy status first — it changes everything.
- Postmenopausal bleeding is a 2-week-wait referral until endometrial cancer is excluded.
- Any pregnant woman with pain + bleeding = exclude ectopic urgently.