Domain – Women’s health (case)

Aamiina, aged 51, presents with a change in her menstruation and menopausal symptoms which are impacting her quality of life and relationships with her adult children and grandchildren. She has never had cervical cancer screening, breast cancer screening or bowel cancer screening. Her husband died 10 years ago. She is Muslim and originally from Somalia. She came to Australia via a refugee camp six years ago.

Communication and consultation skills
What communication strategies would you use to sensitively take a thorough history?
How would you explore Aamiina’s understanding of her symptoms? 
How would you approach this consultation if English is not Aamiina’s first language? How would you manage if she attended with her daughter as interpreter?

Clinical information gathering and interpretation
What specific information would you like to know about Aamiina’s menstrual cycle, vaginal bleeding and menopause symptoms?
How would you sensitively perform an appropriate physical examination?

Specific Information about Aamiina’s Menstrual Cycle, Vaginal Bleeding, and Menopause Symptoms

1. Menstrual Cycle:
   • Last Menstrual Period (LMP): When was her last menstrual period?
   • Menstrual Regularity: Has she noticed any changes in the regularity or frequency of her periods?
   • Duration and Flow: How long do her periods last, and has there been any change in the flow (heavier or lighter)?
   • Associated Symptoms: Are there any associated symptoms such as severe cramping, clotting, or changes in the color of the blood?
2. Vaginal Bleeding:
   • Intermenstrual Bleeding: Has she experienced any bleeding between periods?
   • Postcoital Bleeding: Any bleeding after sexual intercourse?
   • Postmenopausal Bleeding: Has there been any bleeding since her periods have stopped (if applicable)?
   • Pattern and Quantity: Can she describe the pattern and quantity of the bleeding? Has it been consistent, or does it vary?
3. Menopause Symptoms:
   • Vasomotor Symptoms: Is she experiencing hot flashes, night sweats, or chills?
   • Genitourinary Symptoms: Any vaginal dryness, discomfort, or changes in urinary habits?
   • Sleep Disturbances: Issues with insomnia or disrupted sleep patterns?
   • Psychological Symptoms: Any mood swings, anxiety, depression, or cognitive changes?
   • Sexual Function: Has she noticed any changes in libido or sexual function?
   • Overall Impact: How are these symptoms impacting her daily life and relationships?

Performing a Sensitive Physical Examination

1. Preparation:
   • Explain the Process: Clearly explain the purpose of the examination and each step you will take.
   • Obtain Consent: Ensure you have explicit consent before starting the examination. Reassure her that she can stop the examination at any time if she feels uncomfortable.
   • Chaperone: Offer a chaperone for the examination. This can provide additional comfort and support.
2. Creating a Comfortable Environment:
   • Privacy: Ensure the examination room is private and that she is comfortable.
   • Draping: Use drapes to cover her appropriately and maintain her dignity throughout the examination.
3. General Examination:
   • Vital Signs: Measure her blood pressure, heart rate, and temperature.
   • General Appearance: Assess her overall appearance, including signs of distress, anxiety, or discomfort.
4. Abdominal Examination:
   • Inspection: Look for any visible abnormalities, distention, or scarring.
   • Palpation: Gently palpate the abdomen to assess for tenderness, masses, or organomegaly.
5. Pelvic Examination (if indicated and with consent):
   • Positioning: Help her into a comfortable position, typically lying on her back with her knees bent and feet flat or in stirrups.
   • External Examination: Inspect the external genitalia for any abnormalities, lesions, or signs of infection.
   • Speculum Examination: If indicated, use a speculum to inspect the vaginal walls and cervix. Explain each step and ensure she is comfortable throughout.
   • Bimanual Examination: Palpate the uterus and adnexa to assess for tenderness, masses, or other abnormalities.
6. Breast Examination:
   • Inspection: Observe for any asymmetry, skin changes, or visible lumps.
   • Palpation: Systematically palpate each breast and the axillary regions to detect any lumps or abnormalities.

Sensitive Communication During Examination

• Verbal Reassurance: Continually reassure Aamiina throughout the examination, explaining what you are doing and why.
• Check for Comfort: Frequently check if she is comfortable and address any concerns she might have.
• Cultural Sensitivity: Be mindful of her cultural and religious background, and ensure she feels respected and valued throughout the process.

Making a diagnosis, decision making and reasoning
Aamiina has had prolonged, irregular heavy periods for six months, and intermenstrual spotting. She has not been sexually active since her husband’s death. She has also had low energy, low mood, poor sleep and hot flushes. What diagnoses are you considering? What red flag condition/s are important to consider?
What investigations would you consider and why?
What if Aamiina was 39 years old?
Would you consider other diagnoses and arrange other investigations?

Potential Diagnoses

1. Menorrhagia and Dysfunctional Uterine Bleeding (DUB): Given her age and the duration of symptoms, menorrhagia (heavy menstrual bleeding) and dysfunctional uterine bleeding are primary considerations.
2. Perimenopause or Menopause: Her symptoms of hot flushes, mood changes, and sleep disturbances suggest she may be transitioning through perimenopause or menopause.
3. Anemia: Prolonged heavy periods can lead to iron-deficiency anemia, contributing to her low energy levels.
4. Thyroid Dysfunction: Hypothyroidism or hyperthyroidism can cause menstrual irregularities and mood changes.
5. Endometrial Pathologies: Conditions such as endometrial hyperplasia or endometrial cancer need to be ruled out, particularly with her history of irregular bleeding and intermenstrual spotting.

Red Flag Conditions

1. Endometrial Cancer: Postmenopausal bleeding is a significant red flag and warrants investigation for endometrial cancer.
2. Uterine Fibroids: These can cause heavy and irregular bleeding and need to be considered.
3. Coagulopathies: Disorders that affect blood clotting can cause abnormal uterine bleeding.

Investigations to Consider

1. Blood Tests:
   • Complete Blood Count (CBC): To check for anemia.
   • Thyroid Function Tests (TFTs): To rule out thyroid dysfunction.
   • Hormone Levels: Including FSH, LH, estradiol, and possibly prolactin to assess menopausal status and other hormonal imbalances.
2. Pelvic Ultrasound:
   • To visualize the uterus, endometrium, and ovaries. This can help identify fibroids, polyps, and other structural abnormalities.
3. Endometrial Biopsy:
   • To rule out endometrial hyperplasia or cancer, especially if the ultrasound suggests thickened endometrial lining or other abnormalities.
4. Pap Smear:
   • Given her lack of cervical cancer screening, a Pap smear is essential to screen for cervical cancer or dysplasia.
5. Transvaginal Ultrasound:
   • For detailed imaging of the endometrium and to help guide any necessary biopsies.

If Aamiina was 39 Years Old

If Aamiina were 39 years old, the differential diagnoses would include:

1. Premature Ovarian Insufficiency (POI): Early menopause or POI could explain her menopausal symptoms at a younger age.
2. Polycystic Ovary Syndrome (PCOS): Irregular heavy periods and other systemic symptoms could indicate PCOS.
3. Fibroids or Polyps: These are common causes of abnormal uterine bleeding in women of reproductive age.

Additional Investigations for a 39-Year-Old Aamiina

1. Hormonal Assays:
   • FSH, LH, Estradiol: To evaluate ovarian reserve and function.
   • Androgens: To check for elevated androgen levels indicative of PCOS.
2. Pelvic MRI:
   • If the ultrasound is inconclusive, an MRI may provide more detailed imaging.
3. Hysteroscopy:
   • Direct visualization of the uterine cavity to assess for polyps, fibroids, or other intrauterine pathology.
4. Glucose Tolerance Test:
   • If PCOS is suspected, a glucose tolerance test may be useful to screen for insulin resistance or diabetes.

Management Approach

• Symptom Management:
  • Discuss options for managing heavy bleeding (e.g., hormonal therapy, tranexamic acid).
  • Address menopausal symptoms (e.g., hormone replacement therapy, lifestyle modifications).
  • Treat anemia if present (iron supplementation).
• Regular Monitoring and Follow-Up:
  • Schedule follow-ups to monitor symptoms, treatment efficacy, and any new developments.

Clinical management and therapeutic reasoning
You arrange for Aamiina to perform self-collected cervical screening. Aamiina’s results show non-16/18 HPV. How do you manage this result?

You think Aamiina has late perimenopause. What is your approach to management? How will you ensure she is involved in the decisions about management?
What are your management options for her prolonged heavy menstrual bleeding?
What about managing menopausal symptoms impacting her quality of life?

Management of Late Perimenopause

Approach to Management:

1. Education and Involvement:
   • Discuss the symptoms and stages of perimenopause with Aamiina, ensuring she understands what is happening to her body.
   • Involve her in decision-making by discussing the benefits and risks of different management options.
2. Symptom Management:
   • Lifestyle Modifications: Encourage regular exercise, a balanced diet, and stress reduction techniques (e.g., yoga, mindfulness).
   • Non-Hormonal Treatments: Consider options such as SSRIs/SNRIs for mood symptoms, and gabapentin or clonidine for hot flushes if hormone therapy is not suitable or desired.
3. Hormonal Therapy:
   • Hormone Replacement Therapy (HRT): Discuss the potential benefits and risks of HRT. If she is a suitable candidate and consents, HRT can be effective in managing vasomotor symptoms and mood changes.

Management of Prolonged Heavy Menstrual Bleeding

Management Options:

1. Non-Hormonal Options:
   • Tranexamic Acid: Taken during periods to reduce bleeding.
   • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Can reduce menstrual bleeding and relieve pain.
2. Hormonal Options:
   • Levonorgestrel Intrauterine System (LNG-IUS): Highly effective in reducing menstrual bleeding.
   • Combined Oral Contraceptive Pill (COCP): Can regulate menstrual cycles and reduce bleeding.
   • Oral Progesterone or Injectable Progesterone: Can be used to control heavy bleeding.
3. Surgical Options:
   • Endometrial Ablation: For women who do not respond to medical management and do not desire future fertility.
   • Hysterectomy: Considered for severe cases where other treatments have failed and the woman has completed her family.

Management of Menopausal Symptoms Impacting Quality of Life

Management Options:

1. Hormone Replacement Therapy (HRT):
   • Individualized Approach: Tailor the therapy based on her symptoms, medical history, and preferences.
   • Forms of HRT: Oral, transdermal patches, gels, or vaginal preparations depending on her needs and risk factors.
2. Non-Hormonal Treatments:
   • SSRIs/SNRIs: For mood symptoms and vasomotor symptoms if HRT is contraindicated or not desired.
   • Gabapentin or Clonidine: For hot flushes and night sweats.
3. Lifestyle Modifications:
   • Encourage a balanced diet rich in calcium and vitamin D to support bone health.
   • Promote regular physical activity to improve mood, sleep, and overall well-being.
   • Suggest techniques like yoga, mindfulness, and relaxation exercises to manage stress and improve sleep quality.
4. Complementary Therapies:
   • Consider discussing the use of phytoestrogens, acupuncture, or other complementary therapies if Aamiina is interested, with a focus on evidence-based options.

Preventive and population health
What barriers to accessing care might exist for Aamiina and how might these be managed?
What communication and other approaches in relation to health screening would increase safety and improve communication with culturally and linguistically diverse patients?
What screening would you offer Aamiina?
What screening would you consider for Amiina’s mental health relating to menopause and her social and emotional wellbeing?

Barriers to Accessing Care for Aamiina and Management Strategies

Potential Barriers:

1. Language Barrier: Aamiina might struggle to understand medical information and communicate her symptoms effectively if English is not her first language.
2. Cultural Barriers: Cultural beliefs and practices might influence her perceptions of illness and treatment. She might prefer female healthcare providers for certain examinations due to cultural or religious reasons.
3. Socioeconomic Barriers: Limited financial resources may affect her ability to afford healthcare services, medications, or transportation to appointments.
4. Immigration and Refugee Experience: Previous trauma or instability from her refugee experience might affect her mental health and trust in healthcare systems.
5. Lack of Awareness: She may not be aware of the healthcare services available to her, including preventive screenings.

Management Strategies:

1. Language Support:
   • Provide professional interpreter services for consultations.
   • Use translated written materials and visual aids to enhance understanding.
2. Cultural Sensitivity:
   • Train healthcare staff in cultural competence to ensure respectful and appropriate care.
   • Allow for flexibility in scheduling to accommodate her religious practices.
3. Socioeconomic Support:
   • Connect her with social services that can provide financial assistance, transportation, or other support.
   • Inform her about bulk-billing practices and other affordable healthcare options.
4. Trust Building:
   • Build a trusting relationship through empathy, patience, and consistent follow-up.
   • Be aware of and address any past trauma sensitively.
5. Education and Outreach:
   • Provide education on the importance of preventive screenings and how to access them.
   • Use community health workers or liaisons who understand her cultural background to bridge gaps in communication.

Approaches to Health Screening for Culturally and Linguistically Diverse Patients

1. Clear Communication: Use simple, jargon-free language.Utilize interpreters or bilingual healthcare providers to facilitate communication.
2. Patient-Centered Care:
   • Take the time to understand the patient’s cultural and personal context.
   • Involve family members if appropriate and consented by the patient.
3. Educational Materials:
   • Provide culturally appropriate educational materials in the patient’s preferred language.
   • Use visual aids and diagrams to explain procedures and the importance of screenings.
4. Community Engagement:
   • Engage with community leaders and organizations to promote awareness about health screenings.
   • Organize community health events to provide information and services in a comfortable environment.

Screenings to Offer Aamiina

1. Cervical Cancer Screening: Pap smear or HPV test (already performed, showing non-16/18 HPV).
2. Breast Cancer Screening: Mammography given her age and lack of previous screening.
3. Bowel Cancer Screening: Fecal occult blood test (FOBT) or colonoscopy, as appropriate for her age group.
4. Bone Health: Bone mineral density test (DEXA scan) due to menopausal status and risk of osteoporosis. not medicare funded
5. General Health Screenings:
   • Blood pressure, cholesterol levels, and blood glucose levels to monitor cardiovascular health.
   • Comprehensive blood panel including CBC to check for anemia or other deficiencies.

Mental Health Screening Relating to Menopause and Social and Emotional Wellbeing

1. Mental Health:
   • DASS21 or GAD-7: To screen for symptoms of depression and anxiety.
   • PCL-5: To screen for PTSD, particularly considering her refugee background.
   • MRS: To assess the impact of menopausal symptoms on her quality of life.
2. Social and Emotional Wellbeing:
   • MSPSS: To evaluate her perceived social support network and identify areas where additional support may be needed.
   • Direct Inquiry: Ask about her social support network, including family, friends, and community involvement.
3. Referral and Support:
   • Mental Health Services: Refer to appropriate mental health services for counseling or psychiatric care if significant symptoms are identified.
   • Community Support: Connect her with community support groups, particularly those tailored to immigrant and refugee populations, to provide social and emotional support.

Enhancing Safety and Communication

1. Use of Interpreters: Ensure the interpreter understands medical terminology and the patient’s cultural context.
2. Patient Empowerment: Empower patients by providing them with clear information about their health and involving them in decision-making processes.
3. Regular Follow-Ups: Schedule regular follow-ups to monitor health, address concerns, and reinforce the importance of preventive care.
4. Holistic Approach: Address not only physical health but also emotional, social, and psychological well-being.

Professionalism
How would you determine if you are performing clinician-collected cervical cancer screening tests effectively? 
Where would you look for referral pathways for patients who are culturally and linguistically diverse, including refugee patients?

Determining Effective Performance in Clinician-Collected Cervical Cancer Screening

1. Adherence to Guidelines:
   • Ensure compliance with the National Cervical Screening Program (NCSP) guidelines in Australia, including the frequency of testing and management of abnormal results.
2. Quality Assurance Measures:
   • Cytology Results: Regularly review the quality of the collected samples by evaluating the adequacy of the cytology results. Ensure that samples are sufficient for accurate assessment.
   • Colposcopy Referrals: Monitor the follow-up rates for abnormal results, ensuring timely referrals to colposcopy and further management as indicated.
   • Positive Detection Rates: Track the rate of positive detections and compare them with regional or national averages to ensure effectiveness without over or under-diagnosing.
3. Patient Outcomes and Feedback:
   • Patient Follow-Up: Monitor patient outcomes, including treatment success and recurrence rates for pre-cancerous or cancerous lesions.
   • Patient Feedback: Gather feedback from patients regarding their experience, including comfort, understanding of the procedure, and overall satisfaction.
4. Continued Education and Training:
   • Ongoing Training: Participate in continuing professional development (CPD) activities to stay updated with the latest guidelines and techniques.
   • Peer Review: Engage in peer review or mentorship programs to receive feedback and improve techniques.
5. Audit and Benchmarking:
   • Conduct regular audits of screening processes and outcomes.
   • Benchmark performance against national standards and peer performance.

Referral Pathways for Culturally and Linguistically Diverse (CALD) Patients, Including Refugees

1. Local Health Networks and Hospitals:
   • Check with local health networks and hospitals, which often have established pathways and resources for managing CALD and refugee patients. These include multicultural health services and specialized clinics.
2. Multicultural Health Services:
   • New South Wales: Multicultural Health Communication Service.
   • Victoria: Victorian Refugee Health Network.
   • Queensland: Queensland Health Multicultural Services.
3. Non-Governmental Organizations (NGOs) and Community Organizations:
   • Refugee Council of Australia: Provides information and support for refugees and asylum seekers.
   • Australian Red Cross: Offers various programs for refugees, including health support.
   • Multicultural Health Connect: National information and referral service that can assist in finding appropriate health services for CALD populations.
4. Primary Health Networks (PHNs):
   • PHNs often have resources and referral pathways tailored for CALD and refugee patients, facilitating access to appropriate healthcare services.
5. Professional Associations and Guidelines:
   • RACGP (Royal Australian College of General Practitioners): Offers guidelines and resources for treating refugee and migrant patients.
   • Australasian Society for Infectious Diseases (ASID): Provides guidelines on healthcare for refugees and asylum seekers.

General practice systems and regulatory requirements
How do you obtain and record informed consent for physical examination?
Does your medical software capture information about cultural and linguistic diversity?
What processes has your practice got in place for managing abnormal results?

Obtaining and Recording Informed Consent for Physical Examination

Steps to Obtain Informed Consent:

1. Explain the Procedure:
   • Clearly describe the purpose, process, and benefits of the physical examination. Use straightforward language and avoid medical jargon. For example, “I need to examine your abdomen to check for any pain or abnormalities. This involves gently pressing on different areas to feel for any unusual lumps or tenderness.”
2. Discuss Potential Risks and Discomforts:
   • Inform the patient about any potential discomfort or risks associated with the examination. For instance, “You might feel a bit of pressure when I press on your abdomen, but it shouldn’t be painful. Please let me know if you experience any pain or discomfort.”
3. Offer Opportunity for Questions:
   • Allow the patient to ask questions and address any concerns they might have. This can help alleviate anxiety and ensure they fully understand what will happen. For example, “Do you have any questions about the examination or any concerns you’d like to discuss?”
4. Verify Understanding:
   • Ask the patient to repeat back their understanding of the procedure to confirm comprehension. You might say, “Can you tell me in your own words what we will be doing today and why it’s important?”
5. Seek Explicit Consent:
   • Obtain verbal or written consent, depending on the practice’s policy. Verbal consent can be sufficient for routine exams, while written consent may be necessary for more invasive procedures. For example, “Do I have your permission to proceed with the abdominal examination?”

Recording Informed Consent:

• Documentation in Medical Records:
  • Record the details of the consent process in the patient’s medical record. Include the date, the information provided, and the patient’s consent. An entry might look like this: “Explained the abdominal examination procedure, including purpose, steps, and potential discomfort. Patient expressed understanding and gave verbal consent to proceed.”
• Electronic Medical Records (EMR):
  • Use the designated fields in your EMR software to document consent. Many systems have specific sections for recording informed consent, ensuring that this critical information is easily accessible.

Capturing Information about Cultural and Linguistic Diversity in Medical Software

Steps to Capture Cultural and Linguistic Diversity:

1. Patient Demographics Section:
   • Ensure that the EMR has fields for recording cultural background, preferred language, and any specific cultural or religious considerations. This might include fields for “Country of Origin,” “Primary Language,” and “Cultural Considerations.”
2. Data Entry During Registration:
   • Train administrative staff to collect this information during patient registration. They should ask questions such as, “What is your preferred language for medical communication?” and “Are there any cultural or religious practices we should be aware of to provide better care?”
3. Regular Updates:
   • Encourage staff to update this information regularly, particularly if the patient’s circumstances change. This ensures that the most current and relevant information is always available.
4. Utilize Alerts and Flags:
   • Set up alerts or flags in the EMR to notify clinicians of important cultural or linguistic information. For example, a flag might indicate, “Patient requires an interpreter for medical consultations.”

Processes for Managing Abnormal Results

Steps to Manage Abnormal Results:

1. Prompt Review and Documentation:
   • Ensure abnormal results are reviewed promptly by the responsible clinician. Document the review and any immediate actions taken in the patient’s record.
2. Communication with Patient:
   • Communicate abnormal results to the patient in a timely and sensitive manner. Use clear and empathetic language, and ensure the patient understands the significance of the results and the next steps. For instance, “Your recent blood test showed higher-than-normal cholesterol levels. This can increase your risk of heart disease, so we need to discuss lifestyle changes and possibly medication to manage this.”
3. Follow-Up Plan:
   • Develop a follow-up plan that includes further tests, referrals, or treatments as needed. Document this plan in the patient’s record and communicate it clearly to the patient.
4. Tracking and Reminders:
   • Use the EMR to set reminders for follow-up appointments and additional tests. This ensures that no abnormal results are overlooked and that the patient receives ongoing care.
5. Referral Pathways:
   • Have clear referral pathways for further investigation and specialist consultations. Maintain a list of trusted specialists and services that you can refer patients to based on their specific needs.
6. Multidisciplinary Team Meetings:
   • Discuss complex cases in multidisciplinary team meetings to ensure comprehensive care planning and coordination. Document the outcomes of these meetings in the patient’s record.

Procedural skills
How would you perform a gynaecological examination, including speculum examination?
How would your approach differ in a patient who had experienced trauma, such as female genital cutting or circumcision?
What if she had experienced sexual abuse?
What would you do if you could not find Aamiina’s cervix? What if there was blood or discharge obscuring the cervix?
What would you do if Aamiina wanted screening for sexually transmissible infections at the same time?
When would you suggest a clinician collected cervical cancer screening test?

Performing a Gynecological Examination, Including Speculum Examination

Steps for a Standard Gynecological Examination:

1. Preparation:
   • Explain the Procedure: Clearly explain the purpose, steps, and what the patient can expect during the examination. Ensure informed consent is obtained.
   • Gather Equipment: Ensure you have a speculum (appropriate size), lubricant, gloves, light source, swabs, and collection tools for cervical screening or STI testing.
   • Patient Positioning: Help the patient into the lithotomy position, with her feet in stirrups and her buttocks at the edge of the examination table.
2. External Examination:
   • Inspection: Inspect the external genitalia for any abnormalities, lesions, or signs of infection.
   • Palpation: Gently palpate the labia, clitoris, and perineum to check for any tenderness or masses.
3. Speculum Examination:
   • Selection and Lubrication: Choose an appropriate-sized speculum and apply a small amount of water-based lubricant.
   • Insertion: Gently separate the labia with your non-dominant hand. With the patient’s relaxation encouraged, slowly insert the speculum at a 45-degree angle, pointing downwards and posteriorly. Once inside, open the blades slowly to visualize the cervix.
   • Inspection: Inspect the cervix and vaginal walls. Note any abnormalities, lesions, or discharge.
   • Cervical Screening: Collect samples for Pap smear or HPV testing using the appropriate brush and spatula, rotating them gently to collect cells from the ectocervix and endocervix.
   • STI Screening: If requested, collect swabs for gonorrhea, chlamydia, and other STIs as needed.
   • Removal: Carefully close the speculum blades and gently remove it, ensuring the patient remains comfortable.
4. Bimanual Examination:
   • Insertion of Fingers: Insert two lubricated fingers into the vagina while applying gentle pressure on the lower abdomen with your other hand.
   • Palpation: Assess the size, shape, and position of the uterus, as well as any adnexal masses or tenderness.

Approach for Patients Who Have Experienced Trauma (e.g., Female Genital Cutting or Sexual Abuse)

1. Initial Interaction:
   • Respect and Comfort: Begin the consultation with the patient sitting upright and fully clothed. This helps to maintain their sense of control and dignity.
   • Open Communication: Engage in a conversation to build rapport and trust before discussing the examination.
2. Patient Education:
   • Clear Explanation: Clearly explain the purpose, steps, and benefits of the pelvic exam. Break down the information into understandable parts and ensure the patient understands each component.
   • Use of Visual Aids: Consider using diagrams or models to help explain the procedure.
3. Consent Process:
   • Explicit Consent: Obtain explicit verbal or written consent while the patient is still fully clothed. Ensure they understand that they can withdraw consent at any time.
   • Interpreter Services: If the patient prefers another language, use a professional interpreter to facilitate clear communication.
4. Empathy and Sensitivity:
   • Acknowledging Trauma: Be sensitive to the patient’s trauma history. Acknowledge their feelings and validate their concerns.
   • Allowing Time: Allow extra time for the patient to ask questions and express any fears or anxieties they may have.
5. Chaperone Offer:
   • Optional Support: Offer the presence of a chaperone or a support person during the examination for added comfort and reassurance.
6. Step-by-Step Process:
   • Explain Each Step: As you move to the actual examination, explain each step before performing it. For example, “I am now going to gently insert the speculum. Please let me know if you feel any discomfort, and we can stop at any time.”
   • Patient Control: Reassure the patient that they have control over the examination process and can pause or stop the procedure if they feel uncomfortable.
7. Minimizing Discomfort:
   • Gentle Techniques: Use gentle techniques and appropriate lubrication to minimize physical discomfort.
   • Small Speculum: Consider using a smaller speculum if it is appropriate for the patient’s anatomy and comfort.
8. Female Genital Cutting (FGC):
   • Modified Techniques: Be aware that anatomical changes from FGC may require adjustments in technique and positioning. Use additional lubrication and a smaller speculum.
   • Communication: Communicate each step clearly and ask for feedback on comfort. Be prepared to pause or stop if the patient experiences discomfort or distress.
9. Sexual Abuse:
   • Extra Sensitivity: Take extra care to explain each step and proceed slowly. Validate the patient’s feelings and provide emotional support.
   • Chaperone Presence: Ensure the presence of a trusted chaperone or support person if desired by the patient.
   • Gradual Approach: Consider breaking the examination into stages if needed, starting with less invasive components.

Handling Difficulties in Finding the Cervix or Obstructions

1. Difficulty Finding the Cervix:
   • Adjust Position: Reposition the speculum or adjust the angle of insertion. Have the patient perform a slight pelvic tilt if needed.
   • Withdraw the speculum: rather than continuing to manipulate it, and locate the position of the cervix with a gloved hand (moistened with water, not lubricant). Reinsert the speculum at the appropriate angle in the direction of the cervix.
   • Use of Tools:
     • Use a longer speculum or consider the use of a tenaculum to gently grasp the cervix and bring it into view.
   • Vaginal wall laxity:
     • If the vaginal walls are lax making visualisation difficult, consider using a wider or longer speculum. A condom with the end cut off placed over the speculum may prevent the vaginal wall from collapsing.
     • Ensure the woman has no history of a latex allergy.
2. Blood or Discharge Obscuring the Cervix:
   • Clear the View: Use swabs to gently clean the area and remove blood or discharge.
   • Consider Rescheduling: If visibility remains poor, consider rescheduling the examination for a time when the patient is not menstruating.

Concurrent Screening for Sexually Transmissible Infections (STIs)

1. Incorporate STI Screening:
   • Collection During Exam: Collect appropriate swabs or urine samples for STI screening during the speculum examination.
   • Inform the Patient: Explain the additional steps and why they are being done, ensuring consent is obtained for STI screening.

Clinician-Collected Cervical Cancer Screening Test Indications

• Routine Screening: Recommend clinician-collected cervical cancer screening every 5 years for women aged 25-74, following the National Cervical Screening Program guidelines.
• Symptomatic Patients: Suggest a clinician-collected test if the patient presents with symptoms such as abnormal bleeding, discharge, or pelvic pain.
• History of Abnormal Results: Conduct more frequent screening if there is a history of abnormal cervical screening results or HPV infections.
• Patient Preference: Offer a clinician-collected test if the patient prefers this method over self-collection, or if there are concerns about the adequacy of a self-collected sample.

Managing uncertainty
If Aamiina has HPV non-16/18 with normal liquid-based cytology, normal transvaginal pelvic ultrasound, and normal colposcopy and cervical biopsy, would you perform other investigations for her intermenstrual bleeding?

Differential Diagnoses to Consider:

1. Endometrial Pathologies:
   • Endometrial Hyperplasia: Even with a normal biopsy, consider repeating if symptoms persist or worsen.
   • Endometrial Polyps: Sometimes polyps can be missed on ultrasound and colposcopy.
2. Hormonal Imbalances:
   • Thyroid Dysfunction: Thyroid function tests (TSH, Free T4) to rule out hypo or hyperthyroidism.
   • Prolactin Levels: Hyperprolactinemia can cause menstrual irregularities.
   • Other Hormonal Tests: FSH, LH, estradiol, and androgens to evaluate for perimenopause, polycystic ovary syndrome (PCOS), or other endocrine disorders.
3. Coagulopathies:
   • Bleeding Disorders: Coagulation profile, including platelet count, PT, aPTT, and von Willebrand factor, to rule out bleeding disorders.
4. Structural Abnormalities:
   • Hysteroscopy: Direct visualization of the uterine cavity to identify any structural abnormalities such as polyps or submucosal fibroids that might not be detected on ultrasound.
5. Infections:
   • Endometritis: Consider endometrial cultures to rule out chronic endometritis, especially if there is associated pelvic pain.
6. Systemic Conditions:
   • Liver or Kidney Disease: Basic metabolic panel to rule out systemic diseases that might contribute to abnormal bleeding.

Recommended Investigations:

1. Repeat Endometrial Biopsy:
   • Consider repeating an endometrial biopsy if symptoms persist or if there is a high index of suspicion for endometrial pathology.
2. Hormonal Assays:
   • TSH and Free T4
   • Prolactin
   • FSH, LH, estradiol (consider timing within the menstrual cycle)
3. Coagulation Profile:
   • PT, aPTT, platelet count, von Willebrand factor antigen
4. Hysteroscopy:
   • Consider diagnostic hysteroscopy to directly visualize the endometrial cavity and identify any lesions or abnormalities that might have been missed on ultrasound.
5. Infectious Workup:
   • Endometrial cultures or swabs for chronic endometritis, particularly if there’s a history of pelvic pain or previous infections.
6. Systemic Screening:
   • Basic metabolic panel (BMP) or comprehensive metabolic panel (CMP) to evaluate liver and kidney function.

Management Approach:

• Symptom Management: Address her symptoms with appropriate medical therapy, such as nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and bleeding, hormonal therapies (e.g., combined oral contraceptives, progesterone therapy), or tranexamic acid.
• Follow-Up: Schedule regular follow-up appointments to monitor her symptoms and the effectiveness of any treatments initiated.
• Patient Education: Educate Aamiina on the potential causes of her symptoms, the purpose of each investigation, and involve her in the decision-making process regarding her care.

Identifying and managing the significantly ill patient
Aamiina presents seven days after colposcopy and biopsy with fevers, chills, light-headedness, malodorous vaginal discharge and pelvic pain. What are your differential diagnoses?
What if her anaemia was clinically significant and her Hb was 72g/L?
What clinical features would influence your decision to refer her for treatment in hospital?

Differential Diagnoses

1. Post-Procedure Infection:
   • Endometritis: Infection of the endometrial lining, especially following invasive procedures.
   • Pelvic Inflammatory Disease (PID): Infection of the upper genital tract, which may include endometritis, salpingitis, and oophoritis.
   • Cervical or Vaginal Infection: Localized infection at the site of biopsy.
2. Sepsis:
   • A systemic inflammatory response to infection that can lead to severe systemic symptoms and requires urgent intervention.
3. Hematoma Formation:
   • Formation of a hematoma at the biopsy site, which could become infected or cause significant discomfort.
4. Retained Foreign Material:
   • Rarely, retained material such as a gauze or tampon used during the procedure could cause infection.

Clinical Considerations for Significant Anemia

If Aamiina’s anemia was clinically significant with a hemoglobin level of 72 g/L, this would suggest severe anemia which could contribute to her symptoms of light-headedness and fatigue.

1. Potential Causes of Anemia:
   • Chronic Blood Loss: From prolonged heavy menstrual bleeding.
   • Nutritional Deficiency: Such as iron deficiency, which may need to be addressed.
   • Chronic Disease: An underlying chronic condition contributing to anemia.
2. Management of Severe Anemia:
   • Immediate Evaluation: Assess the severity of anemia and its impact on her hemodynamic stability.
   • Transfusion: Consider the need for blood transfusion, particularly if she is symptomatic or hemodynamically unstable.
   • Iron Supplementation: Oral or intravenous iron supplementation may be necessary.

Clinical Features Influencing Referral for Hospital Treatment

1. Signs of Sepsis:
   • High Fever: Persistent fever above 38°C.
   • Chills and Rigors: Indicating a systemic infection.
   • Tachycardia: Heart rate above 100 bpm.
   • Hypotension: Systolic blood pressure below 90 mmHg or a significant drop from baseline.
   • Confusion or Altered Mental Status: Indicative of severe infection or sepsis.
   • Respiratory Distress: Increased respiratory rate or difficulty breathing.
2. Severe Pelvic Pain:
   • Uncontrolled pain that does not respond to oral analgesics, suggesting possible severe infection or complication.
3. Malodorous Discharge:
   • Suggestive of an infectious process that requires intravenous antibiotics and further investigation.
4. Hemodynamic Instability:
   • Light-headedness, dizziness, or syncope indicating potential hemodynamic compromise due to anemia or sepsis.
5. Severe Anemia:
   • Hemoglobin level of 72 g/L, especially if symptomatic, indicating the need for transfusion and further investigation.

Immediate Actions and Hospital Referral

1. Immediate Assessment:
   • Perform a thorough clinical assessment including vital signs, physical examination, and laboratory tests (CBC, blood cultures, inflammatory markers).
2. Stabilization:
   • Initiate intravenous fluids and broad-spectrum antibiotics to cover likely pathogens causing post-procedure infections.
3. Hospital Referral:
   • Refer Aamiina to the hospital for further evaluation and treatment due to the severity of her symptoms, potential sepsis, and significant anemia. The need for possible transfusion, intravenous antibiotics, and close monitoring would be best managed in a hospital setting.