You wake up one morning and discover a small rash on your tummy, just above your belly button. It does not itch at first. In the next couple of days, the rash gradually spreads towards your chest and your upper legs. You feel otherwise well except for mild-flu like symptoms.
The rash starts to itch more and more. You visit your local drugstore and the woman behind the counter recommends a menthol gel to rub on your rash to relieve the itch. However this does not work. It is almost 12 days since you had these symptoms and panic really starts to set in.
You are convinced it is due to an allergic reaction you have and call your GP practice for an appointment.
The assistant is very understanding and arranges an appointment with your GP the same day.
At the GP, you are asked several questions like:
- When did it start?
- How does it affect your daily life?
- Are you taking any medication?
- Have you ever had this before?
- Did you feel generally unwell before the onset of the rash?
- Have you developed any fever, weight loss, changes in appetite?
- Any possible factors that cause this for instance changes in your diet or new hobbies?
- Does this type of condition occur with other family members?
You answer accordingly and note that you had taken ibuprofen a few days prior to your rash due to throat pain and general aches. Then your GP performs a focused physical examination. She then says you have a urticaria (a medical word for rash) possibly due to the Ibuprofen you took. She concludes it will go away and would like to send you home with some medication against the itch and review if things get worse. However, you are convinced that it could be your diet or something else you are allergic to and would like to have blood tests.
In general screening tests for dietary causes of allergies or IgE specific allergens are not needed for a rash that is persistent for less than 6 weeks without any other serious complications.
Your GP will only consider doing further tests for allergies if the following occur
- You develop a rash within 60 minutes of ingesting one specific food type.
- You have no rash when you do not ingest that specific type of food
If symptoms persist for more than 6 weeks your GP will refer you to a dermatologist.
Here are other reasons your GP will refer you to a specialist if you have urticaria
- If they suspect that you are allergic to a certain type of medication for which there are no alternative treatments
- If you suffer from a hereditary condition called C1-esterase inhibitor deficiency. This condition is when you have angio-oedema (swelling), abdominal complaints, laryngeal oedema but NO rash.
Your GP has managed to convince you that for now you do not need further tests.
She prescribes you antihistamines. Here are 2 antihistamine medications you will most likely receive from your GP for a rash that is itchy.
- Levocetirizine or
If you are pregnant then your GP will prescribe you
Levomenthol gel is not effective in treating the rash however can be used in combination with the antihistamines for a soothing effect.
You try the medication for a few days but see no effect. You contact your GP as she suggested. This time an appointment is not made, but your GP increases the antihistamine dose to one tablet twice a day. She reassures you that this will eventually go away in 3 to 4 weeks.
Women who experience vaginal blood loss during menopause will visit their GP due to menstruation when they are no longer supposed to be menstruating (post-menopausal).
Here are 5 key questions your GP will ask you before referring you to a specialist
- Is the blood loss only from your vagina? You might find this an awkward question, but this is to make sure to rule out any rectal blood loss which could look and feel like blood coming from the vagina. Especially if the woman is known to have haemorrhoids, it is a topic that your GP will want to briefly touch on and move on to the next question
- The 3 How’s: How does the vaginal blood loss occur, how often does it occur a day/week and how long does it last for.
- Does vaginal blood loss occur after sexual intercourse. If this is the case, the GP will need to determine whether it is a cervical polyp or the lining of the vagina that is wearing thin and after friction bleeds easily. This is also known as vaginal atrophy.
- Do you use any medication?
- Could you possibly be at risk of a sexually transmitted disease? May sound strange that your GP asks you this for vaginal blood loss, however diseases like chlamydia can cause similar symptoms.
Things you must ask your GP during your consultation.
What are the changes that even after I have been referred to a specialist, I will be sent back to my GP for further treatment?
50% of the women who have post menopausal blood loss and are referred to a specialist do not have any serious underlying medical condition. In the majority of the cases, the blood loss is due to vaginal atrophy.
Do I have endometrial cancer with these symptoms?
Endometrial cancer is known to cause post menopausal blood loss. It occurs in about 2000 women per year in the Netherlands and of these 20% (400 women) will unfortunately die from this disease. In the majority of cases, when endometrial cancer is screened and treated early, just over 90% of women will make a full recovery.
Should my GP perform a PAP smear even if I’ve had one just recently?
Yes. For any woman with new onset of post menopausal blood loss regardless of the results of an old PAP smear, a new one must be requested. This is because it is important to rule out a cervical tumor. If a PAP smear is performed and the results are negative, then the GP will not need to refer you to a specialist. However if the laboratory finds slightly abnormal cells, they will proceed with further testing.
Your GP may decide to refer you for an ultrasound of your uterus and ovaries.
How certain am I that an ultrasound will accurately determine I do not have cancer?
A negative ultrasound has a strong predictive value, meaning if the ultrasound of the thickness of your uterus is small, then you can be 99% sure you do not have endometrial cancer.
So in summary for new onset post menopausal vaginal blood loss your GP will request a PAP smear and/or transvaginal ultrasound. Once these results are known, then a decision will be made whether to refer you to a specialist.
What if the vaginal blood loss returns despite the previous ‘ negative ‘ results? should I then get a referral?
Absolutely! Early screening is very important, and if you develop a recurrence of vaginal blood loss, your GP should refer you immediately to a specialist for further work-up such as histology.
Need to speak with HelloDoc about (post-menopausal) vaginal blood loss? Book an appointment with Dr. Irina Zenevica (GP with special interest in endocrinology and hormonal imbalance. She consults in English, Russian, Swedish and Dutch)