CCFP priority topic 102 of 105
Vaginal Bleeding on the CCFP exam
4 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 22, 2026.
What the exam tests
Key features
The CFPC’s 4 key features for Vaginal Bleeding. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 4
Pregnancy test first
Check for pregnancy first in every patient who comes in with bleeding.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Health Canada
On the exam
A 17-year-old with heavy bleeding and cramps, two days after a fall. Expect a short menu (pick several from a list) of first tests.
Pick the first tests.
Common mistakes
An X-ray or CT for pain after the fall before you know if she is pregnant. Or cultures and a clotting screen that do not explain the bleeding.
Approach
- Test every patient who could be pregnant, from the first period to menopause. Test even when sex is denied.
- Ask a teen about sex alone, without a parent in the room.
- Positive test: find out where the pregnancy is.
- Know the result before any X-ray or CT.
- Do not start a combined pill until pregnancy is excluded. Canadian product labels list suspected pregnancy and unexplained bleeding as reasons not to.
- A work-up for a bleeding disorder comes after a negative test, not before it.
Key feature 2 of 4
Bleeding in pregnancy
When a pregnant patient bleeds, find the dangerous cause, give Rh care, and treat shock.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, diagnosis, treatmentSources Society of Obstetricians and Gynaecologists of Canada
On the exam
Positive test, empty uterus, a mass beside the ovary, then falling pressure. Expect one best answer at each step.
Pick the diagnosis, then the next step.
Common mistakes
Calling it a completed miscarriage, or rescanning once the pressure falls. Then giving Rh immunoglobulin at six weeks, which current Canadian guidance advises against.
Approach
- Early pregnancy: think ectopic pregnancy and miscarriage. Later on: think placental abruption, the placenta pulling away from the uterine wall.
- No clear pregnancy in the uterus on ultrasound: keep ectopic in mind. A mass beside the uterus makes an ectopic more likely.
- Consider a second blood level of the pregnancy hormone, human chorionic gonadotropin (hCG), 48 hours later. It lowers the chance of missing an ectopic.
- Do not call it a complete miscarriage on an empty uterus alone. Without an earlier scan or lab proof of a pregnancy in the uterus, follow hCG levels.
- Falling pressure with a likely ectopic: two large intravenous (IV) lines, fluids and blood, a crossmatch (matching donor blood for transfusion), and straight to surgery. No more imaging.
- Rh D-negative, not already sensitized (no anti-D antibodies in her blood), and bleeding: no Rh immunoglobulin before 8 weeks. From 8 to 12 weeks, usually none. After 12 weeks, the guideline suggests 300 µg.
- From 20 weeks, after a bleed that may have let fetal blood cross, measure how much fetal blood entered the mother's blood. Use a Kleihauer-Betke test or flow cytometry. The result sets the dose.
| Weeks pregnant | Rh immunoglobulin | Know this |
|---|---|---|
| Under 8 | Not recommended | Routine blood typing is not needed yet |
| 8 to 12 | Usually not | May be considered if the patient wants to avoid any risk |
| 12 to 19 | 300 µg suggested | Type and screen first; give it if she is Rh D-negative |
| 20 or more | Dose set by the test: 120 µg under 12 mL, 300 µg for 12 to 30 mL, more over 30 mL | Measure fetal blood with Kleihauer-Betke or flow cytometry |
Key feature 3 of 4
Not pregnant, bleeding heavily
Not pregnant: find serious causes by age, treat shock, and pick medicine or surgery.
CFPC skill Clinical reasoning, selectivityPhase Investigation, diagnosis, treatmentSources Society of Obstetricians and Gynaecologists of Canada, Choosing Wisely Canada, Health Canada
On the exam
A 15-year-old with heavy periods since her first one, nosebleeds and migraine with aura. Expect a short menu (pick several from a list), then one best answer.
Pick the work-up, then the treatment.
Common mistakes
Missing the bleeding-disorder clues at 15. Then a combined pill despite her aura, even a low-dose one, or ablation in a teen.
Approach
- Ask for clues to a bleeding disorder: heavy periods since the first one, nosebleeds, easy bruising, bleeding after dental work, and family history.
- Von Willebrand disease is the commonest inherited bleeding disorder. Its factor tests are usually done in specialised centres.
- Pick tests by age. In a teen with heavy periods since the first one, check for a bleeding disorder. In older patients, weigh structural causes and cancer.
- No Pap test at 15. It screens for cervical cancer; it does not explain heavy periods.
- Unstable: fluids, blood and urgent gynecology come before any office work-up.
- Stable but heavy: medical treatment first, such as a levonorgestrel intrauterine device (IUD) or tranexamic acid. Endometrial ablation (surgery that destroys the uterine lining) comes only if medical options fail or are declined.
- Migraine with aura rules out combined pills. Canadian product labels list it as a contraindication.
| Option | Fits her? | Why |
|---|---|---|
| Combined pill | No | Migraine with aura is a contraindication |
| Levonorgestrel IUD | Yes | A first medical choice, before any surgery |
| Tranexamic acid | Yes | Taken during the period to slow bleeding |
| Desmopressin | Maybe | Raises von Willebrand factor; used at the start of a period or before a procedure. |
| Endometrial ablation | No | Only after medical options fail or are declined |
Key feature 4 of 4
After menopause
Work up bleeding after menopause soon, with an exam, ultrasound and tissue sampling.
CFPC skill Clinical reasoningPhase InvestigationSources Choosing Wisely Canada
On the exam
A 62-year-old woman spots for the first time in nine years. Expect a short menu (pick several from a list) of first steps.
Pick the first steps.
Common mistakes
Calling it atrophy (a thin, dry vaginal lining) and giving vaginal estrogen with no work-up. Or a Pap test alone: it checks the cervix and misses the uterine lining.
Approach
- See any bleeding after menopause soon. Do not wait for the next routine visit.
- Ask about risk: obesity, diabetes, never having been pregnant, tamoxifen, and estrogen taken without a progestin.
- Examine the vulva, vagina and cervix with a speculum, then do a bimanual exam (two fingers in the vagina, the other hand on the belly). Blood can also come from the bladder or bowel.
- Book the work-up soon, or refer to gynecology if you cannot do it.
- Do a Pap test only if screening is due. It checks the cervix, not the lining.
- Bleeding that keeps coming back after normal tests still goes to gynecology.
Flashcards
Answer it first, then check.
KF 1Heavy bleeding and cramps in a teen who says she has never had sex. First test?
A pregnancy test. Her history cannot exclude pregnancy, and the result decides every next step.
KF 2Rh D-negative and miscarrying at 6 weeks. Does she need Rh immunoglobulin?
No. Canadian guidance since 2024 advises against it for any pregnancy loss before 8 weeks. Source: Society of Obstetricians and Gynaecologists of Canada
KF 2Rh D-negative with a threatened miscarriage at 14 weeks. What dose?
300 µg of Rh immunoglobulin. After 12 weeks, the 2024 guideline suggests giving it. Source: Society of Obstetricians and Gynaecologists of Canada
KF 2Positive test, empty uterus, a mass beside the ovary, pressure 80/50. Next step?
Resuscitate and go to the operating room now. Do not send her for more imaging.
KF 3Heavy periods since the first one, nosebleeds, and oozing after a tooth was pulled. Likeliest cause?
Von Willebrand disease, the commonest inherited bleeding disorder. Heavy periods are its most common sign in women. Source: Society of Obstetricians and Gynaecologists of Canada
KF 3Heavy periods and migraine with aura. Can she take a combined pill?
No. Aura is a contraindication. Offer a levonorgestrel IUD or tranexamic acid instead. Source: Health Canada, Choosing Wisely Canada, Society of Obstetricians and Gynaecologists of Canada
KF 4A 64-year-old has spotted twice. Her Pap last year was normal. Is that enough?
No. A Pap checks the cervix, not the uterine lining. Bleeding after menopause needs its own work-up soon.
FAQ
Does the exam still expect Rh immunoglobulin for every early bleed?
The CFPC names no guideline. Answer with the SOGC's 2024 guideline: none before 8 weeks, usually none from 8 to 12 weeks, and 300 µg suggested after 12.
Does every pregnant patient who bleeds need a blood type?
Not for Rh before 8 weeks: the 2024 guideline drops routine typing that early. After 8 weeks, type and screen. A patient bleeding heavily still needs a crossmatch for transfusion.
Is a lower-dose combined pill safe with migraine with aura?
No. The Canadian product monograph for a common low-dose combined pill lists migraine with aura as a contraindication, with no dose exception. Pick a levonorgestrel IUD or a non-hormonal option instead.
Is Rh immunoglobulin dosed in micrograms or units?
Either. In Canada, 120 µg is 600 IU and 300 µg is 1,500 IU. The vials come in 120, 300 and 1,000 µg. This page uses micrograms.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 22, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Drug Product DatabaseHealth Canada
- SOGC guidelines and JOGCSociety of Obstetricians and Gynaecologists of Canada
- Choosing Wisely recommendationsChoosing Wisely Canada