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Transcript
Vaginal Bleeding and Abdominal
Pain in the Non-Pregnant Patient
December 6, 2005
Eli Denney, DO
Normal Menstrual Cycle



28 Days
4 Phases – Follicular, Ovulatory,
Luteal, and Menses
Follicular Phase – 14 days, beginning
of increased estrogen production

Increased estrogen stimulates FSH & LH
production causing release of oocyte, Ovulatory Phase
Normal Menstrual Cycle

Luteal Phase – remaining follicular cells
form corpus luteum. C. luteum produces
estrogen and progesterone to aid in
implantation.



If no fertilization – C. luteum involutes
Fertilization occurs. HCG is produced
stimulating corpus luteum.
Menses – C. luteum involutes causing
vasoconstriction of arteries of endometrium
– sloughing of tissue.
Normal Menstrual Cycle


Average menstrual fluid loss is 25-60
cc.
Average tampon or pad holds 20-30
cc.
Abnormal Vaginal Bleeding

In Non-pregnant Pt. Divided into one of
3 Categories



Ovulatory bleeding
Anovulatory bleeding
Nonuterine bleeding
Ovulatory Bleeding




Low estrogen
Cervical CA
Endometrial CA
Fibroids



Polyps
Inflammation
Lacerations
Ovulatory Bleeding

Heavy bleeding may be due to




Ovarian CA
PID
Endometriosis
Uterine causes




Fibroids
Endometrial hyperplasia
Adenomyosis
Polyps
Ovulatory Bleeding

Other Causes


Pregnancy and postpartum period
Coagulopathies
Anovulatory Bleeding


Anovulatory uterine bleeding is usually due
to developing hypothalamic – pituitary axis
in adolescence
Further work up is necessary when




>9 days of bleeding
Less than 21 days between menses
Anemia
If anemia requires transfusion – must rule
out a coagulopathy
Anovulatory Bleeding



In reproductively mature females,
cycles are characterized by long
periods of amenorrhea with occasional
menorrhagia.
Caused by lack of progesterone and
long periods of unopposed estrogen
stimulation
Increased risk for adenocarcinoma
Midcycle Bleeding




OCPs
Stress
Exercise
Eating Disorders


Weight Loss
Antiseizure
Medications
Anovulatory Bleeding (Menopausal
and Perimenopausal)




Always consider malignancy
Evaluate for vaginal irritation –
pessaries, douches.
Cervical polyps
Endometrial Biopsy – ultimately
needed
Anovulatory Bleeding (Menopausal
and Perimenopausal)



Endometrial
Hyperplasia
Adenomyosis
CA


Polyps
Leiomyomas
Nonuterine Bleeding - Causes




Coagulation disorders
Thrombocytopenic disorders
Myeloproliferative disorders
Any structure from cervix on – GU, GI
or any disease that may affect these
structures
Evaluation of Abnormal
Vaginal Bleeding

History






Age of first
menarche
Date of LMP
+/- dysmenorrhea
Pregnant?
Hx - STDs
Pattern of bleeding





Presence of other
discharge
Menstrual history
Sexual activity –
contraception
Symptoms of
coagulopathy
Pain – description
Evaluation of Abnormal
Vaginal Bleeding

History





Pain - complete description
ROS – GU, GI, MS
ROS – Endocrine (Pit, thyroid)
Fever, syncope, dizziness
Stress
Evaluation of Abnormal
Vaginal Bleeding



P.E.
V.S. with orthostatic B.P.s
Special consideration of





Abdominal exam
Femoral/Inguinal lymph nodes
Goiters – hypothyroidism
Galactorrhea
Hirsutism
Evaluation of Abnormal
Vaginal Bleeding

P.E.





Speculum exam – visualize vaginal walls –
cervix
Bimanual exam – palpate masses, illicit
tenderness
Rectovaginal exam – palpate masses –
hemoccult
Cultures – Take at this time – GC, Chlamydia,
Wet Mount
In virgins use Petersen–type adolescent or
Huffman pediatric speculum
Evaluation of Abnormal
Vaginal Bleeding

P.E.




In menopausal females – complete exam
is necessary
Caution – possible atrophic vagina
Adherent vaginal walls
Ovaries should not be palpable 5 years
after menopause - if felt - abnormal
Evaluation of Abnormal
Vaginal Bleeding

Lab/Radiology




Pregnancy test
CBC
Coagulation studies
if indicated
TSH/Prolactin ? ED use



Ultrasound –
Transvaginal
CT
Further evaluation
performed by –
OB/GYN
Treatment – Abnormal Vaginal
Bleeding (Non-Pregnant)


ABCs/Resuscitation
Main job for ED physician is to
determine if there is risk for significant
future bleeding
Treatment – Abnormal Vaginal
Bleeding (Non-Pregnant)

If no hemodynamic compromise, only the
following problems need to be ruled
out/treated






Pregnancy
Trauma (Abuse) – injury
Coagulopathy
Infection
Foreign bodies
If not one of the above – further outpatient
evaluation
Treatment – Abnormal Vaginal
Bleeding (Non-Pregnant)

Unstable Patient



Resuscitation
D&C may be needed for uterine bleeding
Estrogens may be needed for bleeding
not caused by pregnancy or treatable
with surgery
Treatment – Abnormal Vaginal
Bleeding (Non-Pregnant)

Stable Patient



Thin endometrium shown on ultrasound –
short term estrogen therapy useful
See attached Table 101-3 for short-term
treatment regimens
If diagnosis is cannot be made, patient
should be referred for further evaluation OB/GYN
Long-Term Therapy



OCPs are very effective and provide
contraception
NSAIDs aid in dysmenorrhea and help
decrease bleeding
Other more uncommon therapies –
progesterones, Danazol, hysteroscopy,
endometrial ablation, and
hysterectomy
Genital Trauma


Commonly due to vigorous
voluntary/involuntary sexual activity
Posterior fornix is most common area
injured
Adenomyosis



Caused by endometrial glands growing
into myometrium
May cause menorrhagia and
dysmenorrhea at the time of
menstruation
Treatments are analgesics for pain –
surgery may be needed for severe
bleeding refectory to medical therapy
Leiomyomas





Fibroids – smooth muscle cell tumors responsive to estrogen, usually multiple
Size increases in first part of pregnancy and
at times with OCP use
Size decreases with menopause
Fibroids are usually found during manual
exam or by ultrasound
If acute degeneration or torsion occurs –
patients will present with acute abdomen
symptoms on physical exam
Leiomyomas


Treatment is NSAIDs, progestins,
GNRHs, or surgery if indicated
Uterine artery embolization is a new
promising therapy
Blood Dyscrasias




Menstrual bleeding may be excessive and
be the presenting symptom of a bleeding
disorder
Treatment includes antifibrinolytics and
OCPs. OCPs increase levels of factor VIII
and vWF factor
Desmopressin (DDAVP) – increases release
of factor VIII and vWF
In these groups NSAIDs are not helpful and
may cause increased bleeding
Polycystic Ovary Syndrome





PCOS – caused by hyperandrogenism and
anovulation without disease of adrenal or pituitary
glands
Triad usually seen – obese, hirsutite,
oligomenorrhea
Menses are heavy and prolonged
Other characteristics – alopecia, increased
androgens, increased LH and FSH and acne
Therapy – OCPs – low doses or cyclic progestins
Abdominal and Pelvic Pain in
the Non-Pregnant Female
Classification of Pain



Visceral – caused by stretch of smooth muscle from
obstruction of hollow organ. Ischemia and
inflammation may also be involved.
Autonomic nerve fibers produce poorly localized
abdominal pain – cramping in nature, midline.
Examples:




Appendicitis
Obstruction
Nephrolithasis
PID
Classification of Pain


Somatic – well localized pain – sharp
Any cause for inflammation can cause
somatic pain in these structure




Muscle
Peritoneum
Skin
Abdominal Wall
Classification of Pain



Referred pain – pain from an organ is
perceived at another area
Nerve fibers from visceral structures
enter the spinal cord at the same level
as somatic nerve fibers
Table 102-1 – list of examples
Abdominal and Pelvic Pain in
the Non-Pregnant Female

History







Complete description of pain characteristics
Obstetric, gynecologic, and sexual history
Negative history does not rule out pregnancy
PMH/PSH
STDs/PID
Birth Control
Physical/Sexual Assault
Abdominal and Pelvic Pain in
the Non-Pregnant Female

Pain – as best as possible describe


Migration and radiation – e.g.. appendicitis
Quality –




colicky type pain – BO, biliary, renal, ovarian torsion,
ectopic pregnancy
sharp - peritoneal inflammation
Severity/Onset – awakens from sleep, severe
sudden onset
Exacerbating/Alleviating Factors –


pain with movement (e.g. – car ride bumps in road)
may indicate peritonitis
Related to eating – GI cause
Associated Signs/Symptoms



Nausea
Vomiting
Constipation


Diarrhea
Anorexia
Above symptoms are nonspecific
Associated Signs/Symptoms





Hematuria
 Flank Pain
Dysuria
Urgency
Possible Pyleonephritis, UTI,
Nephrolithasis
Above symptoms may also be caused
by a gynecologic cause
Physical Exam



Vitals first – continue to monitor
throughout ER stay
Orthostatics
General appearance –




Peritoneal inflammation/Colicky Pain
Involuntary/Voluntary guarding
Mass
Rebound Tenderness
Physical Exam

Rectal Exam





Perirectal abscess
Stool – grossly bloody, occult, melena
Perform bimanual and speculum exam
GC, Chlamydia, wet mount and cultures
Numerous studies have shown that
Pelvic/Bimanual exams are not reliable
by themselves for diagnosis. If exam
indicates a disease state, confirmatory
tests should be utilized.
Differential Diganosis of Nontraumatic
Pelvic Pain in Non-Pregnant
Adolescents and Adults

Table 102-2
Laboratory

Pregnancy Test – Performed on all
females of childbearing age


ELISA Pregnancy detects ß-HCG at 20
mIU/ml
CBC


High WBC may aid diagnosis, normal count
though does not rule out
Hgb/Hct – may not be accurate with acute
blood loss
Laboratory

UA





Not specific for GU pathology
Can be (+/-) in appendicitis –
periappendiceal inflammation
Can be (+/-) in PID
Sensitivity is 84% for nephrolithasis
Urine C & S should be obtained if high
probability of UTI regardless of UA results
Radiology

Pelvic ultrasound with doppler






Ovarian cysts
Tuboovarian abscess
PID
Adenexal Torsion
Leiomyoma
Masses
Radiology



Pelvic Ultrasound is the radiological
test of choice for pelvic/gynecologic
pathology – high sensitivity and
specificity
CT has high sensitivity for detecting
pelvic pathology
CT and Pelvic Ultrasound have not yet
been studied head to head
Laparoscopy

Aids in both diagnosis and treatment of




Ovarian Torsion
Adnexal Masses
Tuboovarian Abscess
Gold standard in diagnosing PID
Treatment




Rule out pregnancy as soon as possible
Pain control is important to help patient give
more accurate history and aid in physical
exam – short acting narcotics are indicated
Evaluation for cause of pain dictates
ultimate treatment – surgery, ABX or pain
medications
Repeat evaluation with note of changing
pain patterns/characteristics and physical
exam findings of 6-12 hours can aid
diagnosis
Disposition

Depends upon treatment



Medical intervention/surgery – admission
Uncontrolled pain – admission, further
evaluation
Undetermined cause/pain controlled –
discharged home


Signs/symptoms to return for
FU in 12-24 hours
Specific Diagnoses

Functional Ovarian Cysts - pain can
result from one of the following




Rupture
Torsion
Infection
Hemorrhage
Specific Diagnoses




Tenderness/peritoneal signs may be present
Hemorrhage may cause hemodynamic
compromise
Ultrasound aids in diagnosis and helps
quantitate blood loss
Unilocular, unilateral cysts less than 8 cm
can be observed. Usually resolve within 2
cycles
Specific Diagnoses


Multilocular, large >5 cm or solid cysts
suggest another pathology that must
be definitively diagnosed
Pelvic ultrasound must be used to
confirm FOC
Endometriosis



Up to 15% of females may have –
cause is undetermined
Usually present in 30s with pain
associated with menses
Endometrium with glandular tissue
may be located on ovaries, peritoneum
or anywhere in abdominal/pelvic cavity
Endometriosis





Adhesions may form causing chronic
pain
Physical exam may show diffuse or
localized tenderness
Ultrasound may show endometriomas
Diagnosis is made with laparoscopy
Therapy is hormonal therapy,
analgesics
Adenomyosis






Caused by endometrial glands and stroma invading
myometrium
Pt is typically in 40’s and presents with
dysmenorrhea and menorrhagia
Physical exam may show enlarged uterus or mass
Diagnosis rarely made in ED – endometrial biopsy
needed to rule out endometrial CA
Therapy in ED is pain control
Hormonal therapy and hysterectomy may be
needed
Adnexal Torsion



Surgical emergency – pain relief and
for preservation of ovary
Torsion can be intermittent – can
present with sudden onset of
unrelenting pain or sharp intermittent
pains with dull aching pain
Ovarian masses or cysts increase risk
Adnexal Torsion



PE may demonstrate involuntary
guarding and rebound
Ultrasound with Doppler makes
diagnosis
Consult surgery / OB/GYN early
Leiomyomas (Fibroids)





Most common pelvic tumor and need
for surgery in females
Incidence increases after 40
More common in blacks
Cause is unclear
Cells are responsive to estrogen –
anything that increases estrogen may
cause fibroid growth (pregnancy)
Leiomyomas (Fibroids)



Physical exam may reveal pelvic or
abdominal masses
Fibroids can be located in all layers of
uterus
Have a pseudocapsule – blood
vessels rarely able to penetrate –
fibroids often outgrew blood supply
and degenerate causing pain
Leiomyomas (Fibroids)




Pedunculated fibroids can tourse causing
acute pain. May have localized tenderness,
involuntary guarding, rebound and fever
Ultrasound may be used to demonstrate
size, location, and number of fibroids
ED intervention – analgesia
Myomectomy/Hysterectomy for patients who
fail medical management