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Download Vaginal Bleeding and Abdominal Pain in the Nonpregnant Patient
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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
