Vaginal Bleeding and Abdominal Pain in the Non-Pregnant 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
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Vaginal Bleeding and Abdominal Pain in the Non-Pregnant PatientDecember 6, 2005Eli Denney, DONormal 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
  • PolypsInflammationLacerationsOvulatory Bleeding
  • Low estrogen
  • Cervical CA
  • Endometrial CA
  • Fibroids
  • 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
  • Weight LossAntiseizure MedicationsMidcycle Bleeding
  • OCPs
  • Stress
  • Exercise
  • Eating Disorders
  • Anovulatory Bleeding (Menopausal and Perimenopausal)
  • Always consider malignancy
  • Evaluate for vaginal irritation – pessaries, douches.
  • Cervical polyps
  • Endometrial Biopsy – ultimately needed
  • Endometrial HyperplasiaAdenomyosisCAPolypsLeiomyomasAnovulatory Bleeding (Menopausal and Perimenopausal)Nonuterine Bleeding - Causes
  • Coagulation disorders
  • Thrombocytopenic disorders
  • Myeloproliferative disorders
  • Any structure from cervix on – GU, GI or any disease that may affect these structures
  • HistoryAge of first menarcheDate of LMP+/- dysmenorrheaPregnant?Hx - STDsPattern of bleedingPresence of other dischargeMenstrual historySexual activity – contraceptionSymptoms of coagulopathyPain – descriptionEvaluation of Abnormal Vaginal BleedingEvaluation 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
  • Lab/RadiologyPregnancy testCBCCoagulation studies if indicatedTSH/Prolactin - ? ED useUltrasound – TransvaginalCTFurther evaluation performed by – OB/GYNEvaluation of Abnormal Vaginal BleedingTreatment – 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 FemaleClassification 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
  • DiarrheaAnorexia Associated Signs/Symptoms
  • Nausea
  • Vomiting
  • Constipation
  • Above symptoms are nonspecific
  • Flank PainAssociated Signs/Symptoms
  • Hematuria
  • 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
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