Vaginal Bleeding and Abdominal Pain in the Non-Pregnant Patient December 6, 2005 Eli Denney, DO

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


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.


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


History Pain - complete description ROS – GU, GI, MS ROS – Endocrine (Pit, thyroid) Fever, syncope, dizziness Stress


P.E. V.S. with orthostatic B.P.s Special consideration of

Abdominal exam Femoral/Inguinal lymph nodes Goiters – hypothyroidism Galactorrhea Hirsutism


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


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/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


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


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


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


Somatic – well localized pain – sharp Any cause for inflammation can cause

somatic pain in these structure Muscle Peritoneum Skin Abdominal Wall


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


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


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 Dysuria Urgency Possible Pyleonephritis, UTI,

Nephrolithasis Above symptoms may also be caused

by a gynecologic cause

Flank Pain

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)


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


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

Documents

Vaginal Bleeding and Abdominal Pain in the Non-Pregnant Patient December 6, 2005 Eli Denney, DO