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

2. 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

3. 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.

4. Normal Menstrual Cycle Average menstrual fluid loss is 25-60 cc. Average tampon or pad holds 20-30 cc.

5. Abnormal Vaginal Bleeding In Non-pregnant Pt. Divided into one of 3 Categories  Ovulatory bleeding  Anovulatory bleeding  Nonuterine bleeding

6. Ovulatory Bleeding Low estrogen Cervical CA Endometrial CA Fibroids Polyps Inflammation Lacerations

7. Ovulatory Bleeding Heavy bleeding may be due to  Ovarian CA  PID  Endometriosis Uterine causes  Fibroids  Endometrial hyperplasia  Adenomyosis  Polyps

8. Ovulatory Bleeding Other Causes  Pregnancy and postpartum period  Coagulopathies

9. 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

10. 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

11. Midcycle Bleeding OCPs Stress Exercise Eating Disorders Weight Loss Antiseizure Medications

12. Anovulatory Bleeding (Menopausal and Perimenopausal) Always consider malignancy Evaluate for vaginal irritation – pessaries, douches. Cervical polyps Endometrial Biopsy – ultimately needed

13. Anovulatory Bleeding (Menopausal and Perimenopausal) Endometrial Hyperplasia Adenomyosis CA Polyps Leiomyomas

14. Nonuterine Bleeding - Causes Coagulation disorders Thrombocytopenic disorders Myeloproliferative disorders Any structure from cervix on – GU, GI or any disease that may affect these structures

15. 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

16. Evaluation of Abnormal Vaginal Bleeding History  Pain - complete description  ROS – GU, GI, MS  ROS – Endocrine (Pit, thyroid)  Fever, syncope, dizziness  Stress

17. 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

18. 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

19. 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

20. 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

21. Treatment – Abnormal Vaginal Bleeding (Non-Pregnant) ABCs/Resuscitation Main job for ED physician is to determine if there is risk for significant future bleeding

22. 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

23. 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

24. 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

25. 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

26. Genital Trauma Commonly due to vigorous voluntary/involuntary sexual activity Posterior fornix is most common area injured

27. 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

28. 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

29. Leiomyomas Treatment is NSAIDs, progestins, GNRHs, or surgery if indicated Uterine artery embolization is a new promising therapy

30. 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

31. 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

32. Abdominal and Pelvic Pain in the Non-Pregnant Female

33. 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

34. Classification of Pain Somatic – well localized pain – sharp Any cause for inflammation can cause somatic pain in these structure  Muscle  Peritoneum  Skin  Abdominal Wall

35. 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

36. 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

37. 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

38. Associated Signs/Symptoms Nausea Vomiting Constipation Diarrhea Anorexia  Above symptoms are nonspecific

39. Associated Signs/Symptoms Hematuria Dysuria Urgency Possible Pyleonephritis, UTI, Nephrolithasis Above symptoms may also be caused by a gynecologic cause Flank Pain

40. Physical Exam Vitals first – continue to monitor throughout ER stay Orthostatics General appearance –  Peritoneal inflammation/Colicky Pain Involuntary/Voluntary guarding Mass Rebound Tenderness

41. 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.

42. Differential Diganosis of Nontraumatic Pelvic Pain in Non-Pregnant Adolescents and Adults Table 102-2

43. 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

44. 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

45. Radiology Pelvic ultrasound with doppler  Ovarian cysts  Tuboovarian abscess  PID  Adenexal Torsion  Leiomyoma  Masses

46. 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

47. Laparoscopy Aids in both diagnosis and treatment of  Ovarian Torsion  Adnexal Masses  Tuboovarian Abscess Gold standard in diagnosing PID

48. 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

49. 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

50. Specific Diagnoses Functional Ovarian Cysts - pain can result from one of the following  Rupture  Torsion  Infection  Hemorrhage

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. Adnexal Torsion PE may demonstrate involuntary guarding and rebound Ultrasound with Doppler makes diagnosis Consult surgery / OB/GYN early

58. 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)

59. 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

60. 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