Vaginal Bleeding and Abdominal Pain in the Non-Pregnant Patient

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

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

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

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

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. 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

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. Lab/Radiology Pregnancy test CBC Coagulation studies if indicated TSH/Prolactin - ? ED use Ultrasound – Transvaginal CT Further evaluation performed by – OB/GYN Evaluation of Abnormal Vaginal Bleeding

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

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

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