Vaginal Bleeding and Abdominal Pain in the NonPregnant 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
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

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Nonuterine Bleeding - Causes

• Coagulation disorders
• Thrombocytopenic disorders
• Myeloproliferative disorders
• Any structure from cervix on GU, GI or any
  disease that may affect these structures

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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

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Evaluation of Abnormal Vaginal Bleeding

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

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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

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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 Petersentype adolescent or
  Huffman pediatric speculum

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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

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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

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Treatment Abnormal Vaginal Bleeding
(Non-Pregnant)

• ABCs/Resuscitation
• Main job for ED physician is to determine if
  there is risk for significant future bleeding

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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

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Treatment Abnormal Vaginal Bleeding
(Non-Pregnant)

• Unstable Patient
• Resuscitation
• DC may be needed for uterine bleeding
• Estrogens may be needed for bleeding not caused
  by pregnancy or treatable with surgery

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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

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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

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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

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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
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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

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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

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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

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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

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Associated Signs/Symptoms

• Nausea
• Vomiting
• Constipation

• Diarrhea
• Anorexia

• Above symptoms are nonspecific

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Associated Signs/Symptoms

• Hematuria
• Dysuria
• Urgency
• Possible Pyleonephritis, UTI, Nephrolithasis
• Above symptoms may also be caused by a
  gynecologic cause

• Flank Pain

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Physical Exam

• Vitals first continue to monitor throughout ER
  stay
• Orthostatics
• General appearance
• Peritoneal inflammation/Colicky Pain
• Involuntary/Voluntary guarding
• Mass
• Rebound Tenderness

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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

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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

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Specific Diagnoses

• Functional Ovarian Cysts - pain can result from
  one of the following
• Rupture
• Torsion
• Infection
• Hemorrhage

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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

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Adenomyosis

• Caused by endometrial glands and stroma invading
  myometrium
• Pt is typically in 40s 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

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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)

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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