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1、Vaginal Bleeding and Abdominal Pain in the Non-Pregnant Patient,Normal Menstrual Cycle,28 Days4 Phases Follicular,Ovulatory,Luteal,and MensesFollicular Phase 14 days,beginning of increased estrogen productionIncreased estrogen stimulates FSH&LH production causing release of oocyte,-Ovulatory Phase,N
2、ormal 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 involutesFertilization occurs.HCG is produced stimulating corpus luteum.Menses C.luteum involutes causing vasoconstriction
3、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 CategoriesOvulatory bleedingAnovulatory bleedingNonuterine bleeding,Ovulatory Bleed
4、ing,Low estrogenCervical CAEndometrial CAFibroids,PolypsInflammationLacerations,Ovulatory Bleeding,Heavy bleeding may be due toOvarian CAPIDEndometriosisUterine causesFibroidsEndometrial hyperplasiaAdenomyosisPolyps,Ovulatory Bleeding,Other CausesPregnancy and postpartum periodCoagulopathies,Anovula
5、tory Bleeding,Anovulatory uterine bleeding is usually due to developing hypothalamic pituitary axis in adolescenceFurther work up is necessary when9 days of bleedingLess than 21 days between mensesAnemiaIf anemia requires transfusion must rule out a coagulopathy,Anovulatory Bleeding,In reproductivel
6、y mature females,cycles are characterized by long periods of amenorrhea with occasional menorrhagia.Caused by lack of progesterone and long periods of unopposed estrogen stimulationIncreased risk for adenocarcinoma,Midcycle Bleeding,OCPsStressExerciseEating Disorders,Weight LossAntiseizure Medicatio
7、ns,Anovulatory Bleeding(Menopausal and Perimenopausal),Always consider malignancyEvaluate for vaginal irritation pessaries,douches.Cervical polypsEndometrial Biopsy ultimately needed,Anovulatory Bleeding(Menopausal and Perimenopausal),Endometrial HyperplasiaAdenomyosisCA,PolypsLeiomyomas,Nonuterine
8、Bleeding-Causes,Coagulation disordersThrombocytopenic disordersMyeloproliferative disordersAny structure from cervix on GU,GI or any disease that may affect these structures,Evaluation of Abnormal Vaginal Bleeding,HistoryAge of first menarcheDate of LMP+/-dysmenorrheaPregnant?Hx-STDsPattern of bleed
9、ing,Presence of other dischargeMenstrual historySexual activity contraceptionSymptoms of coagulopathyPain description,Evaluation of Abnormal Vaginal Bleeding,HistoryPain-complete descriptionROS GU,GI,MSROS Endocrine(Pit,thyroid)Fever,syncope,dizzinessStress,Evaluation of Abnormal Vaginal Bleeding,P.
10、E.V.S.with orthostatic B.P.sSpecial consideration ofAbdominal examFemoral/Inguinal lymph nodesGoiters hypothyroidismGalactorrheaHirsutism,Evaluation of Abnormal Vaginal Bleeding,P.E.Speculum exam visualize vaginal walls cervixBimanual exam palpate masses,illicit tendernessRectovaginal exam palpate m
11、asses hemoccultCultures Take at this time GC,Chlamydia,Wet MountIn virgins use Petersentype adolescent or Huffman pediatric speculum,Evaluation of Abnormal Vaginal Bleeding,P.E.In menopausal females complete exam is necessaryCaution possible atrophic vaginaAdherent vaginal wallsOvaries should not be
12、 palpable 5 years after menopause-if felt-abnormal,Evaluation of Abnormal Vaginal Bleeding,Lab/RadiologyPregnancy testCBCCoagulation studies if indicatedTSH/Prolactin-?ED use,Ultrasound TransvaginalCTFurther evaluation performed by OB/GYN,Treatment Abnormal Vaginal Bleeding(Non-Pregnant),ABCs/Resusc
13、itation 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/treatedPregnancyTrauma(Abuse)injuryCoagulopathyInfectionForeign bodiesIf
14、not one of the above further outpatient evaluation,Treatment Abnormal Vaginal Bleeding(Non-Pregnant),Unstable PatientResuscitationD&C may be needed for uterine bleedingEstrogens may be needed for bleeding not caused by pregnancy or treatable with surgery,Treatment Abnormal Vaginal Bleeding(Non-Pregn
15、ant),Stable PatientThin endometrium shown on ultrasound short term estrogen therapy usefulSee attached Table 101-3 for short-term treatment regimensIf diagnosis is cannot be made,patient should be referred for further evaluation-OB/GYN,Long-Term Therapy,OCPs are very effective and provide contracept
16、ionNSAIDs aid in dysmenorrhea and help decrease bleedingOther more uncommon therapies progesterones,Danazol,hysteroscopy,endometrial ablation,and hysterectomy,Genital Trauma,Commonly due to vigorous voluntary/involuntary sexual activityPosterior fornix is most common area injured,Adenomyosis,Caused
17、by endometrial glands growing into myometriumMay cause menorrhagia and dysmenorrhea at the time of menstruationTreatments 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 multip
18、leSize increases in first part of pregnancy and at times with OCP useSize decreases with menopauseFibroids are usually found during manual exam or by ultrasoundIf acute degeneration or torsion occurs patients will present with acute abdomen symptoms on physical exam,Leiomyomas,Treatment is NSAIDs,pr
19、ogestins,GNRHs,or surgery if indicatedUterine artery embolization is a new promising therapy,Blood Dyscrasias,Menstrual bleeding may be excessive and be the presenting symptom of a bleeding disorderTreatment includes antifibrinolytics and OCPs.OCPs increase levels of factor VIII and vWF factorDesmop
20、ressin(DDAVP)increases release of factor VIII and vWFIn 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 glandsTriad usually seen obese,hirsutite,oligomenorrheaMenses
21、 are heavy and prolongedOther characteristics alopecia,increased androgens,increased LH and FSH and acneTherapy 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
22、.Ischemia and inflammation may also be involved.Autonomic nerve fibers produce poorly localized abdominal pain cramping in nature,midline.Examples:AppendicitisObstructionNephrolithasisPID,Classification of Pain,Somatic well localized pain sharpAny cause for inflammation can cause somatic pain in the
23、se structureMusclePeritoneumSkinAbdominal Wall,Classification of Pain,Referred pain pain from an organ is perceived at another areaNerve fibers from visceral structures enter the spinal cord at the same level as somatic nerve fibersTable 102-1 list of examples,Abdominal and Pelvic Pain in the Non-Pr
24、egnant Female,HistoryComplete description of pain characteristicsObstetric,gynecologic,and sexual historyNegative history does not rule out pregnancyPMH/PSHSTDs/PIDBirth ControlPhysical/Sexual Assault,Abdominal and Pelvic Pain in the Non-Pregnant Female,Pain as best as possible describeMigration and
25、 radiation e.g.appendicitisQuality colicky type pain BO,biliary,renal,ovarian torsion,ectopic pregnancysharp-peritoneal inflammationSeverity/Onset awakens from sleep,severe sudden onsetExacerbating/Alleviating Factors pain with movement(e.g.car ride bumps in road)may indicate peritonitisRelated to e
26、ating GI cause,Associated Signs/Symptoms,NauseaVomitingConstipation,DiarrheaAnorexia,Above symptoms are nonspecific,Associated Signs/Symptoms,HematuriaDysuriaUrgencyPossible Pyleonephritis,UTI,NephrolithasisAbove symptoms may also be caused by a gynecologic cause,Flank Pain,Physical Exam,Vitals firs
27、t continue to monitor throughout ER stayOrthostaticsGeneral appearance Peritoneal inflammation/Colicky Pain Involuntary/Voluntary guardingMassRebound Tenderness,Physical Exam,Rectal ExamPerirectal abscessStool grossly bloody,occult,melenaPerform bimanual and speculum examGC,Chlamydia,wet mount and c
28、ulturesNumerous 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,Pregnan
29、cy Test Performed on all females of childbearing ageELISA Pregnancy detects-HCG at 20 mIU/mlCBCHigh WBC may aid diagnosis,normal count though does not rule outHgb/Hct may not be accurate with acute blood loss,Laboratory,UANot specific for GU pathologyCan be(+/-)in appendicitis periappendiceal inflam
30、mationCan be(+/-)in PIDSensitivity is 84%for nephrolithasisUrine C&S should be obtained if high probability of UTI regardless of UA results,Radiology,Pelvic ultrasound with dopplerOvarian cystsTuboovarian abscessPIDAdenexal TorsionLeiomyomaMasses,Radiology,Pelvic Ultrasound is the radiological test
31、of choice for pelvic/gynecologic pathology high sensitivity and specificityCT 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 ofOvarian TorsionAdnexal MassesTuboovarian AbscessGold st
32、andard in diagnosing PID,Treatment,Rule out pregnancy as soon as possiblePain control is important to help patient give more accurate history and aid in physical exam short acting narcotics are indicatedEvaluation for cause of pain dictates ultimate treatment surgery,ABX or pain medicationsRepeat ev
33、aluation with note of changing pain patterns/characteristics and physical exam findings of 6-12 hours can aid diagnosis,Disposition,Depends upon treatmentMedical intervention/surgery admissionUncontrolled pain admission,further evaluationUndetermined cause/pain controlled discharged homeSigns/sympto
34、ms to return forFU in 12-24 hours,Specific Diagnoses,Functional Ovarian Cysts-pain can result from one of the followingRuptureTorsionInfectionHemorrhage,Specific Diagnoses,Tenderness/peritoneal signs may be presentHemorrhage may cause hemodynamic compromiseUltrasound aids in diagnosis and helps quan
35、titate blood lossUnilocular,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 diagnosedPelvic ultrasound must be used to confirm FOC,Endometriosis,Up to 15%of f
36、emales may have cause is undeterminedUsually present in 30s with pain associated with mensesEndometrium with glandular tissue may be located on ovaries,peritoneum or anywhere in abdominal/pelvic cavity,Endometriosis,Adhesions may form causing chronic painPhysical exam may show diffuse or localized t
37、endernessUltrasound may show endometriomasDiagnosis is made with laparoscopyTherapy is hormonal therapy,analgesics,Adenomyosis,Caused by endometrial glands and stroma invading myometriumPt is typically in 40s and presents with dysmenorrhea and menorrhagiaPhysical exam may show enlarged uterus or mas
38、sDiagnosis rarely made in ED endometrial biopsy needed to rule out endometrial CATherapy in ED is pain controlHormonal therapy and hysterectomy may be needed,Adnexal Torsion,Surgical emergency pain relief and for preservation of ovaryTorsion can be intermittent can present with sudden onset of unrel
39、enting pain or sharp intermittent pains with dull aching painOvarian masses or cysts increase risk,Adnexal Torsion,PE may demonstrate involuntary guarding and reboundUltrasound with Doppler makes diagnosisConsult surgery/OB/GYN early,Leiomyomas(Fibroids),Most common pelvic tumor and need for surgery
40、 in femalesIncidence increases after 40More common in blacksCause is unclearCells are responsive to estrogen anything that increases estrogen may cause fibroid growth(pregnancy),Leiomyomas(Fibroids),Physical exam may reveal pelvic or abdominal massesFibroids can be located in all layers of uterusHav
41、e 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 feverUltrasound may be used to demonstrate size,location,and number of fibroidsED intervention analgesiaMyomectomy/Hysterectomy for patients who fail medical management,
