Vaginal Bleeding and Abdominal Pain in the Nonpregnant Patient.ppt

Vaginal Bleeding and Abdominal Pain in the Non-Pregnant PatientNormal Menstrual Cyclen28 Daysn4 Phases Follicular,Ovulatory,Luteal,and MensesnFollicular Phase 14 days,beginning of increased estrogen productionIncreased estrogen stimulates FSH&LH production causing release of oocyte,-Ovulatory PhaseNormal Menstrual CyclenLuteal 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.nMenses C.luteum involutes causing vasoconstriction of arteries of endometrium sloughing of tissue.Normal Menstrual CyclenAverage menstrual fluid loss is 25-60 cc.nAverage tampon or pad holds 20-30 cc.Abnormal Vaginal BleedingnIn Non-pregnant Pt.Divided into one of 3 CategoriesOvulatory bleedingAnovulatory bleedingNonuterine bleedingOvulatory BleedingnLow estrogennCervical CAnEndometrial CAnFibroidsnPolypsnInflammationnLacerationsOvulatory BleedingnHeavy bleeding may be due toOvarian CAPIDEndometriosisnUterine causesFibroidsEndometrial hyperplasiaAdenomyosisPolypsOvulatory BleedingnOther CausesPregnancy and postpartum periodCoagulopathiesAnovulatory BleedingnAnovulatory uterine bleeding is usually due to developing hypothalamic pituitary axis in adolescencenFurther work up is necessary when9 days of bleedingLess than 21 days between mensesAnemianIf anemia requires transfusion must rule out a coagulopathyAnovulatory BleedingnIn reproductively mature females,cycles are characterized by long periods of amenorrhea with occasional menorrhagia.nCaused by lack of progesterone and long periods of unopposed estrogen stimulationnIncreased risk for adenocarcinomaMidcycle BleedingnOCPsnStressnExercisenEating DisordersnWeight LossnAntiseizure MedicationsAnovulatory Bleeding(Menopausal and Perimenopausal)nAlways consider malignancynEvaluate for vaginal irritation pessaries,douches.nCervical polypsnEndometrial Biopsy ultimately neededAnovulatory Bleeding(Menopausal and Perimenopausal)nEndometrial HyperplasianAdenomyosisnCAnPolypsnLeiomyomasNonuterine Bleeding-CausesnCoagulation disordersnThrombocytopenic disordersnMyeloproliferative disordersnAny structure from cervix on GU,GI or any disease that may affect these structuresEvaluation of Abnormal Vaginal BleedingnHistoryAge of first menarcheDate of LMP+/-dysmenorrheaPregnant?Hx-STDsPattern of bleedingPresence of other dischargeMenstrual historySexual activity contraceptionSymptoms of coagulopathyPain descriptionEvaluation of Abnormal Vaginal BleedingnHistoryPain-complete descriptionROS GU,GI,MSROS Endocrine(Pit,thyroid)Fever,syncope,dizzinessStressEvaluation of Abnormal Vaginal BleedingnP.E.nV.S.with orthostatic B.P.snSpecial consideration ofAbdominal examFemoral/Inguinal lymph nodesGoiters hypothyroidismGalactorrheaHirsutismEvaluation of Abnormal Vaginal BleedingnP.E.Speculum exam visualize vaginal walls cervixBimanual exam palpate masses,illicit tendernessRectovaginal exam palpate masses hemoccultCultures Take at this time GC,Chlamydia,Wet MountIn virgins use Petersentype adolescent or Huffman pediatric speculumEvaluation of Abnormal Vaginal BleedingnP.E.In menopausal females complete exam is necessaryCaution possible atrophic vaginaAdherent vaginal wallsOvaries should not be palpable 5 years after menopause-if felt-abnormalEvaluation of Abnormal Vaginal BleedingnLab/RadiologyPregnancy testCBCCoagulation studies if indicatedTSH/Prolactin-?ED usenUltrasound TransvaginalnCTnFurther evaluation performed by OB/GYNTreatment Abnormal Vaginal Bleeding(Non-Pregnant)nABCs/Resuscitation nMain job for ED physician is to determine if there is risk for significant future bleedingTreatment Abnormal Vaginal Bleeding(Non-Pregnant)nIf no hemodynamic compromise,only the following problems need to be ruled out/treatedPregnancyTrauma(Abuse)injuryCoagulopathyInfectionForeign bodiesnIf not one of the above further outpatient evaluationTreatment Abnormal Vaginal Bleeding(Non-Pregnant)nUnstable PatientResuscitationD&C may be needed for uterine bleedingEstrogens may be needed for bleeding not caused by pregnancy or treatable with surgeryTreatment Abnormal Vaginal Bleeding(Non-Pregnant)nStable 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/GYNLong-Term TherapynOCPs are very effective and provide contraceptionnNSAIDs aid in dysmenorrhea and help decrease bleedingnOther more uncommon therapies progesterones,Danazol,hysteroscopy,endometrial ablation,and hysterectomyGenital TraumanCommonly due to vigorous voluntary/involuntary sexual activitynPosterior fornix is most common area injuredAdenomyosisnCaused by endometrial glands growing into myometriumnMay cause menorrhagia and dysmenorrhea at the time of menstruationnTreatments are analgesics for pain surgery may be needed for severe bleeding r