Pelvic Pain & Non-pregnant Vaginal Bleeding

1. Pelvic Pain & Non-pregnant Vaginal Bleeding Resident Rounds April 10, 2003 A.F. Chad, MD, CCFP

2. Now Playing: pELVIS and the Non-Pregnant Vaginal Bleeders!

4. Pelvic Pain

5. Pelvina Hurtsia • 30 yo F • RLQ / pelvic pain • VSS • What do you want to ask her (besides the origins of her unique moniker)?

6. History • OPPQRST • LMP, menarche/menopause, Hx of menses, bleeding, dysmenorrhea, G?P?, abuse? • Sex? When? how many? Protection? STD’s? • Single? (just kidding) • PMHx, Meds, all, SHx • ROS GI, GU, MSK • F/C/NS, wt loss, bleeding d/o

7. Pelvina Hurtsia • History somewhat helpful • Perhaps an Exam? • How & What shall you do?

8. Let’s get Physical, Physical, Wanna get Phy-SI-cal, Let’s get into Physical • VS • General appearance (?hairy shim?) & exam • Abdo exam, inguinal nodes pulses • Chaperone for gyne • External genitalia: rash, lesions • WARM speculum, see vault, Cx (rash, d/c, open, red) d/c? injury? Polyp? Tissue? • Bimanual if not obese: CMT? Mass? • Vaginorectal: examines post cul-de-sac (pus, mass)

9. Care to provide a DDXx of Pelvic Pain?

10. Differential DX: HUGE!!! • Pregnant vs. non-pregnant • Gyne: • ectopic, abortion, cysts, CA, dysmenorrhea, torsion, degenerative, mittelschmerz • GI: • gastro, appy, obstruction, diverticulitis, IBD, IBS • GU: • cystitis, pyelo, stone, obstruction • MSK: • abdo wall • Infxn: • PID,abscess, endometritis • Other: • porphyria, thrombophlebitis, aneurysm, VZV

11. Innocent Little Suzy • 18 yo F • LLQ Pelvic Pain • VSS • LMP: “I think it was about a month ago” • “I’ve never had sex before… I’m not some slut… I’m going to be a nun!” • What ONE test MUST you order?

12. Investigations • Urine Bhcg!!!! (I don’t care if she’s Mother Theresa) + by ~30d pregnant • CBC, T&S, serum Bhcg, others as need • Swabs (GC, Chlam, C&S, Yeast, ?pap) • Ultrasound -> gyne rad of choice • CT -> better for non-gyne, other • MRI-> in our dreams, but good

13. Dee S. Menooraya • 27 yo F • Healthy • LMP due in 1-2 days • Crampy lower abdo pain • What’s up?

14. Dysmenorrhea • Most common cause of pelvic pain • Primary (no structural dz) • Pain pre & menstruation, relief during menses • PG mediated • reassurance • NSAIDs (ibuprofen, naproxen, mefenamic acid) • OCP as option • Consider other Dx • Secondary (structural) • IUD, endometriosis, adenomyosis • Less responsive to NSAIDs

15. Mirtle Shmears • 18 yo German exchange student • Sudden onset RLQ pain • LMP 2 wks ago • Healthy, virginal (that’s what the all say) • Exam: sl RLQ tender • Labs: N • U/S: some fluid, N • “Vat ees wrong Doctor?”

16. Mittlschmerz • Transient midcycle pain about ovulation • Increased follicular pressure prior to eruption +/- fluid spillage into peritoneum • R/O other DZ • Reassurance, NSAIDs

17. Cindy Sisstay • Healthy 25 yo • Sudden onset sharp RLQ pain • Sexually active: “condoms are for sailors!” • ?LMP? • Exam N, swabs taken • Bhcg neg • Any ideas?

18. Functional Ovarian Cysts • Follicular cysts • N follicles 2cm, can get to 10cm • Stretch or rupture causes pain • Usually resolve over days • NSAIDs +/- gyne involvement • Corpus Luteal Cysts • Less common • Capillaries invade in luteal phase • Spont hrrg • Regress @ end cycle • NSAIDs +/- gyne

19. Tortia Adnecki • 29 yo Portuguese F • Sudden onset Severe RLQ pain, N&V • In town filming porn • ?LMP, healthy, Hx of “ovarian mass” • VSS • Now What?

20. Adnexal Torsion • Ovary, tube • Unilateral pain, can be intermittent • Usually associated with mass • Difficult DDx!! • Usually torsion on a pedicle • Can cause N&V, Inc WBC, severe pain • Impairs venous / arterial flow,can infarct tissue (ovary/tube) • Surgical intervention

21. Porna Pornokova • 31 yo Russian porn star • Fever, purulent vag d/c, RLQ pain • Hx of multiple STDs • Looks unwell, T=40, HR=120, BP=95/50 • Exam: purulent vag d/c, RLQ mass. +CMT, rest exam N • ?????

22. PID • Inflammation of the endometrium, fallopian tubes, pelvic peritoneum and/or contiguous structures • Polymicrobial • Fever, d/c, pelvc pain, etc • R/O abscess • ABCD • Po Abx if not sick and F/U (cefixime + azithro / doxy) • IV if sick (cefoxitin + doxy, clinda + gent)

23. Edna Metrious • Healthy 27 yo F • Pelvic pain, recurrent over 5 years, just prior or during menses • LMP due, married 3 kids, tubal ligation • Exam: VSS, global Lower abdo tender • Labs & U/S N • ?????

24. Endometriosis • 2nd most common cause pelvic pain (5-10%) reproductive age • Extraneous endometrium->pain with menses • Adhesions, endometriomas • dysmenorrhea, dyschezia, dyspareunia • Dx helped by Hx, need scope Dx • Gyne as outpt • GnRH may be helpful

25. Aiden Miosees • Healthy 37 yo F • Pelvic pain, recurrent over 5 years, just prior or during menses • LMP due, married 3 kids, tubal ligation • Exam: VSS, global Lower abdo tender • Labs & U/S N • ?????

26. Adenomyosis • Endometrial glands grow deep into myometrium • dysmenorrhea, dyschezia, dyspareunia • Scope, MRI • NSAIDs, hyst as last resort

27. Lea “My Oh My” • 40 yo Soul Singer • Chronic pelvic pain • Lumpy uterus on exam • Labs N • What is Dx?

28. Leiomyoma • Benign muscle cell tumour, most common pelvic tumour • Incr in preg, decr in menopause, ocp • Pain usually not acute unless torsion, degeneration (rapid outgrowth blood supply, usually in preg) • Growth post menopause-> CA • Dx: PHx, U/S • Rx: NSAIDs, medical menopause, surgery

29. ABUSE!!!!!! • Always consider abuse in young • Consider in chronic pelvic pain

30. Non-pregnant Vaginal Bleeding

31. Definitions • Abnormal Vaginal Bleeding: bleeding outside regular cycle • Amenorrhea: no bleeding • DUB: abn vag bleeding due to anovulation • Menorrhagia: menses>7d, >60mL, <q21d • Metrorrhagia: irregular bleeding outside regular cycle • Menometrorrhagia: excessive irregular bleeding • Oligomenorrhea: sparse bleeding frequency and/or amount

32. Regina Bleedsalot • 40 yo • Pv bleeding • What to ask her?

33. History • How long? How much (how many pads/tampons: >1soaked/hr is worrisome) • Sx of anemia • Pain? • LMP, menarche/menopause, Hx of menses, bleeding, dysmenorrhea, G?P?, abuse? • Sex? When? how many? Protection? STD’s? • Single? (again, just kidding) • PMHx, Meds, all, SHx • ROS GI, GU, MSK • F/C/NS, wt loss, bleeding d/o

34. Regina Bleedsalot • You’ve got your history • Now What?

35. Physical • ABCD!!! • VS -> Can be unstable!!! • General appearance (?hairy shim?) & exam • Abdo exam, inguinal nodes pulses • Chaperone for gyne • External genitalia: rash, lesions • WARM speculum, see vault, Cx (rash, d/c, open, red) d/c? injury? Polyp? Tissue? Source bleeding? • Bimanual if not obese: CMT? Mass? • Vaginorectal

36. Return of Innocent Little Suzy • You see her one year later • 19 yo F • Vaginal bleeding • VSS • LMP: “I think it was about a month ago” • “I’ve never had sex before (despite + Bhcg 1 year ago)… I’m not some slut… I’m still going to be a nun!” • What ONE test MUST you order?

37. Investigations • Urine Bhcg!!!! (I don’t care if she’s Mother Theresa) + by ~30d pregnant • CBC, T&S, serum Bhcg, coags, TSH, others as need • Swabs (GC, Chlam, C&S, Yeast, ?pap) • Ultrasound -> gyne rad of choice • CT -> better for non-gyne, other • MRI-> in our dreams, but good

38. PV bleed: cause by age • Prepubertal: vulvovaginitis, FB, precocious puberty, CA • Adolescent: anovulation, pregnancy, exogenous hormone, coagulopathy • Reproductive: pregnancy, anovulation, exogenous hormone, fibroid, polyps, thyroid dysfnc • Perimenopausal: anovulation, fibroid, polyps, thyroid dysfnc • Postmenopausal: endometrial lesion, hormone, atrophic vaginitis, CA

39. Ivana Veela Bronnde • 11 yo • Menarche 2 days ago • Heavy pv bleeding • “It just won’t stop” • “My Mom bleeds really easily” • PMHx, meds, all N • ?????

40. Blood dyscrasias • Menarche can be initial presentation • vWD most common • Rx OCP, antifibrinolytics, DDAVP

41. Poly Ovan-Synd • 37 yo F • Heavy pv bleeding x 2 days • Rest Hx unhelpful • Exam: generously proportioned, more facial hair than ZZ Top • Any clue as to Dx?

42. Anovulatory cycle • Prolonged amenorrhea -> periodic menorrhagia • Fluctuating estrogen levels < amount needed for endometrial growth • Endometrium outgrows estrogen supply-> slough • Progesterone deficiency • Follicle degen & sim not in balance -> slough re relative <estrogen

43. PCOS: Polycystic Ovarian Syndrome • Common • Obesity, hirsutism, oligomenorrhea • Hyperandrogenism, acne, alopecia, >LH (hi androgen, no dominant follicle <FSH), hyperinsulinism • OCP or cyclic low dose progestins

44. Regina Bleedsalot • PV bleeding excessively, can’t locate source • HR 130, BP 80/50, confused • Hgb 50 • Now What?

45. Management: Unstable PV • ABCD!!! • O2, Monitors, IV’s, fluids / blood • Do NOT pack vagina • GYNE consult ASAP re D&C, lap, hyst

46. Regina Bleedsalot • Pv bleed • VSS, exam N, save blood in vault • Hgb: 89 • U/S N, Dx presumed DUB • Now What?

47. Management: Stable PV bleed • Premarin 2.5mg po qid OR IV 25mg q-4hr (no difference) • When bleeding stops, add progesterone (provera) 10mg/d or prometrium 400 mg od • Continue both x 10d, then w/d bleed • OR OCP (EE2 35mcg +NETD 1mg) 4tabs od x 7d • OR above OCP: 4 tabs->3->2 (each x 2d)->1 x 3d • Progesterone alone not so good

48. Regina Bleedsalot Senior • Regina’s 60 yo postmenopausal mother, Regina Sr. also complains of pv bleeding • Anything different with regards to management or disposition?

49. Peri / postmenopausal bleeding • Require gyne follow up re work up for endometrial CA • Avoid estrogens in undiagnosed peri / postmenopausal bleed

50. Premenopasal