Pelvic Pain Nonpregnant Vaginal Bleeding Resident Rounds April

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

Now Playing: p. ELVIS and the Non. Pregnant Vaginal Bleeders!

Pelvic Pain

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

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

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

Let’s get 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)

Care to provide a DDXx of Pelvic Pain?

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

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?

Investigations • Urine Bhcg!!!! (I don’t care if she’s Mother Theresa) + by ~30 d 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

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

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

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? ”

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

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?

Functional Ovarian Cysts • Follicular cysts – – N follicles 2 cm, can get to 10 cm 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

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?

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

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 • ? ? ?

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)

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 • ? ? ?

Endometriosis • 2 nd 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 • Gn. RH may be helpful

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 • ? ? ?

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

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

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

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

Non-pregnant Vaginal Bleeding

Definitions • Abnormal Vaginal Bleeding: bleeding outside regular cycle • Amenorrhea: no bleeding • DUB: abn vag bleeding due to anovulation • Menorrhagia: menses>7 d, >60 m. L, <q 21 d • Metrorrhagia: irregular bleeding outside regular cycle • Menometrorrhagia: excessive irregular bleeding • Oligomenorrhea: sparse bleeding frequency and/or amount

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

History • How long? How much (how many pads/tampons: >1 soaked/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

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

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

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?

Investigations • Urine Bhcg!!!! (I don’t care if she’s Mother Theresa) + by ~30 d 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

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

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 ? ? ?

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

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?

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

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

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

Management: Unstable PV • • ABCD!!! O 2, Monitors, IV’s, fluids / blood Do NOT pack vagina GYNE consult ASAP re D&C, lap, hyst

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

Management: Stable PV bleed • Premarin 2. 5 mg po qid OR IV 25 mg q-4 hr (no difference) • When bleeding stops, add progesterone (provera) 10 mg/d or prometrium 400 mg od • Continue both x 10 d, then w/d bleed • OR OCP (EE 2 35 mcg +NETD 1 mg) 4 tabs od x 7 d • OR above OCP: 4 tabs->3 ->2 (each x 2 d)->1 x 3 d • Progesterone alone not so good

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

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

Premenopasal

Perimenopasal

Postmenopasal

The End Thanks!