Gynecologic Pain and Vaginal Bleeding

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124 Gynecologic Pain and Vaginal Bleeding

Vaginal Bleeding

This section of the chapter addresses common causes of vaginal bleeding, including dysfunctional uterine bleeding (DUB), uterine leiomyomas (fibroids), vaginal foreign body, endometrial cancer, and cervical cancer.

Epidemiology

Uterine Leiomyomas (Fibroids)

Uterine leiomyomas (fibroids) are the most common pelvic tumor in women and have been noted on pathologic examination in approximately 80% of surgically excised uteri.2 Risk factors include African American race, early menarche (<10 years of age), nulliparity, and family history. Several studies have shown more subtle correlations with obesity and diet.3,4

Endometrial Cancer

Endometrial cancer is the fourth most common cancer in women and occurs in approximately 25 per 100,000 women.5,6 This malignant disease develops during the reproductive and menopausal years, with most patients being 50 to 59 years of age. About 5% of women younger than 40 have adenocarcinoma, and it is diagnosed in a quarter of patients before menopause. Many cases of endometrial cancer go undetected given that Papanicolaou smears detect only 50% of cases and the diagnosis is rarely considered in perimenopausal women despite the aforementioned statistics.

Pathophysiology

Common terminology and definitions for vaginal bleeding are listed in Box 124.1. An understanding of the normal female reproductive cycle is useful when caring for patients with vaginal bleeding and pelvic pain. The normal reproductive cycle is 28 days, with a range of 21 to 35 days, and the average age at menarche is approximately 12.5 years. The complex hormonal feedback mechanism that governs the female reproductive cycle is controlled by the hypothalamic-pituitary-ovarian (HPO) axis. Days 1 to 14 are known as the follicular or proliferative phase and are dominated by the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus; GnRH in turn stimulates pituitary release of follicle-stimulating hormone (FSH). During this phase a dominant ovarian follicle matures and produces estrogen, which causes the endometrium to thicken and prepare for possible embryo implantation. Positive feedback of estrogen to the pituitary gland induces a surge in luteinizing hormone (LH) on day 14 of the cycle, which results in ovulation. Days 14 to 28 are known as the luteal or secretory phase; this phase is predominated by progesterone production from the corpus luteum, which induces maturation of the endometrium. If conception and implantation do not occur, the corpus luteum involutes, estrogen and progesterone levels fall, and menstruation occurs.

Changes in the endometrium occur at each step of the reproductive cycle. During the proliferative phase the endometrium grows and thickens in response to estrogen as it prepares for implantation of an embryo. During the secretory phase the endometrium matures under the influence of progesterone and glands and secretory vacuoles develop. As progesterone levels drop at the end of the secretory (luteal) phase, prostaglandins are released and cause vasospasm within the endometrial vasculature. This leads to sloughing of the outer layers of the endometrium, and thus menstruation occurs.

Disruption at any point in this feedback loop may cause pelvic pain or abnormal vaginal bleeding.

Dysfunctional Uterine Bleeding

DUB is the most common cause of menorrhagia in menstruating females and is defined as abnormal uterine bleeding in the absence of organic disease. DUB can be ovulatory or anovulatory. Ovulatory DUB is hallmarked by regular intervals of increased menstrual flow. The root cause is an abnormality in uterine hemostasis secondary to cytokine and prostaglandin production. More commonly (accounting for 90% of cases of DUB), anovulatory DUB is hallmarked by irregular intervals of alternating heavy and light flow. This can be caused by primary ovarian disorders or a disruption in the HPO axis.7

Polycystic ovarian disease is classically associated with anovulatory uterine bleeding. It is defined by ovulatory failure, which leads to the absence of a corpus luteum and thus the lack of progesterone production and therefore unopposed action of estrogen on the endometrium. The uterine lining persists in the proliferative phase until it outgrows its vascular supply and degenerates, thereby leading to irregular menses with alternation between heavy and light flow. Women often have signs of hyperandrogenism, including hirsutism, obesity, acne, palpable enlarged ovaries, and acanthosis nigricans (hyperpigmentation typically in the folds of the skin of the neck, groin, or axilla).

Anovulatory DUB is most commonly seen in postpubescent girls secondary to immaturity of hypothalamic function. In general, it is failure to mount an LH surge that causes this dysfunction. As the central nervous system matures, the menses are ultimately regulated. In addition, systemic disease such as thyroid disorders, extreme fluctuations in weight, excessive exercise, or stress can all disrupt the HPO axis and lead to anovulation.

Presenting Signs and Symptoms

Vaginal bleeding can vary greatly in amount and severity. A thorough history and physical examination should be performed to evaluate the onset, duration, amount, and timing within the menstrual cycle of the bleeding. Assessment of severity includes determining the number of tampons or pads changed over a 12- to 24-hour period, whether they were saturated, and whether any clots were associated with the bleeding. Associated symptoms such as orthostatic complaints, fatigue, and dyspnea on exertion should point to underlying anemia from chronic blood loss or hypovolemia from acute blood loss. Vaginal bleeding may not be the primary disorder, and thus a thorough search for causes of secondary vaginal bleeding is prudent. The age of the patient, medical and surgical history, and medication profiles will also provide clues to the cause of the bleeding.

Differential Diagnosis and Medical Decision Making

The first step in evaluating any woman with vaginal bleeding should be to determine whether the patient is pregnant because this will drastically alter the diagnostic and therapeutic approach.

The most common causes of abnormal vaginal bleeding in nonpregnant patients are DUB and uterine leiomyomas. Tables 124.1 and 124.2 list the differential diagnosis of vaginal bleeding in nonpregnant females. Figure 124.1 details an approach to patients seen in the emergency department (ED) with the complaint of vaginal bleeding.

Table 124.1 Common Terminology and Definitions

TERMINOLOGY DEFINITION
Amenorrhea Cessation of menses for >6 mo
Dysmenorrhea Pain associated with menses
Hypomenorrhea Menstrual volumes < 20 mL/cycle
Menorrhagia Menses > 80 mL/cycle or occurring for >7 days
Metrorrhagia Vaginal bleeding between menstrual cycles or irregular cycles
Menometrorrhagia Prolonged or heavy bleeding at irregular intervals
Oligomenorrhea Decreased frequency of cycles (>35 days per cycle)
Polymenorrhea Increased frequency of cycles (<21 days per cycle)
Postmenopausal bleeding Bleeding 6-12 mo after menopause

Table 124.2 Systemic Causes of Abnormal Vaginal Bleeding

CAUSE MECHANISM
Weight loss
Stress
Excessive exercise
Hypothalamic suppression of GnRH
Polycystic ovarian disease Excessive estrogen effects on the endometrium
Anovulatory cycles
Hypothyroidism Anovulatory cycles
Hyperthyroidism Changes in androgen and estrogen production
Hyperprolactinemia (prolactinoma) Mass effect on the pituitary stalk reduces GnRH secretion
Liver failure Decreased production of vitamin K–dependent clotting factors
Increased estrogen levels secondary to decreased metabolism
Renal failure Inherent platelet dysfunction

Platelet dysfunction Cushing disease Mass effect on the pituitary stalk reduces GnRH secretion
Decreased LH, FSH function

FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone.

Treatment

Dysfunctional Uterine Bleeding

Oral contraceptive pills (OCPs) remain first-line therapy for DUB. OCPs suppress endometrial development, reestablish predictable bleeding patterns, decrease menstrual flow, and lower the risk for iron deficiency anemia. Treatment can be effective in either a cyclic or continuous regimen, and many gynecologists recommend tapering of OCPs over 1-week period to control acute blood loss in patients with DUB. The typical regimen includes low-dose OCPs two to three times daily for 7 days, 7 days off for withdrawal bleeding, followed by once-daily OCP use for 3 months. Single-agent therapy with estrogen or progesterone alone is used in selected cases and is best prescribed with gynecologic consultation.

If significant hemorrhage from a uterine source is leading to hemodynamic instability, the physician must consider a primary bleeding disorder. In this case, laboratory analysis should focus on identification of disseminated intravascular coagulation, thrombocytopenia, or inherited coagulopathies with a focus on repletion of blood products as necessary and prompt gynecologic consultation. In certain cases, desmopressin has been shown to be effective in controlling hemorrhage because it rapidly increases von Willebrand factor and factor VIII with duration of action lasting about 6 hours.

In these extreme cases or in patients with medical failure, surgical intervention may be necessary, including dilation and curettage or endometrial ablation; if all else fails, abdominal or vaginal hysterectomy may be indicated.

Uterine Leiomyomas (Fibroids)

Treatment of leiomyomas is generally initiated when the tumors become symptomatic and is dependent on size, location, severity, age, and reproductive plans. OCPs again are the first-line treatment for medical management; however, although they may work well in regulating abnormal uterine bleeding, they are not very effective in reducing the bulk symptoms. More effective at medical management of fibroids are GnRH agonists. They work by causing an increase in the release of gonadotropins, which in turn desensitizes and downregulates the reproductive tissue and thus causes a hypogonadal state.12,13 Most women will experience amenorrhea and a significant reduction (35% to 60%) in uterine size within 3 months of initiation of therapy. Even though these medications are quite effective, initiation of therapy should be guided by a gynecologist, and they are rarely started in the ED setting. The addition of nonsteroidal antiinflammatory drugs (NSAIDs) is useful in this population to regulate painful menses, but they do not have much action on uterine bleeding.

Surgical intervention is the definitive treatment of uterine myomas, which is the most common indication for hysterectomy. Hysterectomy is reserved for patients with acute hemorrhage that does not respond to medical management, women with increased risk for malignancy, those in whom minimally invasive procedures fail, or patients who no longer wish to preserve fertility. Several minimally invasive procedures such as myomectomy, endometrial ablation, or uterine artery embolization have increased in popularity and can be used in patients who wish to retain their uterus or have not yet completed childbearing.

Pelvic Pain

This section of the chapter focuses on gynecologic causes of pelvic pain, including ovarian torsion, ovarian cysts, ovarian tumors, and endometriosis. Other causes of pelvic pain are covered in other sections of this textbook.

Epidemiology

Ovarian Torsion

Ovarian torsion is the fifth most common gynecologic surgical emergency, and because of vague, nonspecific findings, the diagnosis is usually delayed, which can result in necrosis of the ovary and poor salvage rates.14 Several studies have reported salvage rates as low as 10% to 25%. Adnexal torsion can occur at any age, but the highest incidence is in the early reproductive years, with approximately 80% of cases occurring in those younger than 50 years.

Ovarian Tumors

Ovarian cancer is the most common cause of death from gynecologic tumors in the United States. Worldwide, the reported lifetime risk for the development of ovarian malignancy is 1 in 70, and it accounts for 100,000 deaths annually.15 Ovarian cancer affects white women more than black women, and the incidence increases with age. The mean age of females with ovarian carcinoma is 56. The overall prognosis for ovarian cancer is poor, with reported 5-year mortality rates reaching 46%, but it is closely related to staging. In girls younger than 9 years, 80% of ovarian masses are malignant, with the majority being germ cell tumors. These tumors are generally localized to the ovary and have cure rates of 90% after chemotherapy.

Pathophysiology

Causes of gynecologic pelvic pain in nonpregnant females can be divided into infectious, ovarian, cervical, uterine, or extrauterine. As with vaginal bleeding, an understanding of the female reproductive cycle is paramount in understanding the pathophysiology of disease.

Presenting Signs and Symptoms

Pelvic pain may be acute or chronic. Acute pain should raise concern for a life-threatening or organ-threatening process that may warrant urgent treatment or intervention. Chronic pain is more likely to represent an indolent process such as scarring or malignancy. A good history and complete physical examination focusing on the abdomen and genitourinary system will provide great insight into possible causes of the pain. Paying close attention to age, past medical and surgical history, sexual history, and timing in the reproductive cycle will further narrow the differential diagnosis.

Differential Diagnosis and Medical Decision Making

The differential diagnosis of pelvic pain in women is quite extensive and includes disease processes in the gastrointestinal, urinary, and reproductive systems (Box 124.2). Careful consideration should always be given to the possibility of acute appendicitis and ovarian torsion in a nonpregnant female with pelvic pain.

Ovarian Torsion

The clinical diagnosis of ovarian torsion is based on findings on physical examination and clinical suspicion, in coordination with pelvic imaging; however, definitive diagnosis is based on surgical findings.19,20 Pelvic ultrasound is the first-line diagnostic imaging modality used to aid in identification of ovarian torsion. Doppler ultrasound can be used to identify the physical anatomy of the pelvic organs, as well as to detect ovarian vessel flow. Data on the sensitivity of Doppler ultrasound in detecting ovarian torsion are controversial, especially with regard to vessel flow. Sensitivities as low as 43% and as high as 100% have been reported. In contrast, Doppler ultrasound is quite specific for diagnosing torsion, with sensitivities found to be anywhere from 92% to 97%.21 It has been reported that up to 50% of patients with torsion may have normal findings on pelvic ultrasound. Therefore, despite negative findings on imaging, if the EP has high enough suspicion for ovarian torsion, prompt gynecologic consultation is warranted. CT and MRI have also been shown to aid in the diagnosis, but their cost and the time required for imaging are prohibitive to regular use of these imaging modalities as long as ultrasound is readily available.

Laboratory testing is generally performed in the setting of acute abdominal pain. Changes in the white blood cell count, hematocrit, and electrolytes have been seen with torsion but are quite nonspecific. Research to identify serum markers is promising, with several studies reporting that increased levels of interleukin-6 are associated with ovarian torsion; however, further investigation is warranted.22,23

Ovarian Tumors

Many laboratory tests and serum markers can be used to evaluate an ovarian mass; however, much of the work-up is done on an outpatient basis and is guided by a gynecologist. The laboratory testing done by an EP is usually limited to evaluation of pelvic pain in conjunction with vomiting. Further laboratory testing will probably include serum markers such as CA 125, which can be elevated in 80% of women with ovarian malignancy and is 90% sensitive in women with advanced disease. However, given that it has low sensitivity in women with early disease and can be associated with several other gynecologic and nongynecologic illnesses, routine testing in the regular population is discouraged.24,25 Promising studies of human epididymal secretory protein E4 have been shown to be more specific for ovarian carcinoma, but further investigation is warranted.

If the EP suspects or finds an ovarian mass on examination, pelvic ultrasound should be performed. Several characteristics of ovarian tumors should raise the EP’s suspicion for malignancy, such as having a complex internal structure, including complex cysts with solid components; masses in prepubescent or postmenopausal women; or persistence beyond the length of a normal menstrual cycle.

If the findings on ultrasound are equivocal or limited, further diagnostic imaging could include CT scanning of the abdomen and pelvis or MRI. CT scanning is often helpful to the EP who may be trying to evaluate or rule out other causes of pelvic pain or symptoms of a mass effect in these specific patients.

Treatment

Both acute and chronic pelvic pain can be debilitating, and thus early pain management is essential. In a patient with acute pelvic pain a diligent search for the cause in concert with pain management is the best course of action. Oral and intravenous narcotic medications are often needed in this patient population. Unfortunately, in patients with chronic pelvic pain, acute control of pain may be the only intervention that EPs can offer. Disease-specific diagnostic testing and treatment options are described in the following sections.

References

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