Thomas W. Lukens
VAGINAL BLEEDING
CLINICAL FEATURES
Patients with the chief complaint of vaginal bleeding are commonly seen in emergency departments (EDs).
History should include amount, duration, and characteristics of the bleeding along with reproductive and sexual history. Medications, presence of a bleeding diathesis, endocrine disorders, liver disease, and existence of GU and systemic symptoms should also be used in developing the differential diagnosis.
Assessment of the abdomen and gynecological organs is necessary, as well as a speculum and bimanual examination.
Conjunctival pallor, skin color, and changes in vital signs can indicate significant anemia.
DIFFERENTIAL DIAGNOSIS
Sexual assault or genital trauma needs to be excluded in each prepubertal patient.
Nonspecific vulvovaginitis is the most frequent cause of vaginal bleeding in prepubertal females. Specific etiologies, eg, candidiasis, Escherichia coli, Shigella, and pinworms, are less commonly seen.
Less common causes of bleeding in this age group are precocious puberty and menarche, congenital abnormalities, and tissue sensitivity to soaps and chemicals.
Bleeding with discharge suggests possible retained foreign body.
In reproductive age women, abnormal vaginal bleeding may be uterine or cervical in origin.
Primary coagulation disorders can be found in up to 20% of younger patients with menorrhagia.
Common causes are anovulation, pregnancy, exogenous hormone use, uterine leiomyomas, pelvic infections, and polyps. Bleeding disorders and thyroid dysfunction are possible etiologies.
Bleeding in postmenopausal women commonly is associated with exogenous estrogens, atrophic sor endometrial lesions or other tumors.
Dysfunctional uterine bleeding (DUB) is diagnosed only after structural or systemic causes are excluded.
DUB may be ovulatory or anovulatory, typically anovulatory in perimenarchal and perimenopausal patients.
Symptoms are prolonged menses, irregular cycles, or intermenstrual bleeding that is usually mild and painless, although severe bleeding may occur.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Obtain a pregnancy test in all reproductive age patients to rule out pregnancy-related conditions causing bleeding.
Other laboratory evaluations are guided by the history and examination.
Hemoglobin/hematocrit to determine the extent of blood loss, coagulation studies, and thyroid functions, if appropriate.
If necessary, pelvic ultrasound is the imaging modality of choice and may be obtained as an outpatient in stable patients.
In those who are hemodynamically stable, no acute intervention is necessary.
Unstable patients with persistent bleeding need IV resuscitation, consideration of blood products use, and emergent gynecological consultation.
Estrogens may be used in cases of more severe bleeding; IV and PO have similar efficacy. Hormonal therapy should be deferred, until gynecologic evaluation, if any concern for malignancy.
Withdrawal bleeding typically begins 3 to 10 days after the hormonal therapy is stopped.
See Table 60-1 for drug therapy for excessive vaginal bleeding.
TABLE 60-1 Drug Therapy for Excessive Vaginal Bleeding
PELVIC PAIN
Gynecologic pathology is the usual cause, but referred pain from extrapelvic abdominal conditions needs to be considered. Pregnancy needs to be excluded.
CLINICAL FEATURES
Differentiate pain as chronic or acute, intermittent or continuous, and determine its characteristics and location to aid diagnosis.
Ruptured ovarian cysts, torsion, and obstruction typically present as unilateral sudden onset pain. Gradual onset suggests infection or enlarging mass lesion.
Abdominal and gynecologic assessments, with speculum and bimanual examination, are essential. Other testing is guided by the history and physical examination.
DIAGNOSIS AND DIFFERENTIAL
Primary dysmenorrhea—excessive pain with menstruation. Pain tapers as bleeding diminishes. Pain can radiate to lower back and thighs, and may be associated with nausea/vomiting.
Treatment with NSAIDs is usually sufficient, hormonal contraceptives in some cases.
Mittelschmerz—self-limited unilateral mid-cycle pelvic pain due to leakage of follicular fluid.
Ovarian cyst—pain from leakage of cyst fluid or pressure on adjacent structures. Sudden onset suggests rupture. Pelvic US is generally diagnostic.
Cysts less than 5 cm generally involute in 2 to 3 cycles. Follow-up with gynecologic provider recommended.
Ovarian torsion—a surgical emergency. Sudden onset severe unilateral adnexal pain. Risk factors: pregnancy, large ovarian cysts or tumors, and chemical induction of pregnancy. US with Doppler flow images diagnostic of venous congestion early followed by arterial obstruction.
Intermittent torsion possible and images during detorsion period can be normal.
Endometriosis—endometrium-like stroma implanted outside of the uterus, most commonly the ovaries. Recurrent pain associated with menstrual cycle, dysmenorrhea, and dyspareunia are symptoms. Infertility may be associated with endometriosis.
Nonspecific pelvic pain may be the sole finding on examination and definitive diagnosis usually not made in the ED. Ultrasound may show endometriomas.
Fibroids (leiomyomas)—benign estrogen-dependent uterine smooth muscle tumors, often multiple, found in the middle or later reproductive years. Symptoms include pain, abnormal vaginal bleeding, bloating, dyspareunia, and possibly urinary complaints. Severe pain can result from torsion of a pedunculated fibroid or ischemia and degeneration of the tumor.
Bimanual examination often can reveal a mass. Pelvic US is confirmatory. Treatment consists of analgesia and referral to a gynecologist.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Most patients with pelvic pain can be discharged from the ED with gynecologic follow-up. Patients need to receive detailed discharge instructions about the signs and symptoms to expect and when to return. Reevaluation in 12 to 24 hours is appropriate if concerns remain.
Analgesics should be offered and NSAIDs are effective for most conditions. Opioids such as oxycodone/acetaminophen (5 milligrams/325 milligrams) for several days can be used if appropriate.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 99, “Vaginal Bleeding in the Nonpregnant Patient,” by Laurie J. Morrison and Julie M. Spence and Chapter 100, “Abdominal and Pelvic Pain in the Nonpregnant Female,” by Thomas W. Lukens.