Chapter 58. Vaginal Bleeding and Pelvic Pain in the Nonpregnant Patient

Vaginal bleeding is a common complaint in females presenting to the ED. Determination of pregnancy status in each patient is important in order to formulate the appropriate differential diagnosis and to guide subsequent testing and decision making.

Clinical Features

Adolescents and adults should be asked about amount and duration of bleeding, reproductive history, sexual history, history of sexually transmitted infections, history of trauma, medication, possibility of foreign bodies; bleeding disorders (history of bruising, epistaxis, other abnormal bleeding), endocrine disorder, liver disease and associated GU or systemic symptoms. An abdominal and gynecologic examination, including speculum examination as well as a vaginoabdominal examination (bimanual) should be performed on nonvirginal adults and adolescents to look for structural or traumatic causes of bleeding. Skin or conjunctiva pallor or abnormal vital signs can indicate significant anemia.

Diagnosis and Differential

In prepubertal children, bleeding from genital trauma and/or sexual assault needs to be considered and excluded. Vulvovaginitis is unusual but is the most common cause of vaginal bleeding in the prepubertal female and can be associated with pain. Although nonspecific vulvovaginosis is most commonly diagnosed, specific infections with candidiasis, streptococcal infections, Escherichia coli and Shigella, viruses and pinworms also occur. Bleeding coupled with vaginal discharge raises concerns for retained foreign bodies. Less common etiologies include precocious puberty and menarche, congenital abnormalities, urethral prolapse, and tissue sensitivity to chemicals in soaps and creams.

In women of reproductive age or perimenopausal women, bleeding can arise from the uterus or cervix and is most commonly due to anovulation, pregnancy, exogenous hormone use, coagulopathy, uterine leiomyomas, cervical and endometrial polyps, pelvic infections, and thyroid dysfunction. In postmenopausal women, the most common causes of vaginal bleeding are exogenous estrogens, atrophic vaginitis, endometrial lesions including cancer, and other tumors. Primary coagulation disorders account for up to 20% of menorrhagia in teenagers, and include von Willebrand disease, myeloproliferative disorders, and immune thrombocytopenia. Skin signs such as petechiae may be absent.

Dysfunctional uterine bleeding (DUB) may only be diagnosed after organic and systemic causes of bleeding have been excluded. DUB may be ovulatory or anovulatory. Typically, perimenarcheal and perimenopausal DUB is anovulatory. Patients with anovulatory cycles present with prolonged menses, irregular cycles, or intermenstrual bleeding. Usually the bleeding is painless and minimal, but severe bleeding can occur, resulting in anemia and iron depletion.

A pregnancy test must be obtained on all women of reproductive age to rule out pregnancy as a cause of bleeding. Other laboratory evaluation is guided by the history and physical examination. A CBC should be checked if signs of excessive bleeding or anemia are present. A PT or INR may identify a coagulopathy. Obtain thyroid function tests in patients with symptoms and signs of thyroid dysfunction. Ultrasonography is an important imaging modality to determine uterine size, characteristics of the endometrium and to detect structural abnormalities. Ultrasound may be deferred for outpatient evaluation in a stable patient.

Emergency Department Care and Disposition

Most patients with vaginal bleeding are hemodynamically stable and need no acute intervention. Patients who are unstable with persistent bleeding require resuscitation: IV crystalloids, blood products and gynecologic consultation for urgent D and C.

1. For patients with severe, vaginal bleeding/dysfunctional bleeding, hormonal manipulation with estrogens may be tried. The efficacy of PO and IV formulations are similar. Conjugated estrogen (eg, Premarin®) 25 milligrams IV every 2 to 6 hours until bleeding slows or conjugated estrogen 2.5 milligrams PO 4 times a day may be started. Medroxyprogesterone (eg, Provera®) 10 milligrams daily is started when bleeding subsides; both drugs are continued for 7 to 10 days.

2. In stable patients in whom the diagnosis of DUB is clear, short-term hormonal therapy may be prescribed. Choices include the following:

   1. Oral contraceptive regimen: ethinyl estradiol 35 micrograms and norethindrone 1 milligram, (eg, Ortho-Novum 1/35®) 4 tablets daily for 7 days. Alternatively, a taper may be given: 4 tablets for 2 days, 3 tablets for 2 days, 2 tablets for 2 days, and 1 tablet for 3 days.

   2. Medroxyprogesterone 10 milligrams daily for 10 days.

   3. Tranexamic acid, (eg, Lysteda®) an antifibrinolytic agent, 600 to 1300 milligrams every 8 hours for 3 days. Withdrawal bleeding may be heavy and typically occurs 3 to 10 days after the hormonal therapy has stopped.

3. If there is any concern for malignancy, hormonal therapy is best deferred until the patient is evaluated by gynecology and decision about a biopsy is made.

4. NSAIDs, such as naproxen 500 milligrams twice daily PO or ibuprofen 400 milligrams every 6 hours PO, may reduce bleeding.

5. Stable patients may be discharged home and instructed to follow-up with their gynecologic provider.

Pelvic pain generally arises from gynecologic pathology but referred pain from extrapelvic conditions, such as inflammatory bowel disease, urinary tract infections or stones, diverticulitis, leaking abdominal aneurysm or appendicitis need to be considered. Pregnancy should be excluded in all women of reproductive age. Pelvic inflammatory disease is a common cause of pelvic pain and is discussed in Chapter 64.

Clinical Features

Pelvic pain may be acute or chronic, intermittent or continuous. Attention to the characteristics of the pain will aid in determining etiologies. Sudden onset of unilateral pain suggests an ovarian cyst, adnexal torsion, obstruction, or renal lithiasis. Gradual onset suggests an infectious process or slowly enlarging mass. Other attributes, such as the relationship of the pain with the menstrual cycle, aggravating and relieving factors, and associated urinary, GI, and systemic symptoms assist in developing the differential diagnosis.

An abdominal and gynecologic examination, including speculum examination, and a vaginoabdominal examination (bimanual) should be performed. A pregnancy test should be done to rule out pregnancy. Other testing, such as urinalysis, CBC, and ultrasound are guided by the history and physical examination.

Diagnosis and Differential

Primary Dysmenorrhea

Almost 90% of menstruating women experience dysmenorrhea at some point. Symptoms include mild to severe lower abdominal cramping during menses that diminishes as menstruation tapers. The pain can radiate to the thighs or lower back and may be accompanied by nausea and vomiting. Other gynecologic, urologic, or gastrointestinal conditions should be ruled out. NSAIDs, such as naproxen 500 milligrams twice daily PO or ibuprofen 400 milligrams every 6 hours PO, may alleviate symptoms. Further treatment, such as hormonal contraceptives, may be investigated at follow-up.

Mittelschmerz

Mittelschmerz is a self-limited, unilateral dull, aching pain that occurs at mid cycle due to leakage of prostaglandin-containing follicular fluid. Patients frequently offer a history of previous similar pain. Treatment is symptomatic.

Ovarian Cysts

Pain results from 2 mechanisms: leak of contents causing tissue irritation or mechanical pressure on adjacent organs. Sudden onset of pelvic pain in a patient with ovarian cysts suggests acute rupture. A ruptured cyst can mimic a ruptured ectopic pregnancy. Pelvic/transvaginal ultrasound is the diagnostic imaging modality of choice (Fig. 58-1). Patients with cyst rupture who present with hemoperitoneum and hypotension require emergent gynecological surgery intervention. Hemodynamically stable patients with pain from cyst leakage or rupture can be treated as outpatients with NSAIDs. Patients with unruptured cysts less than 5 cm in size frequently require no treatment as these cysts usually involute within 2 to 3 menstrual cycles. All patients should follow-up with their gynecologic provider for further evaluation.

Ovarian Torsion

Ovarian torsion results in the acute onset of severe adnexal pain from ischemia of the ovary. A history of intermittent pain, sometimes associated with exertion, preceding the severe symptoms may be obtained. Risk factors for torsion are pregnancy (enlarged corpus luteum), large ovarian cysts or tumors, and chemical induction of ovulation. Ultrasound with Doppler flow imaging is the diagnostic procedure of choice but is not 100% sensitive. Imaging early in the process may show congestion from venous outflow obstruction with preserved arterial flow and images obtained during a transient period of detorsion may appear normal. Analgesia, gynecologic consultation, and preparation for surgery are warranted if the diagnosis is suspected.

Endometriosis

Endometriosis results from endometrium-like stroma implanted outside of the uterus, most commonly the ovaries. Symptoms include recurrent pelvic pain associated with menstrual cycle—secondary dysmenorrhea and dyspareunia. Nonspecific pelvic pain on examination is the usual finding but if the ectopic tissue ruptures, more severe pain may be present. Ultrasound may show endometriomas. The definitive diagnosis is usually not made in the ED. Treatment consists of analgesics and gynecologic referral.

Leiomyomas

Leiomyomas (uterine fibroids) are benign smooth muscle tumors, often multiple, seen most commonly in women in middle and later reproductive years. About 30% of women with leiomyomas will develop symptoms such as abnormal vaginal bleeding, dysmenorrhea, bloating, backache, urinary symptoms and dyspareunia. Severe pain can result with torsion of a pedunculated fibroid, or ischemia and infarction of a fibroid. Bimanual examination may demonstrate a mass or an enlarged uterus. Pelvic ultrasound is confirmatory. Treatment consists of NSAIDs or other analgesics for pain, hormonal manipulation for excessive bleeding, and referral to a gynecologist for definitive therapy.

Emergency Department Care and Disposition

Most patients are ultimately discharged from the ED even though there may not be a specific diagnosis. Patients should receive detailed discharge instructions about signs and symptoms to expect and warnings of when to return and when to follow-up. Reevaluation in 12 to 24 hours can be scheduled if any concern persists. Analgesics, such as NSAIDs, provide effective pain control for most outpatients, although some patients will require opioids, such as oxycodone/acetaminophen (5/325) 1 to 2 tablets every 4 to 6 hours PO for a few days.