Vaginal bleeding is excessive when it saturates more than eight pads or twelve tampons per day. On average, a tampon holds about 5 mL of blood; a pad holds about 5 to 15 mL.
o Types of abnormal vaginal bleeding include amenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, and menometrorrhagia. In nonpregnant women, abnormal vaginal bleeding can result from hormonal imbalances, gynecologic or systemic disorders, trauma, infections, malignancies, drugs, and other causes.
o Dysfunctional uterine bleeding is the most common cause of abnormal vaginal bleeding. It is confirmed only after organic and structural causes have been ruled out. Usually, it results from anovulation.
o After obtaining a history of past and current menstruation and other data, obtain specimens and prepare for pelvic or intravaginal ultrasonography.
o For a hemodynamically unstable patient, focus on resuscitation and stabilization. For a stable one, teach about oral contraceptives and iron supplements if prescribed and refer to a gynecologist for further evaluation.
LESSON OUTLINE
Pelvic (lower abdominal) pain has many causes and may be acute, cyclic, or chronic.
o Primary dysmenorrhea is marked by crampy, low, midline pain due to prostaglandin- mediated uterine contractions and arteriolar spasms. It typically causes pain that precedes menstrual flow by up to 24 hours and subsides after menses begins. Management calls for nonsteroidal anti-inflammatory drugs.
o Secondary dysmenorrhea is characterized by cyclic menstrual pain associated with pelvic pathology, such as endometriosis. Both types of dysmenorrhea require gynecologic referral.
Endometriosis commonly causes cyclic pain when endometrial tissue grows outside the uterus. A definitive diagnosis of endometriosis typically requires laparoscopy. However, common ED tests include pregnancy test, complete blood count, and urinalysis. As ordered, manage pain with nonsteroidal anti-inflammatory drugs and opioids.
Mittelschmerz is characterized by sudden, sharp, unilateral pelvic pain with ovulation. Expect to provide antiprostaglandin therapy with nonsteroidal anti-inflammatory drugs for pain relief.
Ovarian cysts are fluid-filled or semi–fluid-filled sacs in an ovary.
o Follicular cysts develop during the first 2 weeks of the menstrual cycle, cause pelvic
discomfort, and regress spontaneously over 1 to 3 months. If ruptured, they cause sudden, sharp pelvic pain that resolves over a few days.
o Less commonly, corpus luteal cysts develop in the latter half of the menstrual cycle and usually regress at the end of the cycle. If ruptured, they produce sharp pelvic pain and bleeding and may lead to hemorrhage and hypovolemic shock.
Ovarian torsion occurs when the ovary and its fallopian tube twist. It causes severe unilateral pain;
nausea; vomiting; fever; leukocytosis; flank, back, or groin pain; and rebound pain and guarding.
After confirmation by ultrasonography, the disorder requires surgery to untwist the torsion.
Analgesics manage pain until surgery occurs.
Vaginal discharge normally is odorless and clear to milky white. Infection alters the amount, color, and odor of the discharge and causes itching, burning, or irritation.
o Types of vaginitis include bacterial vaginosis (with a thin malodorous white to gray
discharge), vaginal candidiasis (with a thick, odorless, white, cottage cheese-like discharge), and trichomoniasis (with a copious, frothy, malodorous, white to greenish-yellow discharge).
o Oral or intravaginal antibiotic selection depends on the type of vaginitis and infecting organism.
Pelvic inflammatory disease is an infection of the upper reproductive tract, usually as a result of an ascending sexually transmitted infection.
o Signs and symptoms include lower abdominal or pelvic pain that increases with movement (causing the PID shuffle), mucopurulent vaginal discharge, vaginal or postcoital bleeding, dyspareunia, fever, malaise, nausea, and vomiting. Gynecologic examination reveals lower abdominal tenderness, mucopurulent cervicitis, cervical motion tenderness, and bilateral adnexal tenderness.
LESSON OUTLINE
Tuboovarian abscess occurs when bacteria invade a disrupted ovarian capsule. With rupture, bacteria spill into the peritoneal space, which may lead to bacteremia and septic shock. Effects include a high fever, severe pelvic pain, nausea, vomiting, purulent vaginal discharge, and vaginal bleeding.
Treatment calls for hospital admission, analgesics, intravenous antibiotics, and surgery for incision and drainage.
Bartholin’s glands may develop a cyst, a painless lump that resolves with warm sitz baths. A
Bartholin’s gland abscess is a primary infection of the gland that causes pain when sitting or walking, increasing labial pain, labial swelling and redness, and a palpable mass that is red, tender, and fluctuant. Treatment may include incision and drainage, word catheter placement, wound culture, sitz baths, analgesics, and gynecologic follow-up.
Although most sexually transmitted infections are preventable, they commonly occur. Without treatment, they can cause such complications as salpingitis, infertility, spontaneous abortion, puerperal or perinatal infection, cancer, and hepatitis.
o Genital herpes usually is caused by herpes simplex virus type 2, which may produce painful grouped vesicles or ulcerative and crusted lesions as well as fever, malaise, headache, myalgias, lymphadenopathy, dysuria, and urine retention. Treatment calls for antivirals, analgesics, and sitz baths. The patient is likely to experience recurrences and should avoid sex during these periods.
o The human papillomavirus is responsible for genital warts, which typically are single or multiple papular eruptions in cauliflower-like, plaquelike, or other shapes. Their color may vary from skin-toned to erythematous or hyperpigmented. Treatment aims to remove symptomatic warts (by cryotherapy, electrodessication, or other methods) and to induce wart-free periods. A vaccine is available to prevent cervical cancer and other diseases caused by the human papillomavirus in females.
o Chancroid results from Haemophilus ducreyi and causes a papule or pustule that then becomes a painful shallow ulcer surrounded by an erythematous ring. Related signs and symptoms include dyspareunia, vaginal discharge, fever, weakness, and painful inguinal lymphadenopathy (buboes). The patient should receive appropriate antibiotics and should avoid sex until the ulcers are healed.
o Syphilis is caused by Treponema pallidum and occurs in three distinct phases. The primary phase causes a single, painless genital ulcer (chancre) and nontender inguinal
lymphadenopathy. The secondary phase produces a dull symmetric rash on the palms and soles, fever, chills, lethargy, patchy alopecia, lymphadenopathy, loss of the lateral third of the eyebrows, and nonspecific findings. The tertiary (latent) phase produces findings that range from meningitis to dementia to thoracic aneurysm. Treatment requires penicillin G
benzathine, doxycycline, or tetracycline.
LESSON OUTLINE
o Chlamydial infection is the most common sexually transmitted bacterial infection. In most people, it is asymptomatic. However, it may cause dysuria, mild abdominal pain, urethral itching, and vaginal or urethral discharge. Azithromycin or doxycycline may be used to treat the infection. Complications in men differ from those in women.
o Gonorrhea is the second most common sexually transmitted infection and frequently appears with chlamydial infection. Women with gonorrhea may be asymptomatic carriers or have cervicitis or pelvic inflammatory disease. In men, gonorrhea is likely to involve the urethra, epididymis, and prostate gland and cause fever, chills, and a rash. Treatment calls for ceftriaxone or cefixime.
PRECEPTOR EXERCISES
Discuss the following questions with your preceptor:
Assessment
1. Based on the patient populations our emergency department commonly serves, do we use any specific cultural interventions for women who present with gynecologic emergencies?
2. Do we have a policy regarding who chaperones a pelvic examination?
3. Review the equipment used by your facility for routine pelvic examinations.