CRACKCast E100 – Gynecologic Disorders

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This (centennial!) episode of CRACKCast covers Rosen’s Chapter 100, Gynecologic Disorders. This chapter covers the common presentation of pelvic pain and vaginal bleeding in the emergency department, including can’t miss life or organ diagnoses.

 

Shownotes – PDF Here

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Rosen’s in Perspective

Pelvic pain and Vaginal bleeding is a common presentation in our departments!!!

***REMEMBER: all females or biologically anatomic females of childbearing potential are PREGNANT UNTIL PROVEN OTHERWISE***

After that, we look for life or organ threats (think massive bleeding or ovarian torsion etc).

This chapter looks specifically at common some common entities:

  • Ovarian torsion
  • Ovarian cysts
  • Abnormal uterine bleeding
  • Emergency contraception

Some important Definitions to jog your memory:

  • Menorrhagia: > 80ml or longer than 7 days
  • Abnormal Uterine bleeding: excessive bleeding PRIOR TO exclusion of pathologic causes
    • Premenarchal: always abnormal
    • Reproductive age: “a change in the frequency, duration or amount of bleeding, or bleeding between menstrual cycles”
    • Postmenopausal: any bleeding 1 year after cessation of menses
  • Dysfunctional uterine bleeding: excessive bleeding AFTER exclusion of pathologic causes *** THIS TERM IS NO LONGER USED ***
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1) Describe the presentation and RF for Adnexal torsion

 Primer: Adnexal torsion = ~approximately 3% of gynecologic emergencies

Def: Happens when the ovary and fallopian tube on twist on the axis between the utero-ovarian and infundibulopelvic ligaments.

  • Usually as one unit, but ovary and tube can (RARELY) independently twist on their own.
  • Usual saving grace is double arterial blood supply to ovary (uterine and ovarian arteries)
  • Progression of venous & lymphatic congestion → ovarian edema → ischemia → necrosis → possible hemorrhage / infection / peritonitis

Presentation: Sneaky diagnosis, often missed! Pre-surgery diagnosis only ~40%

Typical sudden onset sharp, severe unilateral abdo pain. +/- Nausea / Vomiting.

Risk Factors:

  • Reproductive age
    • 2o to regular development of corpus luteal cysts during menstrual cycle
  • Relative adnexal mobility: seen in premenarchal patients
  • Enlarged ovary (>5.0 cm)
    • Benign neoplasm or cysts,
    • Recent Infertility Treatment (ovulation induction & hyperstimulation syndrome)
    • polycystic ovarian syndrome
  • Pregnancy: Torsion rare but possible in 1st and early 2nd trimesters
  • Hx/ tubal ligation

***Note: “Masses prone to creating adhesions, such as malignant tumors, endometriomas, or tubo-ovarian abscesses, are less likely to develop torsion than benign lesions.” Rosen’s 9th edition***

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2) List the imaging findings of adnexal torsion (US vs CT)

Ultrasound:

  • Enlargement of ovary
  • Associated ovarian mass
  • Loss of enhancement
  • Edema
  • Free pelvic fluid
  • Loss of venous waveforms
  • Loss of arterial waveforms

 CT:

  • Enlargement of the ovary
  • Associated ovarian mass
  • Thickening of the fallopian tube
  • Free pelvic fluid
  • Edema of the ovary
  • Deviation of the uterus to the affected side
  • Associated hemorrhage
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3) What is the management of adnexal torsion?

  • Treat pain & N/V
  • Volume resuscitate if ++ vomiting
  • Labs & R/O pregnancy
  • Obtain imaging
  • STAT OB/GYN Consult for OR
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4) List different types of Ovarian Cysts

  • Follicular cyst
    • 1st half of menstrual cycle
    • MOST COMMON type of cyst
    • Pathologic when > 3.0 cm
    • Thin-walled & filled with clear fluid
  • Corpeus luteum cyst
    • 2nd half of menstrual cycle
    • Often filled w/ hemorrhagic fluid
  • Benign Cystic Teratoma (dermoid cyst)
  • Endometriomas (chocolate cysts),
  • Fibroma
  • Cystadenoma
  • various types of malignant neoplasms
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5) Describe the menstrual cycle

From: https://menstrual-cycle-calculator.com/menstrual-cycle-calculating-manually/

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6) Describe the classification of Abnormal Uterine Bleeding

Since 2011, we have a new terminology scheme here. Its no Lippism, but sounds cool.

Box 90.2

PALM-COEIN

PALM – Structural Causes

  • Polyp
  • Adenomyosis
  • Leiomyoma (submucosal or other)
  • Malignany and hyperplasia

COEIN

  • Coagulopathy
  • Ovulatory
  • Endometrial
  • Iatrogenic
  • Not yet classified

Who needs w/o for potential coagulopathy?

  • FamHx bleeding disorders
  • Heavy menses
  • Mucosal surface / post dental procedure bleeding
  • Easy bruising
  • Excessive bleeding with surgery

*Pearl: Von Willebrand’s is the most common coagulopathy*

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7) Describe the pharmacologic treatment options of Acute Abnormal Uterine bleeding

(See Table 31.1 for suggested doses and contraindications – Chapter 31 9th edition)

Drugs

  • Hormonal treatments (conjugated equine estrogen)
  • Combination oral contraceptive pills
  • Progestin-only contraceptive pills
  • NSAIDs
  • Ibuprofen
  • Mefenamic (tranexamic) acid
  • Naproxen

***Note: Mefenamic Acid = Tranexamic Acid

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8) Describe the dosing, timeline, indications, and contraindications for emergency contraception

“Morning after pill”

3 forms:

  • Ulipristal acetate
    • progesterone receptor modulator,
  • Levonorgestrel
    • Progestogen- progesterone receptor agonist
  • OCP
    • Combination of progestin and estrogen
    • “Yuzpe method”
    • Fallen out of favour

IUD: Copper vs Mirena (not used as emergency contraception)

AgentDosingTx Window (from intercourse)Contraindications
ulipristal acetateSingle 30 mg doseUp to 120hrs●      Known or suspected pregnancy

●      Hypersensitivity to ulipristal acetate

●      Breast-feeding;

●      Genital bleeding of unknown etiology

●      Severe liver diseases

●      Severe asthma on steroids (antiglucocorticoid effects)

 

Levonorgestrel

“Plan B”

Single 1.5mg dose

Or

0.75mg Q12 x 2 doses

Up to 72hrs●      Known or suspected pregnancy

●      Hypersensitivity to levonorgestrel or any component of the formulation;

●      Undiagnosed vaginal bleeding

Copper IUDSingle device5 days●      Septic pregnancy or abortion

●      Abnormal vaginal bleeding

●      Untreated cervical / uterine cancer

●      Malignant gestational trophoblastic disease

●      STI or PID in last 3 months

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Wisecracks

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1) List 10 DDx for menorrhagia / vaginal bleeding

From Episode 34:

PrepubertalAdolescentReproductivePerimenopausalPostmenopausal
Most commonVaginitisAnovulationPregnancyAnovulationEndometrial lesions including cancer
AnovulationPregnancyAnovulationUterine leiomyomasExog hormone use
Genital trauma or foreign bodiesExog hormone useExog hormone useCervical and endometrial polypsAtrophic vaginitis
CoagulopathyUterine leiomyomasThyroid dysfunctionOther tumor (vulvar, vaginal, cervical)
Least commonThyroid dysfunction

Structural causes

  • Polyps, fibroids, malignancy, hyperplasia, endometriosis

Non-structural causes

  • Coagulopathies (VWF, Factor XI deficiency, thrombocytopenia, ITP)
  • Endocrine (PCOS, Hypothyroid, Hyperprolactinemia, Adrenal hyperplasia, Cushing’s)
  • Weight loss, extreme exercise
  • Stress
  • Obesity
  • Trauma (sexual abuse)
  • Infections (STIs, tuboovarian abscess, vaginitis)
  • Systemic disease (liver or kidney disease)
  • Foreign bodies
  • Medications (Antiepileptics, Antipsychotics, Anticoagulants, Hormonal medications, Steroids)
  • Intrauterine device
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2) List 6 life threatening causes of acute pelvic pain in women

Life threatening diagnoses NOT to miss:

    1. PID
    2. Tubo-ovarian abscess
    3. Ectopic pregnancy
    4. Hemorrhagic ovarian cyst (ruptured)
    5. Appendicitis
    6. Bowel/uterine perforation
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3) List 8 Dx of pelvic pain in women that are of reproductive tract origin (not pregnant)

Reproductive tract

  1. Ovarian torsion / cyst / uterine perforation – mechanical
  2. PID / Salpingitis / endometritis / TOA  – infectious
  3. Endometriosis / fibroids / neoplasm – neoplastic

Dysmenorrhea  – dx of exclusion

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This post was uploaded and copyedited by Colin Sedgwick (@colin_sedgwick)

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.

Chris Lipp

Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..