Special Operations Forces Medical Handbook

3-41

to pelvic examination.
Pregnancy - always rule out first
Anatomic abnormalities - uterine fibroids, uterine and cervical polyps and large ovarian cysts may secrete
estrogen, which disrupts normal menstrual function. Uterine fibroids are a common cause of AUB in women
from ages 30 through menopause. After menopause, most fibroids become asymptomatic. A postmenopausal
woman with AUB and an enlarged irregular uterus has cancer until proven otherwise.
Infection - cervicitis and endometritis, pelvic inflammatory disease
Cancer and pre-cancerous lesions - post-coital bleeding is a presenting symptom of cervical cancer.
Postmenopausal bleeding is a primary presenting symptom of uterine carcinoma and endometrial hyperplasia/
dysplasia. Ovarian cancer may present with bleeding due to estrogen secretion by the tumor.
Endocrine disorders - disorders of prolactin secretion, hyper and hypothyroidism, adrenal dysfunction. This
category includes anovulation which results in irregular/heavy and occasional absent menses. Stressful
conditions such as basic training may cause anovulation in female soldiers.
Hematologic - suspect coagulopathies in a young, newly menstruating female with abnormally heavy flow

Plan:

Treatment
Significant vaginal hemorrhage:

1. Stabilize patient (ABCs, etc.); monitor vital signs closely and transfuse if necessary


2. Maintain patient on bed rest


3. If evacuation delayed, give oral contraceptive pill qid (estrogen can stabilize the uterine lining) - anticipate
   nausea and treat with oral or IV antiemetic.


4. Give antibiotics (see below) liberally for: febrile patient (start immediately), tender uterus (suspect
   infection of the uterine lining), foul-smelling discharge.

Minor menstrual irregularities:

1. If HCG negative and HCT and physical examination are normal, treatment may be delayed until
   appropriate consultative services are available.


2. NSAIDs (ibuprofen 800 mg po tid or Naprosyn 500 mg po bid) may reduce blood flow.


3. Oral contraceptive pills are the most effective way to control menstrual irregularities (see Contraception
   section on CD-ROM).

Treatment of other AUB is dependent on appropriate diagnosis that will not be obtainable in the field.

Antibiotic regimens:
Primary: Ampicillin/sulbactam 3 gm IV q 4-6 hours
Alternate: Cefotetan 1-2 gm IV q 12 hours or piperacillin 3-4 gm IV q 4 hours, or ticarcillin/clavulanate 3.1
gm IV q 6 hours, or gentamicin 1.5 mg/kg load then 1.0 mg/kg IV q 8 hours and clindamycin 900 mg IV q 6
hours (if patient remains febrile after 48 hours, add ampicillin 2 gm IV q 6 hours).
Empiric: If IV therapy is not available, treat the patient as per oral PID protocol with IM ceftriaxone 250 mg
and 1 gm of oral azithromycin or 100 mg doxycycline po bid.

Follow-up Actions
Evacuation/Consultation Criteria: Evacuate after initial stabilization for significant hemorrhage. Consult
OB/GYN expert as needed for continued or recurrent symptoms.

Symptom: GYN Problems: Pelvic Pain, Acute

MAJ Ann Friedmann, MC, USA

Introduction: Internal gynecologic pathology is a common cause of pelvic and abdominal pain. Acute pain
may be secondary to an ectopic pregnancy, a ruptured ovarian cyst, torsion of the ovary, pelvic inflammatory