OBSTETRICS AND GYNECOLOGYDIAGNOSIS
■ Pregnancy test and CBC are needed in most cases of vaginal bleeding.
■ Vaginal ultrasound can be useful to characterize the uterus and endo-
metrium and determine the presence of leiomyomas (fibroids), tumors,
and endometriosis. In stable patients, ultrasound may be deferred to the
outpatient setting.
■ Gynecology referral for endometrial biopsy should be obtained for women
over the age of 35 with abnormal uterine bleeding and for women <35
with risk factors for endometrial cancer (obesity, chronic anovulation).
TREATMENT
■ Treatment depends upon hemodynamic stability.
■ If unstable, fluid resuscitation and blood are indicated along with emer-
gent D&C. Intravenous conjugated estrogen 25 mg IV q 2–4 hours may
be used in nonpregnant patients with bleeding not amenable to surgical
intervention.
■ If stable, hormonal treatment can help stabilize the endometrium.
■ Oral conjugated estrogen (Premarin) 2.5 mg PO qid for 1 day, then
add medroxyprogesterone and continue both meds for 7–10 days.
■ A 7-day course of ethinyl estradiol and norethindrone may also be used.
ENDOMETRIOSISDisease is defined by the presence of endometrial glands/stroma outside of
the uterus and seen exclusively in women of reproductive age. The size of the
lesions vary from microscopic to large invasive masses that erode into underlying
organs and cause extensive adhesions.
SYMPTOMS
■ Infertility
■ Dysmenorrhea
■ Dyspareunia
■ Pelvic pain or low sacral pain that occurs premenstrually and resolves after
the onset of menses is common.
EXAM
Pelvic exam will show tender nodules in the posterior vaginal fornix and pain
with movements of the uterus.
DIAGNOSIS
■ The diagnosis should be suspected in any woman of reproductive age
complaining of pain or infertility.
■ Confirmation requires direct visualization of the implants with laparoscopy
or laparotomy.
TREATMENT
■ Treatment is directed based on the woman’s desire for future fertility.
■ NSAIDs are the analgesic therapy of choice.
■ Hormonal therapy is used to interrupt the cycles of stimulation and bleed-
ing of endometrial tissue.
All patients of childbearing
age with vaginal bleeding
need a pregnancy test.