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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:
- Stabilize patient (ABCs, etc.); monitor vital signs closely and transfuse if necessary
- Maintain patient on bed rest
- If evacuation delayed, give oral contraceptive pill qid (estrogen can stabilize the uterine lining) - anticipate
nausea and treat with oral or IV antiemetic. - Give antibiotics (see below) liberally for: febrile patient (start immediately), tender uterus (suspect
infection of the uterine lining), foul-smelling discharge.
Minor menstrual irregularities:
- If HCG negative and HCT and physical examination are normal, treatment may be delayed until
appropriate consultative services are available. - NSAIDs (ibuprofen 800 mg po tid or Naprosyn 500 mg po bid) may reduce blood flow.
- 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