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612 SECTION 11: Obstetrics and Gynecology A multidisciplinary approach is recommended. Initial treatment options are similar to those without bleeding disorder, except the use of NSAIDs is contraindicated. Hormonal agents raise factor VIII and von Willebrand factor levels and are an effective and popular form of therapy. If standard treatment fails, consider desmopressin acetate to stimulate endogenous release of factor VIII and von Willebrand factor. Patients must be typed and screened for antibodies before administering desmopressin acetate because it may induce thrombocytopenia in cer tain subgroups. Antifibrinolytics, such as tranexamic acid and recombinant von Willebrand factor, are other treatment options that have shown reduction in bleeding. 26,27  POLYCYSTIC OVARY SYNDROME Polycystic ovary syndrome, one of the most common endocrine disor ders, is the association of hyperandrogenism and anovulation without underlying disease of the adrenal or pituitary glands. 28 A triad of obesity, hirsutism, and oligomenorrhea is classically described, although obesity is not universally seen. When menses occurs, it is heavy and prolonged. The syndrome is further characterized by acne, androgen-dependent alopecia, elevated serum concentrations of androgens, hyperinsu linemia, and hypersecretion of luteinizing hormone with a normal or low follicle-stimulating hormone level. Typical ovarian morphology, which may be seen by US, is not necessary for the diagnosis and may, in fact, represent a response of the ovary to chronic anovulation. The differential diagnosis includes hyperprolactinemia, acromegaly, con genital adrenal hyperplasia, and androgen-secreting tumors of the ovary or adrenal gland. Management of menorrhagia in women who do not desire fertility includes low-dose oral contraceptives or cyclic progestin administration.  STRESS, ILLNESS, AND RAPID WEIGHT CHANGE Periods of physical or psychological stress, illness, malnutrition, rapid weight gain or loss, and intense physical regimens affect the hypo thalamus and disrupt the normal pattern of gonadotropin release. This usually causes amenorrhea but may result in irregular, heavy bleeding. In obese women, menorrhagia may be a result of increased circulating levels of estrogen from peripheral conversion of androstenedione to estrone in fatty tissue. Patients with liver and renal disease may also develop irregular bleeding. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Abdominal and Pelvic Pain in the Nonpregnant Female Melanie Heniff Heather R.B. Fleming INTRODUCTION AND EPIDEMIOLOGY This chapter reviews diagnosis and treatment of abdominal and pelvic pain in nonpregnant women, with a focus on gynecologic causes of pain. Even after the possibility of pregnancy is eliminated, abdominal pain in women remains a challenging diagnosis because of physical proximity and overlapping spinal segment innervation and similar symptoms of GI, urologic, and gynecologic organ systems. Discussion of the pregnant woman with abdominal/pelvic pain is found in Chapters 71, “ Acute Abdominal Pain, ” 100, “Maternal Emergencies After 20 Weeks of CHAPTER Pregnancy and in the Peripartum Period, ” and 103, “Pelvic Inflamma tory Disease. ” GENERAL APPROACH  HISTORY Define characteristics of the pain including onset, duration, location, quality, radiation, and exacerbating and alleviating factors.

cute Abdominal Pain, ” 100, “Maternal Emergencies After 20 Weeks of CHAPTER Pregnancy and in the Peripartum Period, ” and 103, “Pelvic Inflamma tory Disease. ” GENERAL APPROACH  HISTORY Define characteristics of the pain including onset, duration, location, quality, radiation, and exacerbating and alleviating factors. History should include questions about GI symptoms (nausea, vomiting, diarrhea, and constipation), urologic symptoms (dysuria, hematu ria, frequency, and urgency), and gynecologic symptoms (vaginal bleeding, discharge, dyspareunia, and menstrual history). History of sexual activity and menstrual history should never be relied upon to exclude pregnancy. Obtain past medical, surgical, and family his tory, as well as details of prior pregnancies and outcomes. Active lactation and medication use, including specific methods of birth control, should be part of the history. Ask about infertility treatments because ovulation-inducing treatments increase risk of ovarian torsion, cysts, and ovarian hyperstimulation syndrome. When obtaining a sexual history and social history, it is wise to interview the patient alone, which may help patients feel more comfortable discussing potentially sensitive or embarrassing topics. Ask about pelvic inflammatory disease risk factors including unprotected intercourse, prior sexually transmitted infections, and multiple sexual partners. While the patient is alone, ask her about safety at home, and assess for any potential abusive situations. Patients with history of physical and sexual abuse may develop a variety of somatic complaints including abdominal and pelvic pain, and this pain is often chronic in nature. Social history should include living situation, occupation, and personal habits (use of tobacco, alcohol, and drugs).  PHYSICAL EXAMINATION A standard head-to-toe systematic approach beginning with vital signs is essential. The patient should be adequately undressed for a careful examination. In focusing on the examination of the abdomen, it is helpful to determine in what quadrant(s) of the abdomen the pain is located; this may help to narrow the differential diagnosis (see Figure 71-1). In addition to palpating for tenderness or masses, evaluate for surgical scars, rashes, bruising, or ascites. Peritoneal signs may be less obvious in patients who are elderly, are obese, or have altered neurologic status. A digital rectal exam is helpful, if indicated, to evaluate complaints of rectal pain or bleeding. A pelvic examination is usually a routine component of the exam of women with lower abdominal pain, but studies report a lack of accuracy and reproducibility of pelvic examination findings. 1,2 Pelvic examination is useful for obtaining lab specimens for sexually transmitted infections, palpation for tenderness or mass, and to check for vaginal bleeding, discharge, or foreign body.  DIAGNOSIS In a nonpregnant female with abdominal pain, ED testing beyond a thorough history and exam is not always mandatory. For example, in a patient with multiple prior similar presentations and recent normal imaging studies, it is unnecessary, rarely helpful, and potentially harmful to repeat imaging. 3 In cases where further ED testing is determined to be unnecessary, the physician must still pay careful attention to symptom control, careful reassessment, and disposition. At the time of discharge, providers should review with the patient arrangements for close follow-up, often in 12 to 24 hours, as well as indications for return to the ED. When benign causes are not clear from the initial evaluation and concerns for seri ous pathology remain, lab and/or imaging tests are necessary.  LABORATORY EVALUATION Obtain a pregnancy test in all women of childbearing age who still have a uterus and ovaries.

to 24 hours, as well as indications for return to the ED. When benign causes are not clear from the initial evaluation and concerns for seri ous pathology remain, lab and/or imaging tests are necessary.  LABORATORY EVALUATION Obtain a pregnancy test in all women of childbearing age who still have a uterus and ovaries. See Chapter 98, “Ectopic Pregnancy and Tintinalli_Sec11_p0607-0668.indd 612 8/2/19 4:20 PM

to 24 hours, as well as indications for return to the ED. When benign causes are not clear from the initial evaluation and concerns for seri ous pathology remain, lab and/or imaging tests are necessary.  LABORATORY EVALUATION Obtain a pregnancy test in all women of childbearing age who still have a uterus and ovaries. See Chapter 98, “Ectopic Pregnancy and Tintinalli_Sec11_p0607-0668.indd 612 8/2/19 4:20 PM CHAPTER 97: Abdominal and Pelvic Pain in the Nonpregnant Female 613 conditions (immunocompromised, unstable medical problems, inability to care for oneself at home) should prompt strong consideration for observation or admission. In most patients with abdominal/pelvic pain in the ED, hospitaliza tion is not necessary. It is common and appropriate to discharge patients with a diagnosis of undifferentiated abdominal pain. In patients who are discharged, instructions for follow-up and indica tions for return to the ED should be very specific. Instructions should specify a time course during which patients should be seen for repeat exam. Reevaluation in 12 to 24 hours is appropriate for patients with acute abdominal pain and diagnostic uncertainty. In more chronic abdominal/pelvic pain, follow-up with a primary care provider is still important, but timing of follow-up should be specified according to individual patient needs. OVARIAN CYSTS Ovarian cysts, when symptomatic, usually present with sudden-onset unilateral pain that is more common on the right than left. Cervical motion tenderness and mild vaginal bleeding are sometimes present. Pain often starts during physical activity such as exercise or sexual intercourse. Functional (benign) cysts are fluid-filled sacs that develop dur ing a normal menstrual cycle. Follicular cysts contain a maturing ovum and rupture at ovulation. Corpus luteum cysts are present after the ovum is released. If no conception occurs, the corpus luteum involutes. If fertilization takes place, the corpus luteum cyst enlarges and secretes estrogen and progesterone. Both follicular and corpus luteum cysts can cause pelvic pain; this is more likely if there is hemorrhage within the cyst or rupture. Ruptured hemorrhagic cysts can occasionally result in significant hemoperitoneum visible in the upper abdominal quadrants with US. 5 Hemorrhagic cysts occur if a blood vessel in the cyst wall ruptures (Figure 97-1). Mittelschmerz (German for middle pain) is midcycle pain at the time of ovulation caused by normal follicular enlargement prior to ovulation or follicular bleeding at ovulation. Pain is usually mild and lasts a few hours up to a few days. Complicated cyst rupture is characterized by abnormal vital signs and an acute abdomen. Hospitalization or observation is needed for serial examinations and hematocrits. Surgery may be necessary to con trol hemorrhage. A dermoid cyst is an ovarian germ cell neoplasm that presents as a multicystic mass that contains various types of tissue including fat, skin, hair, and teeth. These cysts usually occur between age 10 and 30 years. Emergencies in the First 20 Weeks of Pregnancy, ” for a detailed discussion of pregnancy testing. A CBC is often obtained, but the WBC count is not reliable to rule in or exclude serious disease. 4 Obtain a urinalysis, and add a urine culture in pediatric patients, pregnant women, and patients at risk for complicated urinary tract infections. See Chapter 91, “Urinary Tract Infections and Hematuria, ” for detailed discussion of urinalysis. Be cautious in making a definitive diagnosis of urinary tract infection as the sole cause of a patient’s symptoms.  IMAGING US is the imaging modality of choice for genital tract pathology (ovarian cyst, ectopic pregnancy, uterine or ovarian mass, or tuboovarian abscess). Ready availability, relatively low cost, and lack of ionizing radiation make US a good option for imaging in women of reproductive age.

of a patient’s symptoms.  IMAGING US is the imaging modality of choice for genital tract pathology (ovarian cyst, ectopic pregnancy, uterine or ovarian mass, or tuboovarian abscess). Ready availability, relatively low cost, and lack of ionizing radiation make US a good option for imaging in women of reproductive age. Drawbacks of US include operator dependence and technical limitations including body habitus and bowel gas. 5 CT is preferred when GI or GU pathology (appendicitis, diverticulitis, bowel obstruction, or renal stones) is highest in the differential diagnosis. Bedside US can facilitate rapid diagnosis and treatment. For example, a positive FAST exam could help identify bleeding from a ruptured ectopic pregnancy or significant hemorrhage from an ovarian cyst. ED US can quickly identify a normal intrauterine pregnancy. Pelvic US is the primary imaging modality for evaluation of lower abdominal pain in the female patient in whom a gynecologic diagnosis is considered most likely. US is useful in diagnosis of torsion, pelvic inflammatory disease, tubo-ovarian abscess, leiomyoma, and ovarian cysts. In evalua tion of possible ovarian torsion, pelvic US should include Doppler flow. Transabdominal and intravaginal probes are used for imaging of pelvic organs. In transabdominal imaging alone, a full bladder aids visualiza tion of pelvic organs. In transvaginal imaging, an empty bladder aids visualization. US studies should never be delayed waiting for a full bladder, particularly when there is concern for a serious diagnosis such as ovarian torsion. US may be useful to evaluate for appendicitis, but it is less sensitive than CT and is operator dependent. CT of the abdomen and pelvis is sensitive for evaluation of most abdominal and pelvic conditions. Usually IV contrast alone is sufficiently sensitive for evaluation of possible appendicitis. 7 If there is concern for pelvic abscess, or the patient weighs less than 70 kg, oral contrast may enhance accuracy of evaluation. MRI is accurate in diag nosis of many abdominal and pelvic conditions, but cost and limited availability limit its use in most EDs.  TREATMENT Specific treatment depends on diagnosis (see below), but because the diagnostic process can be time consuming, control of pain and nausea and fluid resuscitation take priority. There is no evidence that judicious use of opiates obscures abdominal exam findings or negatively impacts outcomes. Opiates can be titrated to control pain, without causing excessive somnolence or respiratory depression. Antiemetics including ondansetron, metoclopramide, promethazine, and prochlorperazine are safe and effective. Antibiotics should be given in the ED for sus pected severe intra-abdominal infection or sepsis. Choice of antibiotics depends on severity of infection and factors relevant to patients’ indi vidual risk, such as comorbid conditions and possibility of hospitalacquired infections. 8,9 See Chapters 71 and 103 for further discussion of antibiotic selection.  DISPOSITION AND FOLLOW-UP When a serious or potentially surgical diagnosis is considered likely, early consultation with the appropriate specialist (general surgery, urology, or obstetrics/gynecology) is indicated. If there is persistent concern for serious pathology, admission or observation is appropriate. This applies even if the diagnosis is unclear. Patients with abnormal vitals, poorly controlled pain, and/or vomiting are best served by inpatient treatment. In many cases, diagnosis is clear after a period of observation and serial exams. Many patients seen in the ED have significant symp toms, but a specific condition may not be diagnosable in the relatively brief period of time a patient spends in the ED. Significant comorbid FIGURE 97-1.

t served by inpatient treatment. In many cases, diagnosis is clear after a period of observation and serial exams. Many patients seen in the ED have significant symp toms, but a specific condition may not be diagnosable in the relatively brief period of time a patient spends in the ED. Significant comorbid FIGURE 97-1. A 4-cm hemorrhagic ovarian cyst demonstrated by endovaginal US. [Reproduced with permission from Ma OJ, Mateer JR, Blaivas M: Emergency Ultrasound, 2nd ed. © 2008, McGraw-Hill, Inc., New York. Fig. 14-10, p. 362.] Tintinalli_Sec11_p0607-0668.indd 613 8/2/19 4:20 PM

t served by inpatient treatment. In many cases, diagnosis is clear after a period of observation and serial exams. Many patients seen in the ED have significant symp toms, but a specific condition may not be diagnosable in the relatively brief period of time a patient spends in the ED. Significant comorbid FIGURE 97-1. A 4-cm hemorrhagic ovarian cyst demonstrated by endovaginal US. [Reproduced with permission from Ma OJ, Mateer JR, Blaivas M: Emergency Ultrasound, 2nd ed. © 2008, McGraw-Hill, Inc., New York. Fig. 14-10, p. 362.] Tintinalli_Sec11_p0607-0668.indd 613 8/2/19 4:20 PM 614 SECTION 11: Obstetrics and Gynecology Most are benign, but risk factors for malignant teratomas include age over 45, diameter greater than 8 cm, and rapid growth. Most uncomplicated cyst ruptures are from follicular and corpus luteum cysts. Vital signs are stable, and symptoms last only a few days. Ovarian cysts that are <8 cm, unilocular, and unilateral are generally observed and typically resolve within two menstrual cycles. Cysts that are large (>8 cm), solid, and multiloculated are worrisome for neo plasm, dermoid cysts, or endometriomas. Patients with ovarian cysts, regardless of size, and especially if postmenopausal, should be referred to the gynecologist or primary care physician for follow-up. ENDOMETRIOMAS Endometriomas are called “chocolate cysts” because they usually con tain thick brown fluid. They present as a pelvic mass caused by growth of ectopic endometrial tissue within an ovary. Endometriomas may rupture, and patients can present with peritoneal signs/symptoms. Endometriomas may also present similar to endometriosis (pelvic pain, dysmenorrhea, and dyspareunia). OVARIAN NEOPLASM An ovarian mass in a postmenopausal woman is malignant until proven otherwise. The mean age at diagnosis is 50 to 60 years. Patients pres ent with nonspecific and persistent signs/symptoms of undetermined cause, including anorexia, dyspepsia, early satiety, constipation, bloat ing, abdominal discomfort, and ascites. Nearly half of women are not diagnosed until stage III or IV disease is present. When evaluating nonspecific symptoms, ask about family history of gynecologic cancer. Cancers of the endometrium, breast, and GI tract may metastasize to ovaries and fallopian tubes. OVARIAN HYPERSTIMULATION SYNDROME Ovarian hyperstimulation syndrome is a complication of ovulation induction treatments, with a clinical spectrum of severity ranging from mild abdominal bloating to critical and potentially fatal conditions. With incidence and severity of ovarian hyperstimulation syndrome increasing, emergency providers should ask patients of reproduc tive age about a history of fertility treatments and should be able to recognize the potentially severe complications. 10 The syndrome can occur early, 5 to 7 days after ovulation, or later, due to rising human chorionic gonadotropin levels. The most common initial symptom is abdominal bloating. The severe syndrome is characterized by massive transudation of albumin and fluid from the vascular compartment to the peritoneal, pleural, and sometimes, pericardial cavities. 11 Venous and arterial thrombosis are the most dreaded complications. Reports include thrombosis of the jugular, subclavian, retinal, and extremity veins and cerebral venous thrombosis. Stroke, ST-segment elevation myocardial infarction, sepsis, adult respiratory distress syndrome, and pulmonary embolism are also reported. ENDOMETRIOSIS AND ADENOMYOSIS Endometriosis occurs when endometrium-like tissue outside the uterus induces a chronic inflammatory reaction. This is a common cause of pelvic pain and infertility. When endometrial tissue is in the uterine wall, it is termed adenomyosis. Both conditions cause chronic, recurrent, and cyclic pain. Dysmenorrhea and dyspareunia are often reported. US may show cystic or solid masses. Laparoscopy is the definitive method of diagnosis. Primary diagnosis is usually not made in the ED. If suspected, pain control and outpatient referral are appropriate.

omyosis. Both conditions cause chronic, recurrent, and cyclic pain. Dysmenorrhea and dyspareunia are often reported. US may show cystic or solid masses. Laparoscopy is the definitive method of diagnosis. Primary diagnosis is usually not made in the ED. If suspected, pain control and outpatient referral are appropriate. FOREIGN BODY/TRAUMA Vaginal foreign bodies (such as a retained tampon) may cause pelvic pain and vaginal discharge or bleeding. Trauma or foreign body should be considered in the differential diagnosis. Patients are not always immediately forthcoming with history due to fear or embarrassment. Complications such as abscess or perforation are rare. OVARIAN TORSION Ovarian torsion is a surgical emergency that requires prompt diag nosis to preserve ovarian function. Adnexal torsion is an ischemic condition almost always associated with ovarian enlargement, gener ally due to ovarian cysts or masses. The enlargement causes the ovary to twist, creating a fulcrum around which the oviduct revolves. Initial blockage of venous return causes congestion, leading to decreased distal arterial blood flow, which produces ischemia and necrosis of the ovary. Although the process may involve the ovary alone, torsion of both the ovary and the oviduct (adnexal torsion) is more common. Nearly 70% of torsions occur on the right side, due to the increased length of the utero-ovarian ligament on the right and the sigmoid on the left, limiting space for movement. Risk factors for torsion are pregnancy due to enlarged corpus luteum, presence of large ovarian cysts or tumors, polycystic ovaries, chemi cal induction of ovulation (ovarian hyperstimulation syndrome), and tubal ligation. Torsion can occur in females of all ages including infants, adolescents, and postmenopausal women. 13 Classically, patients present with sudden-onset, severe, unilateral, lower abdominal pain that may develop after episodes of exertion. However, pain may be of gradual onset, mild, or intermittent. Atypical presentations are common, with half of patients reporting gradual onset of pain that is intermittent in nature. Nausea and vomiting are present in 70% of cases. Clinical findings classically consist of unilateral lower abdominal tenderness with guarding, unilateral adnexal tenderness on bimanual examination, and presence of a latero-uterine mass. Conversely, nearly 30% of patients have bilateral adnexal tenderness on bimanual exami nation, and a minority of patients may have no tenderness at all. Fifty percent of patients are initially misdiagnosed. Transvaginal US with Doppler is the primary diagnostic modality for suspected torsion; however, US with Doppler is not 100% sensitive or specific for diagnosing ovarian torsion. An ovary >4 cm in size due to cyst, tumor, or edema is the most common ultrasonographic finding associated with torsion. 16 Conversely, given the dynamic nature of the torsion process, up to 26% of US studies reveal normal adnexa. Up to 60% of cases of torsion can be missed on arterial Doppler alone, given that arterial disruption of flow is a late clinical finding. 17 However, a positive Doppler study has a 100% positive predictive value for adnexal torsion. Recent improvements in US technology have led to assessment of venous Doppler flow, which may be the only abnormality identified in early ovarian torsion. 18 A combination of US findings (abnormal blood flow, free fluid, and ovarian enlargement) increases the specificity and positive predictive value of US. CT is not the imaging modality of choice when torsion is suspected, but it is commonly done in EDs to evaluate women with nonspecific lower abdominal or pelvic pain. The most common CT finding of ovarian torsion is an enlarged ovary (>4.0 cm).

enlargement) increases the specificity and positive predictive value of US. CT is not the imaging modality of choice when torsion is suspected, but it is commonly done in EDs to evaluate women with nonspecific lower abdominal or pelvic pain. The most common CT finding of ovarian torsion is an enlarged ovary (>4.0 cm). Other CT findings of torsion include abnormal ovarian enhancement with contrast, an adnexal mass, thickening of the fallopian tube, displacement of the ovary, and devia tion of the uterus to the affected side. There is no radiologic or clinical finding that conveys with certainty the absence of torsion. Thus, clinical suspicion based on history and physical exam remains important in involving gynecologic consultation if US is negative but clinical concern remains high. SPECIAL CONSIDERATIONS  OVARIAN TORSION IN ADOLESCENTS AND PREMENARCHAL GIRLS Ovarian torsion may occur at any age in both pre- and postmenarchal girls but is increased in the first year of life, at menarche, and during pregnancy. 19,21 Pediatric ovarian torsion is rare and difficult to diagnosis, which may result in delayed diagnosis and treatment with resulting ovarian loss. In pediatric and adolescent patients, torsion is more likely to occur in an otherwise normal ovary (without a cyst or mass). 22,23 Presenting symptoms of abdominal pain with nausea and vomiting are Tintinalli_Sec11_p0607-0668.indd 614 8/2/19 4:20 PM