3. Ovary
Ovarian Cysts
◦ Most frequently seen in reproductive
years
◦ Follicular Cyst - MC
1st 2 weeks of cycle
Thin-walled, fluid filled
◦ Corpus Luteal Cyst
Last 2 weeks of cycle
More likely to hemorrhage
◦ Clinical Presentation: Pelvic Pain
(generalized, dull)
4. Ovarian Cysts
Exclude pregnancy
Check Hemoglobin (in case hemorrhagic
cyst)
Dx: ultrasound
Tx: symptomatic treatment &
out-patient follow-up
D/C: torsion precautions
Cyst is considered large if >3 cm
(increased risk for torsion)
5. Ovary
Ovarian Torsion
◦ Ovary twists in its vascular pedicle
◦ 50-80% cases associated with ovarian
tumor or large cysts; previous pelvic
surgery/adhesions
◦ The twist causes venous/lymph
obstruction leading to congestion and
edema, then ischemia & necrosis
◦ Ovary has DUAL blood supply so arterial
obstruction is rare, thus Doppler US may
show flow
7. Ovary
Ovarian Cancer
◦ Peak age 55-65
◦ Affects 1 in 70 women
◦ Disease is often advanced at time of
diagnosis
50% mortality
◦ Risk Factors:
FMH ovarian, breast or colon ca
Infertility, low parity, high-fat diet, lactose
intolerance
◦ Sxs: subacute abdominal pain, bloating,
weight loss/gain, ascites, pleural effusion
◦ Dx: US and CT Scan, CA-125
◦ Tx: surgery, chemotherapy, and/or radiation
8. Cervix
Cervical Cancer
◦ Risk Factor: HPV
HPV Vaccine – Girls 9-26
◦
◦
◦
◦
In patients with HIV AIDS
Mostly squamous cell cancers
Post-coital bleeding
Dx: Pelvic exam, biopsy
13. Uterus
Uterine Prolapse and Cystocele
◦ Vaginal wall weakness caused by age,
multiparity, decreasing estrogen levels, pelvic
trauma
◦ Dx: Can see bladder, uterine prolapse on
pelvic exam
Valsalva maneuver helpful
◦ Tx: digital reduction, Pessary, surgery
14. Uterus
Uterine Fibroids
(Leiomyoma)
◦ Benign tumors of
uterine muscle
◦ Higher incidence in
AA women
◦ Heavy bleeding, pelvic
pain
◦ Can be submuscosal,
suberosal, intramural
◦ Dx: Ultrasound
◦ Tx: hormone
regulation, surgery,
NSAIDs
15. Uterus
Uterine Cancer
◦ MC GYN malignancy, specifically
endometrial
◦ Risk Factors:
Early menses, late menopause, nulliparity
Unopposed estrogen use
DM, HTN, obesity
◦ Sxs: post-menopausal bleeding
◦ Dx: biopsy, D&C, Hysteroscopy
◦ Tx: surgery, chemotherapy, and/or radiation
◦ *Vaginal bleeding in a postmenopausal
woman is (endometrial) cancer until proven
otherwise*
16. While we are in the pelvis…
Pelvic Inflammatory Disease (PID)
◦
◦
◦
◦
Polymicrobial
Complications: infertility, ectopic pregnancy
Clinical Dx – CMT (Chandelier Sign)
Admit: pregnant, oral intolerance, TOA
Fitz-Hugh-Curtis Syndrome
◦ Infection from fallopian tubes contaminates
abdomen
Bacterial infection of perihepatic space
◦ RUQ and shoulder pain
◦ “Violin-string” adhesions
17. Vagina
Vulvovagintis
◦ Vaginal discharge, itching
◦ Causes:
Infection, allergic reaction, foreign body,
irritant/chemical
Atrophic Vaginitis
Post-menopausal secondary to estrogen deficiency
Tx: topical or oral estrogen replacement therapy
◦ MC problem in children
◦ Normal vaginal pH 4.0-4.5
◦ Any condition changing the vaginal pH
18. Vagina
Bacterial Vaginosis
◦ MCC of abnormal vaginal discharge
◦ Gardnerella/anerobes take over normal flora
◦ Dx: Amsel Criteria (3 of 4)
Copious think white discharge
pH >4.5
Clue cells on wet mount; cx not helpful
May have fishy odor with KOH whiff test
◦ Tx: Metronidazole (PO or gel)
500 mg PO bid for 7 days (2 g PO x1not recommended)
19. Vagina
Candidal Vaginitis
◦ Candida Albicans is part of normal flora
◦
◦
◦
◦
Overgrows
Associated with DM, abx, pregnancy
Sxs: vulvar pruritis (MC)
Exam: vulvar erythema
Dx: wet mount (psuedohyphae, budding
yeast);
culture is gold standard
◦ Cottage cheese discharge
◦ Tx: Fluconazole (one dose 150mg PO), or
OTC vaginal creams
Avoid PO in pregnancy
21. Vagina
Bartholin’s Cyst
◦ Bartholin’s glands are normal
Located inferiorly at vaginal introitus
◦ Cyst (painless), abscess (painful)
◦ Abscess: polymicrobial
Staph, Strep, E.Coli, or STD
◦ Tx: I&D, Word Catheter, Abx
◦ Definitive Tx: Marsupialization
22. Uterus
Gestational Trophoblastic Disease
◦ Tumors formed form abnormal placental cells that implant and
proliferate within the uterus
◦ Choriocarcinoma
◦ Hydatidaform Mole – molar pregnancies
Complete
MC
Develops from 1 (duplicates) or 2 sperm fertilizing an empty egg
46XX or 46XY karyotype
Lacks a fetus
Uterus LARGER than dates
„grapelike vesicles‟ „snowstorm‟ on US with empty egg
20% malignant
Partial
2 sperm fertilize a normal egg
69XXX or 69XXY
Fetus present
Uterus SMALLER than dates
Non-viable fetus AND normal &vesicular chorionic villi
5% to malignancy
23. GTDs
Hydatidaform Mole
◦ Sxs:
Painless, abnormal vaginal bleeding
Uterine size greater than normal
Hyperemesis gravidarum (hCG levels >100k)
Symptoms of hyperthyroid
Early preeclampsia
◦ Tx: depends on type/pathology
More benign (80%)or slow growing – D&C,
chemotherapy
Malignant (2% choriocarcinoma), metastatic tumors –
chemo/XRT/surgery
◦ Often fertility can be maintained
Monitor hCG levels after evacuation
24. A Few Questions…
A 17 year old seually active girl present complaining of
dysuria for 3 days. She denies fever, abdominal pain,
vomiting, and diarrhea. Abdominal examis normal.
Pelvic examination reveals a homogenous white
discharge that coats the vaginal walls. Pregnancy tests
is negative, and wet mount shows clue cells. The best
treatment is:
◦
◦
◦
◦
◦
A.
B.
C.
D.
E.
Azithromycin
Ceftriaxone
Fluconazole
Levofloxacin
Metronidazole
25. A Few Questions…
A 17 year old seually active girl present complaining of
dysuria for 3 days. She denies fever, abdominal pain,
vomiting, and diarrhea. Abdominal examis normal. Pelvic
examination reveals a homogenous white discharge that
coats the vaginal walls. Pregnancy tests is negative, and wet
mount shows clue cells. The best treatment is:
◦
◦
◦
◦
◦
A.
B.
C.
D.
E.
Azithromycin
Ceftriaxone
Fluconazole
Levofloxacin
Metronidazole
26.
A 23 year old woman presents complaining of lower
abdominal pain. Pelvic examination reveals yellow vaginal
discharge, as well as moderate cervical motion tenderness.
Adnexa are tender, but no masses are present. Outpatient
management may be considered if the patient has:
◦
◦
◦
◦
◦
A.
B.
C.
D.
E.
A physician who can provide follow-up
Pelvic Abscess
Positive pregnancy test result
Taken antibiotics already for similar complaints
Temperature >38.8C (>102F)
27.
A 23 year old woman presents complaining of lower
abdominal pain. Pelvic examination reveals yellow vaginal
discharge, as well as moderate cervical motion tenderness.
Adnexa are tender, but no masses are present. Outpatient
management may be considered if the patient has:
◦
◦
◦
◦
◦
A.
B.
C.
D.
E.
A physician who can provide follow-up
Pelvic Abscess
Positive pregnancy test result
Taken antibiotics already for similar complaints
Temperature >38.8C (>102F)
28.
A 25 year old female presents to the ER with left lower
quadrant pain, nausea and vomiting for 6 hours. Her last
menstrual period ended 10 days ago, She is afebrile, and
CBC and chemistry are grossly normal. Her pregnancy test
is negative. Ultrasound reveals multiple small cysts
throughout both ovaries consistent with PCOS, the largest of
which is on the left ovary and measures 2.5 cm. What is the
most likely diagnosis?
◦
◦
◦
◦
A.
B.
C.
D.
Arterial blood supply obstruction
Ectopic pregnancy
Follicular rupture
Venous blood supply obstruction
29.
A 25 year old female presents to the ER with left lower
quadrant pain, nausea and vomiting for 6 hours. Her last
menstrual period ended 10 days ago, She is afebrile, and
CBC and chemistry are grossly normal. Her pregnancy test
is negative. Ultrasound reveals multiple small cysts
throughout both ovaries consistent with PCOS, the largest of
which is on the left ovary and measures 2.5 cm. What is the
most likely diagnosis?
◦
◦
◦
◦
A.
B.
C.
D.
Arterial blood supply obstruction
Ectopic pregnancy
Follicular rupture
Venous blood supply obstruction
30.
A 65 year old female presents to the ER with a chief
complaint of vaginal bleeding for 5 days. She is using about
2 pads per day. Prior to this episode, she has not had a
menstrual period for 9 years. She has no PMH, and her only
medications include hormone replacement therapy. Vital
signs are normal and Hgb is 12.5. Pelvic exam reveals a
small amount of blood in the vaginal vault, but no lesions,
CMT, or adnexal tenderness. What is the most likely cause of
this patient’s vaginal bleeding?
◦
◦
◦
◦
A.
B.
C.
D.
Atrophic vaginitis
Estrogen deficiency
Endometrial neoplasm
Hormonal supplementation
31.
A 65 year old female presents to the ER with a chief
complaint of vaginal bleeding for 5 days. She is using about
2 pads per day. Prior to this episode, she has not had a
menstrual period for 9 years. She has no PMH, and her only
medications include hormone replacement therapy. Vital
signs are normal and Hgb is 12.5. Pelvic exam reveals a
small amount of blood in the vaginal vault, but no lesions,
CMT, or adnexal tenderness. What is the most likely cause of
this patient’s vaginal bleeding?
◦
◦
◦
◦
A.
B.
C.
D.
Atrophic vaginitis
Estrogen deficiency
Endometrial neoplasm
Hormonal supplementation
32.
A 23 year old G1P0 woman 7 weeks pregnant by dates, was
discharged form another ED 3 weeks ago with a diagnosis of
‘threatened abortion’ and was given instructions for pelvic
rest. She presents today for persistent vaginal bleeding and
sever nausea and vomiting. She has not passed any tissue.
Urine pregnancy test is positive. The top of the uterus is felt
halfway between the umbilicus and pubic bone. You
repeated the transvaginal ultrasound today, with the finding
below. What is the clinical suspicion at this time?
◦
◦
◦
◦
A.
B.
C.
D.
Choriocarcinoma
Hydatdiform mole, complete
Hydatidiform mole, incomplete
Incomplete abortion
33.
A 23 year old G1P0 woman 7 weeks pregnant by dates, was
discharged form another ED 3 weeks ago with a diagnosis of
‘threatened abortion’ and was given instructions for pelvic
rest. She presents today for persistent vaginal bleeding and
sever nausea and vomiting. She has not passed any tissue.
Urine pregnancy test is positive. The top of the uterus is felt
halfway between the umbilicus and pubic bone. You
repeated the transvaginal ultrasound today, with the finding
below. What is the clinical suspicion at this time?
◦
◦
◦
◦
A.
B.
C.
D.
Choriocarcinoma
Hydatdiform mole, complete
Hydatidiform mole, incomplete
Incomplete abortion
34. References
HippoEM.com
Naderi, Sassan. Intensive Review for Emergency Medicine Qualifying
Examination. McGraw-Hill Companies. New York. 2010
Tintinalli MD, Judith E. Tintinalli’s Emergency Medicine: A Comprehensive
Study Guide. 7th Edition. McGraw-Hill Companies. New York. 2011.
Wagner MD, Mary Jo. Peer VII. ACEP. Dallas, Texas. 2006.
Notes de l'éditeur
Ovarian tumor – usu benign, OHSS (ovarian hyperstimulation syndrome) someone receiving infertility treatment, PCO –hxirreg periods
No labs: anatomic issues, not infectiousDoppler for mass or other suspicious pathology, blood flow but CAN HAVE FALSE -BUT If you clinically suspect torsion in a person with ovarian cysts or mass, there is no foolproof way to rule it out. CALL GYN.
Bloating “pants don’t fit”Ascites is women without other liver hx – gynca until proven otherwise
Refer for bx
Inflammation – “think urethritis in men”Latex allergy, diaphragm
Premarin = IV EstrogenAlso ovulatory bleeding (10%) – less well understood – bleeding d/o (VWB), rx (NSAIDs, Coumadin, ASA)
Chocolate cyst
CC – ‘ball’ or ‘something coming out of my vagina’Sxs: pressure, pain, constipation, back painPessary – retaining wall
US does not have to be ordered in ED, but US is where you will see them/dx.
…while we are in the abd…Polymicrobial – mostly GC, Chlam, other organismsCMT US to r/o abscess/TOACx: scarringF-H-C: BOARD FAVORITE; think outside the box with RUQ pain cc in age approp female
Irritant – douches, soaps
pH closer to six, if using nitrazine paperMay see clue cell slide – ‘potato chip sprinkled with pepper’ epithelial cell + bactCx NOT helpful, gardnerellavaginalis colonized >50% women
Cottage cheese dc – cc or examPO and topical equally effectiveComplicated infections - >4/yr, require longer tx
Strawberry cervix – punctate hemorrhagesDon’t forget to treat sexual partners
Located 4 & 7 o’clock at vaginal opening
TSH and hCG have similar structuresMore sever sxs seen with COMPLETE Mole
Clindamycin vaginal cream or pills can also be used
Remember ADMIT pregnant, oral intolerance, TOA
VB in previously menopausal pts is endometrialca until proven otherwise. Refer to gyn for further eval