Gynaecological Emergencies

(1)

Royal Free NHS Foundation Trust, London, UK

Secondary dysmenorrhea is associated with underlying pelvic pathology and can lead to ED attendance.

Causes of secondary dysmenorrhoea

Lower genital tract:

Painful cryptomenorrhoea:

Acquired cervical stenosis

Uterus:

Pelvis:

Endometriosis (may be associated with dysmenorrhoea, dyschezia, chronic pelvic pain, infertility, haematuria, and rectal bleeding)
Chronic pelvic inflammatory disease
Pelvic adhesions

Key historical features in secondary dysmenorrhoea

Typically, the onset is after several years of painless periods
The pain may not respond to non-steroidal anti-inflammatory agents or oral contraception
Gynaecological symptoms: dyspareunia; abnormal vaginal discharge; menorrhagia; inter-menstrual or post-coital bleeding
Gastrointestinal symptoms: rectal pain and bleeding (endometriosis)

Causes of abnormal vaginal bleeding

Abnormal menstrual bleeding:

Non-menstrual bleeding:

Categories of excessive vaginal bleeding

Menorrhagia: excessive menses (>80 ml monthly menstrual loss, ie >90th centile for menstrual blood loss) but normal cycle (>7 days with one or more days of excessive loss)
Short cycle (<21/7) but normal menses (polymenorrhoea)
Short cycle + excess bleeding (polymenorrhagia)
Excessive menses at long intervals
Metrorrhagia: irregular intervals with excessive menses

Causes of abnormal genital tract bleeding in the reproductive age group

Pregnancy –related

Early pregnancy

Implantation bleeding
Pregnancy failure: miscarriage (haemodynamic status; state of internal os; products of conception)
Ectopic pregnancy
Gestational trophoblastic disease (molar pregnancy)

Later pregnancy (antepartum haemorrhage-from 24 weeks of pregnancy)

Placenta praevia: painless bleeding; soft, non-tender uterus; high presenting part or malpresentation
Placental abruption: severe abdominal or back pain; uterine contractions may be present; uterine tenderness
Vasa praevia
Uterine inversion
Retained placenta
Endometritis

Non-pregnancy-related

Dysfunctional uterine bleeding: anovulatory bleeding; corpus luteum dysfunction.

Structural abnormalities

Infection:

Endocrine dysfunction:

Foreign bodies

Iatrogenic:

Blood dyscrasias:

Symptoms accompanying menorrhagia that indicate significant pathology

Malignancy: persistent inter-menstrual or post-coital bleeding; unexplained vulval lump or vulval bleeding due to ulceration
Other structural disease: pelvic pain; pressure symptoms

Causes of premenarcheal genital tract bleeding

Causes of menorrhagia