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Abnormal Vaginal Bleeding

Ask these questions of any woman with abnormal vaginal bleeding:

''How long have you noticed the vaginal bleeding?'' ''What types of contraceptives do you use?'' ''How often are your periods?'' ''What is the duration of your menstrual flow?''

''How many tampons or napkins do you use on each day of your flow?'' ''Are there any clots of blood?'' ''When was your last period?''

''Have you noticed bleeding between your periods?'' ''Do you have abdominal pain during your periods?'' ''Do you have hot flashes? cold sweats?''

''Do you have children?'' If yes, ''When was your last one born?'' ''Do you think you might be pregnant?'' ''Are you under any unusual emotional stress?''

Have you noticed an intolerance to cold? heat?'' ''Have you noticed a change in your vision?''

Have you had any headaches? nausea? change in hair pattern? milk discharge from your nipples?''

What is your diet like?''

Abnormal uterine bleeding, also known as dysfunctional uterine bleeding, includes amenorrhea, menorrhagia, metrorrhagia, and postmenopausal bleeding. Amenorrhea is the cessation or nonappearance of menstruation. Before puberty, amenorrhea is physiologic, as it is during pregnancy and after menopause. In primary amenorrhea, menstruation has never occurred; in secondary amenorrhea, menstruation has occurred but has ceased, as in pregnancy. Long-distance joggers, patients with anorexia, or any woman with abnormally low body fat may have secondary amenorrhea. Diseases of the hypothalamus, pituitary gland, ovary, uterus, and thyroid gland are associated with amenorrhea. Galactorrhea, or milk discharge from the nipples, occurs in many individuals with pituitary tumors. Chronic disease is also frequently associated with secondary amenorrhea.

Menorrhagia is excessive bleeding at the time of the menstrual period. The flow may be increased, the duration may be increased, or both may occur. The number of pads or tampons a patient uses each day of the cycle helps quantify the flow. Menorrhagia in some cases may be associated with blood disorders such as leukemia, inherited clotting abnormalities, and decreased platelet states. Uterine fibroids are a leading cause of menorrhagia. Menorrhagia secondary to fibroids is related to the large surface area of the endometrium from which bleeding occurs.

Metrorrhagia is uterine bleeding of normal amount at irregular, noncyclic intervals. Foreign bodies such as intrauterine devices, as well as ovarian and uterine tumors, can cause metror-rhagia. Often there is increased bleeding between cycles as well as heavier periods;this is termed menometrorrhagia.

Bleeding that occurs more than 6 to 8 months after menopause is termed postmenopausal bleeding. Any postmenopausal bleeding must be investigated. Uterine fibroids or tumors of the cervix, uterus, or ovary may be responsible.

Dysmenorrhea

Dysmenorrhea, or painful menstruation, is a common symptom. It is often difficult to define as abnormal, because many healthy women have some degree of menstrual discomfort. In most women, these cramps subside soon after the commencement of the menstrual flow. There are two types of dysmenorrhea: primary and secondary. Primary dysmenorrhea is far more common. It begins shortly after menarche, is associated with colicky uterine contractions, and occurs with every period. Childbirth frequently alleviates this state permanently. Secondary dysmenorrhea is caused by acquired disorders within the uterine cavity (e.g., intrauterine devices, polyps, or fibroids), obstruction to flow (e.g., cervical stenosis), or disorders of the pelvic peritoneum (e.g., endometriosis or pelvic inflammatory disease*). It usually occurs after several years of painless periods. Regardless of its cause, dysmenorrhea is described as intermittent, crampy pain accompanying the menstrual flow. The pain is felt in the lower abdomen and back, sometimes radiating down the legs. In severe cases, fainting, nausea, or vomiting may occur.

*Endometriosis is the presence of endometrial tissue outside the uterus and is a cause of chronic pelvic pain.

Masses or Lesions

Masses or lesions of the external genitalia are common. They may be related to venereal diseases, tumors, or infections. Ask these questions of any woman with a lesion on the genitalia:

''When did you first notice the mass (lesion)?''

''Has it changed since you first noticed it?''

''Have you been exposed to anyone with venereal disease?''

Syphilis may result in a chancre on the labia. Often unnoticed, it is a small, painless nodule or ulcer with a sharply demarcated border. Small, acutely painful ulcers may be chancroid or genital herpes. A patient with an abscess of Bartholin's gland may present with an extremely tender mass in the vulva. Benign tumors, such as venereal warts (condylomata acuminata), and malignant conditions manifest as a mass on the external genitalia.

Some affected patients complain of a sensation of fullness or mass in the pelvis as a result of pelvic relaxation. Pelvic relaxation refers to the descent or protrusion of the vaginal walls or uterus through the vaginal introitus. This is caused by a weakening of the pelvic supports. The anterior vaginal wall can descend, producing a cystocele that triggers urinary symptoms such as frequency and stress incontinence. The posterior vaginal wall can descend, producing a recto-cele, which triggers bowel symptoms such as constipation, tenesmus, or incontinence. The uterus can also descend, which results in uterine prolapse. In the most severe state, the uterus may lie outside the vulva with complete vaginal inversion, a condition known as pro-cidentia. The consequences of pelvic relaxation are discussed further in the Clinicopathologic Correlations section of this chapter.

Vaginal Discharge

Vaginal discharges, also known as leukorrhea, are common. Is there an associated foul odor? Although a whitish discharge is often normally present, a fetid discharge often indicates a pathologic problem. The most common pathologic odor is a foul, fishy odor related to the volatilization of amines that are produced by anaerobic metabolism. Is itching also present? Women with moniliasis (candidiasis) complain of intense pruritus and a white, dry discharge that looks like cottage cheese. Has the woman recently taken any medications, such as antibiotics? Antibiotics change the normal vaginal flora, and an overgrowth of Candida may result. Table 19-1 summarizes the important characteristics of vaginal discharge.

Table 19-1 Characteristics of Common Vaginal Discharges

Feature

Physiologic Discharge

Nonspecific Vaginitis

Trichomonas

Candida

Gonococcal

Color

White

Gray

Grayish-yellow

White

Greenish-yellow

Fishy odor

Absent

Present

Present

Absent

Absent

Consistency

Nonhomogeneous

Homogeneous

Purulent, often with bubbles

Cottage cheese-like

Mucopurulent

Location

Dependent

Adherent to walls

Often pooled in fornix

Adherent to walls

Adherent to walls

Discharge at introitus

Rare

Common

Common

Common

Common

Vulva

Normal

Normal

Usually normal

Erythematous

Erythematous

Vaginal mucosa

Normal

Normal

Usually normal

Erythematous

Normal

Cervix

Normal

Normal

May have red spots

Has patches of discharge

Has pus in os

Vaginal Itching

Vaginal itching is associated with monilial infections, glycosuria,* vulvar leukoplakia, and any condition that predisposes a woman to vulvar irritation. Pruritus may also be a symptom of psychosomatic disease.

Abdominal Pain

Ask the following questions, in addition to those listed in Chapter 17, The Abdomen, of any woman with abdominal pain:

''When was your last period?''

''Have you ever had any type of venereal disease?''

''Is the pain related to your menstrual cycle?'' If yes, ''At what time in your cycle does it occur?'' ''Do you experience a burning sensation when you urinate?''

Abdominal pain may be acute or chronic. Is the patient pregnant? Acute abdominal pain may be a complication of pregnancy. Spontaneous abortion, uterine perforation, and ectopic tubal pregnancy all are life-threatening situations. Acute inflammation by gonococci of the fallopian tubes and ovary, salpingo-oophoritis, can produce intense lower abdominal pain. Acute lower abdominal pain localized to one side that occurs at the time of ovulation is termed mittelschmerz. This pain is related to a small amount of intraperitoneal bleeding at the time of ovum release. Urinary tract infection may also cause acute pain. Patients with urinary tract infections usually have associated urinary symptoms of burning sensation or frequency.

Chronic abdominal pain may result from ectopic endometrial tissue, chronic pelvic inflammatory disease of the fallopian tubes and ovaries, and pelvic muscle relaxation with protrusion of the bladder, rectum, or uterus.

Dyspareunia

Dyspareunia is pain during or after sexual intercourse. Dyspareunia may be physiologic or psychogenic. Infections of the vulva, introitus, vagina, cervix, uterus, fallopian tubes, and ovaries have been associated with dyspareunia. Tumors of the rectovaginal septum, uterus, and ovaries have been described in patients who experienced painful sexual intercourse. Dyspareunia is often present in the absence of a physiologic disorder. A history of painful pelvic examinations and a fear of pregnancy are common in these patients. Women may have ''penetration anxiety'' until they are assured that the vagina can be penetrated by a penis. In these individuals, such anxiety may lead to vaginismus, a condition of severe pelvic pain and spasm when the labia are merely touched. In other women, dyspareunia may develop during times of stress or emotional conflict. The examiner can obtain valuable information by asking, ''What else is going on in your life now?'' Dryness of the vagina and labia may cause irritation that can result in dyspareunia.

Changes in Hair Distribution

Hair loss or change in hair distribution may occur during certain states of hormonal imbalance. Hirsutism is an excessive growth of hair on the upper lip, face, earlobes, upper pubic triangle, trunk, or limbs. Virilization is extensive hirsutism associated with receding temporal hair, a deepening of the voice, and clitoral enlargement. Increased androgen production by the adrenal glands or ovaries may be responsible for these phenomena. Tumors of the ovary are commonly associated with amenorrhea, rapidly developing hirsutism, and virilization. Polycystic ovarian disease is the most common ovarian cause of hirsutism, dysfunctional uterine bleeding, infertility, acne, and obesity. Figure 19-6 shows the increased hair growth

*High levels of glucose in the urine, as in diabetes.

on the chest of a 34-year-old woman with polycystic ovary syndrome. She also presented with amenorrhea and obesity. Figure 19-7 shows the face of a 68-year-old woman with an androgen-secreting ovarian tumor. Note the male-pattern baldness and the facial hair. This patient also had clitoral enlargement.

It is important to determine whether the patient is taking any medications. Several drugs such as cyclosporine, minoxidil, diazoxide, penicillamine, and glucocorticoids have the unexpected side effect of causing diffuse hair growth on the face. Figure 19-8 shows such growth in a 42-year-old woman who was taking minoxidil for hypertension. This drug is now used as a topical treatment for androgenetic alopecia. The pathophysiologic process behind the increased hair growth is unknown.

Hair loss, or alopecia, is a distressing problem. Many drugs may have a profound effect on hair growth. The interviewer must inquire whether the patient has taken any chemo-therapeutic agents or has been exposed to radiation. Different areas of the head seem to respond differently to androgens. The top and front of the scalp respond to increased androgen production by hair loss, whereas the face responds with increased hair growth. Has the patient been dieting? Because hair has a high metabolic rate, crash diets and

Figure 19-7 Increased hair growth in a patient with an androgen-secreting ovarian tumor.

Figure 19-7 Increased hair growth in a patient with an androgen-secreting ovarian tumor.

infectious diseases reduce the nutrients available for hair growth, and secondary alopecia may result.

Changes in Urinary Pattern

Changes in the patterns of urination are common. Chapter 18, Male Genitalia and Hernias, reviews many of the symptoms associated with changes in the urinary pattern. These symptoms may occur in women as well.

Stress incontinence is urinary incontinence that occurs with straining or coughing. Stress incontinence is more common among women than among men. The female urinary bladder and urethra are maintained in position by several muscular and fascial supports. It has been postulated that estrogens may be responsible, at least in part, for a weakening of the pelvic support. With aging, the support of the bladder neck, the length of the urethra, and the competence of the pelvic floor are decreased. Repeated vaginal deliveries, strenuous exercise, and chronic coughing increase the chance for stress incontinence. Ask an affected patient these questions:

''Do you lose your urine on straining? coughing? lifting? laughing?'' ''Do you lose your urine constantly?'' ''Do you lose small amounts of urine?'' ''Are you aware of a full bladder?'' ''Do you have to press on your abdomen to void?'' ''Are you aware of any weakness in your limbs?'' ''Have you ever had a loss of vision?'' Do you have diabetes?''

Patients with pure stress incontinence describe urine loss without urgency that occurs during any activity that momentarily increases intra-abdominal pressure. Although stress incontinence is common among women, it is important to rule out other types of incontinence, such as neurologic, overflow, and psychogenic. Neurologic incontinence may result from cerebral dysfunction, spinal cord disease, and peripheral nerve lesions. Multiple sclerosis is a chronic relapsing neurologic disorder causing urinary incontinence. Most affected individuals suffer from an episode of temporary loss of vision as an early symptom. Overflow incontinence occurs when the pressure in the bladder exceeds the urethral pressure in the absence of bladder contraction. This may occur in patients with diabetes and an atonic bladder. In psychogenic incontinence, individuals have been known to urinate in bed at night to ''warm'' themselves or during the daytime in group settings to draw attention to themselves.

Infertility

Infertility may result from failure to ovulate, called anovulation, or from inadequate function of the corpus luteum. Both these conditions can occur in women with cyclic menstrual bleeding. Therefore, having a period does not indicate fertility. A woman with the symptom of infertility should be asked these questions:

''Do you have regular menstrual periods?'' ''Have you kept a chart of your basal body temperature?'' ''Have you ever had venereal disease?'' Have you been tested for thyroid disease?'' Have you taken any medications to promote fertility?''

Charting basal body temperature is a reliable method for detecting ovulation. Gonococcal disease in a woman may lead to salpingo-oophoritis, with scarring of the fallopian tubes and infertility. Hypothyroidism is a well-known cause of infertility.

General Suggestions

Even in the absence of specific symptoms, all women, regardless of age, should be asked several important questions. The answers to the following questions provide a complete gynecologic, obstetric, and reproductive history. The first group of questions is related to the gynecologic history and menstrual cycle:

''At what age did you start to menstruate?''

''How often do your periods occur?'' Are they regular?''

''For how many days do you have menstrual flow?''

''How many pads or tampons do you use each day of your flow?''

''During your menstrual cycle, do you experience any breast tenderness or breast pain? bloating?

swelling? headache? edema?''

''When was your last menstrual period?''

The catamenia refers to the menstrual history and summarizes the age at menarche, the cycle length, and the duration of flow. If a woman reached menarche at age 12 years and has had regular periods every 29 days lasting for 5 days, the catamenia can be summarized as ''CAT 12 x 29 x 5.'' The date of the last menstrual period can be abbreviated as, for example, ''LMP: August 10, 2008.''

Any recurrent, midcyclic symptom associated with the menstrual period, such as breast tenderness, bloating, and so forth, is termed molimen. The presence of molimen is correlated with ovulation, although not all women experience molimen when ovulation occurs. Therefore, molimen is a specific but nonsensitive sign of ovulation.

The next group of questions is related to the obstetric history:

Have you ever been pregnant?''

If the woman has been pregnant, ask the following questions:

What was the outcome of your pregnancy?'' How many full-term pregnancies have you had?''

''Have you had any children born prematurely?'' How many living children do you have?'' ''How were your children delivered (vaginally, cesarean)?'' ''What were the birth weights of your children?''

The obstetric history includes the number of pregnancies, known as gravidity, and the number of deliveries, known as parity. If a woman has had three full-term infants (born at 37 weeks or more of gestation), two premature infants (born at less than 37 weeks of gestation), one miscarriage (or abortion), and four living children, her obstetric history can be summarized as ''para 3-2-1-4.'' An easy way to remember this four-digit parity code is with the mnemonic ''Florida Power And Light,'' which stands for full term, premature, abortions (miscarriages), living. The woman in this example is gravida 6.

In the United States, never ask a woman whether she has had an abortion. This word is charged with many religious, political, and cultural feelings. In many other parts of the world, however, the term abortion is often acceptable because it means the loss of a pregnancy, not the voluntary termination of a pregnancy.

When asking a woman about the date of her last menstrual period, never assume that menopause has occurred. Women of any age should be asked when their last menstrual period occurred. Allow the patient to say that she has not had a period in, for example, 12 years.

A careful sexual history is important. Chapter 1, The Interviewer's Questions, provides several ways of broaching the topic. The interviewer might start by asking, ''Are you satisfied with your sex life?'' It is important for the examiner to determine the marital status of the patient. Is the patient married? How many times? For how long? Are there other sexual partners? If the patient is not married, is she currently having sexual relationships? What type of birth control is being used? It is important to ask all sexually active women the following:

' 'How easily can you reach an orgasm or climax?'' ''How strong is your sex drive?'' ''How easily are you sexually aroused?'' How easily does your vagina become moist during sex?'' ''Are your orgasms satisfying?''

Always determine whether the patient's mother was given diethylstilbestrol (DES)* during her pregnancy.

Use words that the patient will understand. It may be necessary to use such terms as ''lips'' to refer to the labia or ''privates'' to refer to the genitalia.

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