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Vaginal Bleeding : DIAGNOSTIC REASONING: FOCUSED PHYSICAL EXAMINATION

Perform a General Assessment


Determine whether the patient’s general state of health includes problems of nutrition (e.g., obesity or muscle wasting), hirsutism, or skin or hair changes, which may indicate an imbalance in the HPO axis.


Assess Vital Signs

Determine whether a patient with profuse bleeding is hemodynamically stable. Look for orthostatic changes in blood pressure. In patients who are tachycardic and tachypneic, suspect a ruptured ectopic pregnancy. The patient will show signs of hemorrhage and shock.


Determine Patient Weight and Calculate Body Mass Index A body mass index

greater than 25 corresponds to being overweight and an index greater than 30 signals obesity. Excess weight and obesity can cause anovulatory cycles because the adipose cell stroma converts androstenedione to estrogen (estrone) as the body fat increases. Obesity also increases sex hormone binding globulin, thereby increasing free steroid levels. Both processes can cause an imbalance in the HPO axis and increase the probability of an anovulatory cycle and heavy vaginal bleeding. Amenorrhea in anorexia nervosa may precede weight loss by many months.
Perform a Lymph Node Examination Examine the lymph nodes to assess for leukemia or metastatic gynecological cancer. Inguinal lymph nodes can be enlarged from an STI or a vulvar infection (e.g., bartholinitis).
Perform a Thyroid Examination Observe and palpate the thyroid gland. Enlargement may be found in hypofunctioning glands. Hypothyroidism is known to be present in 22% of women with severe menorrhagia.


Perform a Breast Examination

The finding of spontaneous, bilateral, clear, or nonbloody nipple discharge on breast examination could indicate hyperprolactinemia, which can cause amenorrhea or irregular vaginal bleeding, either from either a pituitary microadenoma or from medications (antipsychotics, tricyclic antidepressants, monoamine oxidase inhibitors, and some antihypertensive agents).


Perform a Pelvic Examination

An external and internal pelvic examination can verify bleeding suspected to be uterine in origin. Examine the external genitalia, noting whether the bleeding is coming from external hemorrhoids or a painless labial lesion, such as a squamous cell cancer or condylomata acuminata. Note bruising, lacerations on the vaginal walls, or other signs of sexual abuse. Observe the introitus for signs of a prolapsed uterus or cystocele or rectocele that might be subject to drying, abrasion, or bleeding. These signs are usually accompanied by pelvic pressure or urinary or bowel symptoms. Observe the external genitalia for signs of estrogen deficiency: sparse hair distribution, graying or white hair color, clitoral atrophy, and thin, small labia minora. These signs strongly suggest atrophic vaginitis as the cause for bleeding. Next, perform a vaginal examination. Note the
color and condition of the vaginal walls. Pale, nonrugated vaginal walls are a sign of an atrophic vagina that is easily abraded to cause bleeding. Pale vaginal mucosa with splotchy red patches is also a sign of vaginal atrophy. Bleeding from atrophic vaginitis most commonly follows intercourse or douching. It often is a whitish-brown discharge with no particular foul odor. The patient may also have pruritus and a burning sensation of the vagina, labia, and urinary tract because of a lack of estrogen. Note the amount, color, consistency, and odor of the vaginal discharge. Take samples for wet mount examination from the pooled discharge in the lateral fornices. Note cervical friability and discharge from the cervical os. Take samples of the discharge and assess as noted in Chapter 37. Cervical polyps are red, glossy, nontender masses protruding from the cervical os. They are usually benign and can be removed by twisting them off with ring forceps. The specimen should be sent for pathological evaluation. If a threatened or spontaneous abortion is suspected, check the internal cervical os to determine if it is closed or open.

Ectopic pregnancy will cause adnexal or cervical


motion tenderness. However, uterine enlargement is not often appreciated. Uterine size and contour can be grossly assessed via bimanual examination. On pelvic examination, the uterus is enlarged but smaller than anticipated from dates provided. The cervix is tender to motion, and a tender adnexal mass may be palpable. Diagnosis is confirmed by positive human chorionic gonadotropin (hCG) test results and ultrasound. Serial quantitative serum hCG levels may be useful. A ruptured ectopic pregnancy is a surgical emergency. Uterine leiomyomas (myomas, fibroids) typically
feel firm and may make the uterus asymmetrical. These tumors can progress to a size that mimics an advanced pregnant uterus. The uterine size is measured in weeks, just as the uterus is measured in pregnancy. When the uterus reaches a 12- to 14-week size, referral to a gynecologist for surgery (myomectomy or hysterectomy) is appropriate. The patient may experience urinary or bowel problems (e.g., urinary frequency and constipation) because the fibroid is distorting or obstructing those systems. Carcinogenic tumors of the uterus are classically firm, hard, and rapidly growing, becoming fixed masses. Ultrasound is a valuable tool in documenting the size and growth patterns of tumors. The average-size adult uterus measures 8 cm long,
5 cm wide, and 2.5 cm deep for the nulliparous woman. Add 1 cm to each dimension for the average size of the multiparous uterus (9 3 6 3 3.5 cm). The uterus with adenomyosis is increased in size to 2 to 3 times that of normal, may be globular, and has a uniform consistency. Adenomyosis is accompanied by worsening menorrhagia and dysmenorrhea. The rectovaginal examination can detect lesions
or nodularity of the cul-de-sac, which is present with endometriosis or a primary rectal tumor.


Pediatric Examination: Perform a Breast and Genital Examination

Assess for signs of sexual precocity by determining the presence and stage of secondary sexual characteristics of the breasts and pubic hair. Assess development using Tanner staging (see Chapter 5, Figures 5-2 and 5-3). Inspect the vulva, noting the hygiene status; presence of smegma in the labial folds, urine, fecal material, or erythema and lesions. Examine the urinary meatus. A prolapsed urinary meatus is noted by the presence of dark red tissue surrounding the urinary opening. This tissue is usually tender. Use an appropriate pediatricsize speculum, long otoscope, or nasal speculum. It may be necessary to refer the patient for a vaginoscopy
or cystoscopy under anesthesia for a complete assessment of the vagina and uterus. Consider the possibility of infection or sexual abuse.
See Chapter 37 for assessment of vaginal discharges.