Asynchrony EM: GYN Sampler

BLEEDING, TWISTING AND INFECTION

...in the non-pregnant female patient

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM, with digital content curated into topic modules following our curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM professional community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section. Click here for more about us and for other curated teaching modules!

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

A very interesting ornament....tis the season!

This week in our OB/GYN block, we're surveying a smattering of GYN conditions in the non-pregnant patient. Bleeding, torsion, PID/TOA, and a little bit on newer long-term contraception methods.  At the end we've got a little blurb on STIs and expedited partner therapy. 

Do we have a theme song? Of course we do!

Here's Chaka Khan with her famous "I'm Every Woman."  A reminder to not be biased by age or socioeconomic status in your differential diagnoses of gyn pathology...e.g., she may look like your Nonna, but she could still have chlamydia. (See the extras below!)

OK, let's get some knowledge flowing. ;)

1) First question up for discussion: Is Pelvic Exam in the Emergency Department Useful? From ALiEM, 1/30/14, by Salim Rezaie, MD.  Please read the comments that follow the post. For practical purposes, I like the notion of treating the pelvic exam as a test one orders judiciously. Most seasoned ED docs will be able to tell you a story about when their pelvic exam actually changed their management, so don't throw it out. My two cents: you're much more likely to be faulted in hindsight for skipping it than being diligent, so when it could add to my differential in a woman with significant symptoms, I do it. (Also, the more we use bedside Gyn ultrasound, the more this will just become one exam, right?)

2) "Not Pregnant and Vaginal Bleeding for Two Weeks."   Even more awesome than the title makes it sound! From FreeEmergencyTalks.net, featuring the 2012 AAEM Scientific Assembly -- lectures in podcast form. Did you know tampons are approved as medical devices?  Me neither!

You'll want to jot some notes on the various regimens for temporizing bleeding (put them in your phone for access on your next shift.) You can skip the first minute in which the speaker (Dr. Joelle Borhart) collects a speaking award from a previous lecture. (We only pick award-winning speakers for lectures on vaginal bleeding.) And you can skip the last 4 minutes of Q&A, too.  So about 20 minutes on menorrhagia, and things we can do about it in the ED, besides checking a CBC and telling patients to follow up with their gynecologist. Some very useful tips in the latter half.

3) EM Lyceum has a nice review of answers to your torsion questions. Because you definitely had torsion questions. 

4) And you also definitely had questions about PEDIATRIC ovarian torsion, didn't you?  (Such as: "Um, that really happens?!') FromPediatric EM Morsels -- a quick blog post. I love how, in the twisted (pun intended) way of the universe, pediatric torsion is more often right sided.  As if the diagnosis were not difficult enough. The universe does not seem to be concerned with making our job any easier.

5) Put 3 and 4 together to review, and then add in tubo-ovarian abscess and a tad on PID for a nice podcast review from CORE EM (March 7, 2016).  (Ever heard of in utero ovarian torsion? Now you have.) Thirteen minutes. Ovarian Pathology, Episode 37.0

6a)  Pelvic Inflammatory Disease: Pearls and Pitfalls from EM Docs (November 21, 2016.) Brings us back to part 1: don't dump the pelvic exam entirely. 

b) Because you might never see it, but you'll definitely be asked about it: a tad more on Fitz-Hugh-Curtis syndrome, from Radiopaedia. 

c) We're not doing a full STI review today, but just FYI: Expedited Partner Therapy (i.e., prescribing antibiotics for sexual partners without seeing them as a patient) is LEGAL in many states and encouraged by the CDC, particularly for treatment of male partners of women with chlamydial infection or gonorrhea.  Expedited Partner Therapy

Here's a map of where it's legal (last updated October 2016): http://www.cdc.gov/std/ept/legal/ 

(Check out the discussion question at the end.)

7) Just a little primer on long acting birth control methods, which you may or may not be familiar with, and which are becoming increasingly more popular. 

a) From Medscape: Long-Acting Reversible Contraception: Comparing Methods

b) It is true that, as stated in part A, the risk of 'injury' from a Nexplanon implant is very small -- but if someone says they have a birth control implant, and you can't feel it, perhaps you should go look for it. You might just find a Nexplanon pulmonary embolus. FDA Safety Information: Nexplanon Implants

c) One more thing you might incidentally find on pelvic exam: you don't see IUD strings when the patient says you should. Again, you should consider looking for them. From Radiopaedia: IUCD related uterine perforation. Amazingly, patients can be asymptomatic! This recommends US as first choice for testing, although I have found extra-pelvic IUDs on a gyn-recommended KUB in the past.

And now...The OPTIONAL OB/GYN EXTRAS:

MRI safety, Transgendered Patients, and "Aliens" with an HCG > 1 million, and Grammies with Chlamydia.

1) Recent JAMA (2016 Sep;316(9):952-961) article on safety of MRI in early pregnancy. Bottom line: so far MRI seems safe, but gadolinium doesn't, so avoid the contrast.  https://www.ncbi.nlm.nih.gov/pubmed/27599330

2) Health Issues to Consider in the Transgender Patient from ACEP Now, March 6, 2014.

3) "There's An Alien Inside Me!"  Just when you think you've seen everything. An interestingly layered OB/Gyn case from EP Monthly with valuable teaching points. 

4) She might remind you of your Nonna, but it doesn't mean she can't have chlamydia. Sex and the Single Senior; NYT 1/18/24. 

THAT'S IT! (Brown EM residents, remember you have to complete the discussion section and quiz in Canvas in order to receive credit.)

Tell us in the comments:

• Expedited Partner Therapy is LEGAL in many states. Is this your practice, if you are in a state where it is legal (it's legal where we are in Rhode Island)? If not -- why not?
• Any interesting relevant cases to share?
• Any other #FOAMed resources on these topics that you find helpful?

Click, engage, learn, comment, query, teach, share.  See you next time!