CE Article: Sensitive Subject

Objectives

• At the conclusion of this activity, participants will:
• Recognize the vast differential of gynecological complaints;
• Prioritize initial and continuing education on gynecology;
• Communicate professionally and effectively with patients experiencing gynecological concerns;
• Assess the potential for an emergent gynecological presentation;
• Discuss the physiology, associated symptoms, and complications of menstruation.

You’re called to respond to a young woman experiencing abdominal pain and vaginal bleeding. It’s been one of those days where you can’t catch a break, and now here is a woman wasting your time to talk about her period, right? 

It’s OK—you can admit you’ve felt this way; no one is judging you. My goal is to make sure you don’t feel this way again. Let’s talk about the “menstruation call.”

Menstruation

Menstruation is the 4–7-day monthly event where the uterus sheds the lining it had built in preparation to house a fertilized egg. Depending on the person, this could be a fairly easy ordeal or a tumultuous one. The risk of symptoms from severe bleeding, pain, fluctuation of hormones, and structural abnormalities lurks in the menstruating patient. Are you familiar with common presentations? Do you feel comfortable screening for these problems and educating your patients? 

PMS

We certainly have seen premenstrual syndrome (PMS) portrayed on plenty of sitcoms as a caricature of a hysterical woman alternating between crying and screaming, but popular culture has not revealed the whole picture. Truthfully, not much is known about the pathophysiology of PMS. It is hypothesized that progesterone, which spikes just before menstruation, or fluctuating estrogen can affect the GABA, opioid, serotonin, and catecholamine neurotransmitters; however, a wide variance of PMS prevalence in different nations suggests it may be more complex and include psychosocial factors.¹ In fact, one meta-analysis identified a range of 10% prevalence in Switzerland and 98% in Iran.² Associated symptoms include abdominal pain, back pain, headache, nausea, and mood disruptions up to seven days before the beginning of menstruation, 20% of which is noted to be severe enough to disrupt daily activities.¹ 

PMDD

For 3%–8% of women, these symptoms present as a DSM-5-recognized condition called premenstrual dysphoric disorder.³ In PMDD patients regularly experience:

• Depression
• Irritability
• Difficulty concentrating
• Fatigue
• Anxiety
• Mood swings
• Sleep disturbances 

One study showed the odds of suicidal ideation, plan, and attempt were more than twice as high in people with PMDD.⁴  

Menorrhagia 

Commonly patients experience heavy menstrual bleeding or menorrhagia. Heavy can be quantified as bleeding that:

• Lasts for more than seven days; 
• Soaks through one or more tampons or pads every hour for several hours; 
• Requires multiple pads at a time; 
• Soaks through pads or tampons while sleeping;
• Contains blood clots the size of a quarter or larger.

It is crucial to gather a detailed history. As with any large hemorrhage, watch this patient for signs of shock or anemia.⁵ 

Dysmenorrhea

Dysmenorrhea is defined as painful abdominal cramps associated with menstruation and is the leading gynecological problem of all ages and races.⁶ It is strongly associated with heavy menstrual loss, PMS, and cycle irregularity. Treatment includes pain alleviation with NSAIDs or topical heat and hormonal contraceptives. Persistent pelvic pain refractory to medication can receive laparoscopy, in which 70%–80% of patients will go on to be diagnosed with endometriosis, some even requiring endometrial ablation or hysterectomy.⁷ 

Endometriosis

Endometriosis is the growth and subsequent inflammation of endometrial cells outside the uterus. This aberrant tissue can be found as a cyst on multiple sites, including the ovaries, bowel, or even diaphragm; this will determine associated symptoms. This condition is associated with increased exposure to estrogen from early menarche, hormonal contraception, and menorrhagia. The most common theory of the mechanism is a backward flow of menses into the peritoneal cavity. Definitive diagnosis is made by surgical identification of ectopic endometrial tissue.⁸ 

Other Causes of Vaginal Bleeding

While this article focuses particularly on period symptoms and potential complications, there are many other causes of vaginal bleeding to have on your mind, some more concerning in prehospital care than others. Of course, a patient of childbearing years with abdominal pain and vaginal bleeding must be suspected of an ectopic pregnancy until proven otherwise, because that is the most time-sensitive and critical possibility.⁹ Other pregnancy complications can present similarly.

A common mnemonic to represent these options is divided by structural vs. nonstructural (Figure 3). To remember structural, or directly anatomical, causes of vaginal hemorrhage, use PALM:

• Polyps, which (along with fibroids) are growths in the uterus; 
• Adenomyosis, in which the uterine lining grows into the uterine muscle layer (myometrium); 
• Leiomyoma, which is a benign growth of the myometrium; 
• Malignancy, which accounts for any cancer within the reproductive system.

To account for the nonstructural, or physiological, causes of vaginal hemorrhage, use COEIN as a guideline:

• Coagulopathy: Suppose your patient has Von Willebrand disease and has trouble clotting. Vaginal bleeding may be a hint to look for uncontrolled bleeding elsewhere or a suggestion to take the vaginal bleed more seriously.
• Ovulatory disorders, which can include cysts, irregular periods, and diseases like polycystic ovary syndrome (PCOS); 
• Endometrial dysfunction, which includes endometriosis, endometritis, and endometrial hyperplasia; 
• Iatrogenic, meaning caused by a medical procedure or medication. This could include an infection or perforated uterus secondary to an IUD placement or perhaps an adverse reaction to blood thinners;¹⁰  
• N represents not yet classified.

One final important consideration is trauma: There could be a foreign body in the vaginal cavity. The patient could have been injured in a straddle-position fall. Your patient could have been assaulted. Look for clues in the home or the patient’s relationship with present parties. 

Patient Communication and Education

There is hardly a more focused or private place in healthcare than the back of an ambulance. Where else can you get an uninterrupted half-hour of face time with a clinician? EMS providers have a unique opportunity to counsel patients on sensitive subjects, including substance use, mysteriously inflicted traumas, and gynecological concerns. Often patients find EMS less threatening than physicians. 

We have hacked the crippling power differential; now we must embrace this privilege and do right by our patients. It is imperative that we are skilled in professional and disarming discourse on gynecological topics to perform a detailed and complete assessment of the patient’s complaint. We should be cognizant of a patient’s willingness to disclose and utilize a trauma-informed approach, respecting the potential for a previous sexual assault.¹¹ The core principles of a trauma-informed method of patient interaction and assessment are patient empowerment, choice, collaboration, safety, and trustworthiness (Figure 2). 

Consider ways you can create that sort of environment on your ambulance all the time but especially on gynecology calls. We must be comfortable using anatomical terms, requesting qualitative information about vaginal discharge or bleeding, and eliminating judgment or shame. We cannot tolerate relying on a female partner to run the call; statistics alone tells us that is an unlikely possibility, considering only 35% of EMS providers (and less than a quarter of paramedics) are female.¹² The best way to get comfortable with these skills is to practice, listen to your patients, and enhance your education. 

Speaking of education, imagine the impact you could make on a patient’s life by educating them on the workings of their bodies. On (almost) each call, we have an opportunity to empower a patient to understand and appreciate their own physiology, which could decrease 9-1-1 utilization and healthcare costs and improve patients’ outcomes and autonomy. This is a great chance to talk to patients about things like puberty, safe sex practices, screening for HIV, harm reduction, PrEP, contraception, and menopause! Long gone are the days of high-acuity calls only. Settle into the idea that EMS plays a much bigger role in the holistic health of the community; share that knowledge you’ve worked so hard to build.

Conclusion

I urge you to dive into even just the basics of gynecology. Ask female coworkers, friends, and family about their experiences in healthcare. There is a wide array of potential diagnoses and pathophysiology our current EMS education system does not comprehensively represent. Please play a part in changing that.  

References

1. StatPearls. Premenstrual Syndrome, www.statpearls.com/ArticleLibrary/viewarticle/27664.

2. Zendehdel M, Elyasi F. Biopsychosocial etiology of premenstrual syndrome: A narrative review. J Fam Med Prim Care, 2018; 7(2): 346.

3. Casper RF. Patient education: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (Beyond the Basics). UptoDate, www.uptodate.com/contents/premenstrualsyndrome-pms-and-premenstrual-dysphoric-disorder-pmddbeyond-the-basics.

4. Pilver CE, Libby DJ, Hoff RA. Premenstrual Dysphoric Disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Soc Psychiatry Psychiatr Epidemiol, 2013; 48(3): 437.

5. American College of Obstetricians and Gynecologists. Heavy Menstrual Bleeding, www.acog.org/womens-health/faqs/heavymenstrual-bleeding.

6. Osayande AS, Mehulic S. Diagnosis and Initial Management of Dysmenorrhea. Am Fam Physician, 2014; 89(5): 341–6.

7. Smith RP, Kaunitz AM. Dysmenorrhea in adult women: Treatment. UptoDate, www.uptodate.com/contents/dysmenorrhea-in-adult-women-treatment#H4.

8. Schenken RS. Endometriosis: Pathogenesis, clinical features, and diagnosis. UptoDate, www.uptodate.com/contents/endometriosis-pathogenesis-clinical-features-and-diagnosis.

9. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. UptoDate, www.uptodate.com/contents/ectopicpregnancy-clinical-manifestations-and-diagnosis.

10. Brekelmans MPA, Scheres LJJ, Bleker SM, et al. Abnormal vaginal bleeding in women with venous thromboembolism treated with apixaban or warfarin. Thromb Haemost, 2017; 117(4): 809–15.

11. Trauma-Informed Care Implementation Resource Center. What is Trauma-Informed Care? www.traumainformedcare.chcs.org/what-is-trauma-informed-care/.

12. Crowe RP, Krebs W, Cash RE, et al. Females and Minority Racial/Ethnic Groups Remain Underrepresented in Emergency Medical Services: A Ten-Year Assessment, 2008–2017. Prehosp
Emerg Care, 2020 Mar–Apr; 24(2): 180–7.

13. Brittanica. Menstruation, www.britannica.com/science/menstruation.

14. Lewis-O’Connor A, Warren A, Lee JV, et al. The state of the science on trauma inquiry. Women’s Health (Lond.), 2019 Jan–Dec; 15: 1745506519861234.

15. Olsen M, Rizk B. Office Care of Women. Cambridge University Press, 2016.

Natalie Zink, BS, NRP, is a paramedic at Grady Health in Atlanta and a medical student at the Medical College of Georgia.