Acute pelvic pain

Cite this article as:
Tara George. Acute pelvic pain, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32492

Acute pelvic pain in females is a common presentation. Whilst it often seems to drive terror into the hearts of clinicians patients are often a lot more straightforward to assess that you think they will be.  In fact, the whole of non-specialist gynae is a topic that lends itself well to Bayesian decision modelling. Your patient is either “pregnant” or “not pregnant” and that she might have pain, bleeding, discharge or a combination of these things. Today I want to focus on acute pelvic pain as the primary presenting symptom.

Alina is 15. She presents to A&E in significant pain and is tearful.  She describes a 2-3 day history of intermittent lower abdominal pain which doesn’t appear to localize to any particular side but which is possibly slightly worse on the left. She’s been having 1g paracetamol four times a day for the last 48 hours as well as maximum doses of ibuprofen. They seem to dent the pain a bit but when they wear off she is left crying with pain and unable to cope. She describes it as “like the worst period pain I’ve ever had” but is adamant it isn’t her period as “that was 2 weeks ago”. It is a lot worse today and she has been vomiting with the pain.  Alina is struggling to stand as she sobs her way through triage leaning on her mum.

At this point it is probably worth having a list of possible differential diagnoses in your head to help to tailor your assessment to come to a diagnosis and most importantly to rule out the life threatening “never miss” causes of severe pelvic pain. 

Possible diffentials for acute pelvic pain in the adolescent:

  • Ectopic pregnancy
  • Pelvic Inflammatory Disease
  • Miscarriage
  • Dysmenorrhoea
  • Ruptured or torted ovarian cyst
  • Torted ovary
  • Mittelschmerz
  • Endometriosis
  • Appendicitis
  • UTI
  • Sickle cell crisis
  • Porphyria
  • Haematocolpos
  • Unexplained

Ectopic pregnancy

Top of your list of things to look for and rule out in a case of acute pelvic pain in a female of childbearing age has got to be ectopic pregnancy.  A negative urine pregnancy test, especially in the context of a young person with a reliable menstrual history AND with a LARC method of contraception on board AND/OR a sexual history of not being sexually active is a good way to rule out pregnancy rapidly.  In this presentation there would be little, if any, justification for not doing a urinary pregnancy test. In many A&E departments a pregnancy test is a standard triage investigation along with a urine dip for blood/protein/WBC and nitrite before a clinician even starts their assessment. If the pregnancy test is positive, she needs a comprehensive assessment to exclude other causes of acute pain. But until an ectopic has been fully excluded, it must remain the working diagnosis of the moment with anything else coming second. 

The NICE guidelines from 2019 provide an extremely useful and user-friendly guide to managing ectopic/early miscarriage.  NICE remind us that PV bleeding and pain, whilst common symptoms of an ectopic, are not always present.  In order not to miss it we need to have a low threshold for doing a urinary pregnancy test in any female of reproductive age. This table from the guidelines is a helpful summary of other less common presenting symptoms in which a pregnancy test may well be indicated.

Causes of acute pelvic pain
Presenting complaints of a ruptured ectopic pregnancy

Advice around examining patients with a suspected ectopic pregnancy seem to vary from department to department and, interestingly, NICE make no comment on this. In primary care, the traditional teaching is not to do a bimanual examination in case the pressure of the physical examination on the adnexal mass ruptures the ectopic. In a hospital setting, with resus and surgical facilities, a bimanual looking for cervical excitation and guarding may help make the diagnosis.  If they are stable an expectant approach looking for B-hCG doubling (for a normal pregnancy) or falling (for a failed pregnancy) may be adopted. If medical management with methotrexate is chosen a baseline B-hCG is vital.

A patient with a probable ectopic needs to have bloods taken for FBC, crossmatch and B-hCG and should be referred on the on call gynae service promptly.

Alina’s pregnancy test is negative and she shows you the Nexplanon contraceptive implant she has in her left arm. You start to relax. An ectopic pregnancy is highly unlikely and this almost certainly isn’t a threatened miscarriage.

Pelvic inflammatory disease

Next one down in the serious/scary things to rule in or out urgently is Pelvic Inflammatory Disease.  The British Association for the Study of Sexual Health (BASSH) recommend that acute pelvic pain in a non-pregnant woman aged <25 is PID until proven otherwise.  1 in 60 primary care consultations in women aged under 45 is for PID.  Youth is a major risk factor especially if associated with multiple or new sexual partners.  Taking a sensitive but full sexual history is vital. Asking direct questions such as “when was the last time you had sex?”, “who was it with?”, “did you use a condom?”, “how many other people have you had sex with in the last 3 months?” are likely to yield clearer answers. 

In teenagers try and avoid the phrase “are you sexually active?”. Most won’t understand the nuance of the question and the number of teenagers who answer “no” but later turn out to be “sexually active” is high.  You may well need to ask these questions more than once, ideally without the parent present. Acknowledging that they are having sex, especially with multiple partners, may well not be anything they want their parent to know.  In the UK and the USA the incidence of chlamydia, in the 14-24 age group, is quoted as 1 in 20 women.

Table showing signs and symptoms of PID
Signs and symptoms suggestive of PID. Abnormal bleeding may manifest as post-coital bleeding, menorrhagia or secondary dysmenorrhoea

The Commonest pathogens in PID are chlamydia (4-35%), gonorrhoea (2-3%), mycoplasma genitalium.  Pathogen negative PID is not uncommon (but is a diagnosis of exclusion).  BASSH advice is that “A diagnosis of PID should be considered, and usually empirical antibiotic treatment offered, in any sexually active woman who has recent onset, lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified

Any patient with suspected PID needs cervical and HVS “triple swabs” taking for chlamydia, gonorrhoea, trichomonas and M. genitalium.  The treatment of choice in PID is IM ceftriaxone 1g stat.  If M. genitalium is found the treatment is moxifloxacin 400mg daily for 14 days.  M genitalium is difficult to isolate and culture and is best seen on NAAT swabs done urgently.  All patients with PID need to be referred to the local GUM clinic for ongoing treatment and contact tracing.  Complications of PID include sepsis, pelvic abscess, chronic pain, infertility as well as ectopic pregnancy so it is really important to suspect, identify and treat to prevent disability or serious illness.

When to admit in PID:

  • Pyrexia >38⁰C.
  • Signs of tubo-ovarian abscess (e.g. fluctuant mass in adnexa).
  • Signs of pelvic peritonitis (rebound, guarding, cervical motion tenderness).
  • No response to oral treatment.
  • Pregnancy

Endometriosis

This is an easily missed diagnosis and a common cause of pelvic pain. Ectopic deposits of endometrial tissue appear in locations outside the uterine cavity, typically on the ovaries, fallopian tubes, and in the peritoneum.  These deposits respond to hormonal changes during the menstrual cycle and during menstruation they bleed, causing irritation and pain. The pain, classically, is cyclical, and at its worst in the day or two before menstruation. As the condition progresses and becomes more chronic adhesions can form and the pain can become more severe and constant.  It is worth being aware that laparoscopy findings do not always correlate well with symptoms. Some women can have severe symptoms with what appears visually to be small/minimal deposits and other woman can have minimal symptoms with quite “severe disease”.  On average it can take 6 years from first presentation to make a diagnosis.  Management is usually symptomatic with the combined contraceptive pill, analgesia and sometimes surgery.

Haematocolpos

This is a really rare condition that is worth bearing in mind even though it may well be a once in a career diagnosis presentation. Menstrual blood builds up in the vagina and uterus due to presence of a thick complete vaginal membrane – an “imperforate hymen”. Classically the adolescent presents with cyclical pelvic pain and primary amenorrhoea.  An ultrasound will show a grossly distended uterus filled with old blood and treatment involves surgical division of the vaginal membrane under a general anaesthetic.

Mittelschmerz

Translated literally from the German as “middle pain”, Mittelschmerz is cyclical pain occurring mid-cycle at the point of ovulation. It is uncommon. It will not occur in someone on an anovulant contraception, and whilst painful, is unlikely to render someone unwell enough to present to ED.

Alina’s abdominal examination reveals tenderness globally over the lower abdomen but worst in the left iliac fossa with some guarding.  She tells you she has not had sex for 3-4 months and has no PV bleeding or discharge.  You attempt a bimanual and speculum examination with verbal consent and the support of her mum and a nurse, but she is crying in severe pain and you have to stop. She is tachycardic with a HR of 122 but her other observations are normal. Her FBC, CRP and urine dip are normal as was the urinary pregnancy test. 

You suspect ovarian pathology, either a ruptured or torted cyst or an ovarian torsion and arrange an ultrasound scan.

Ovarian cyst

Ovarian cysts occur in around 10% of pre-menopausal women and are often an incidental finding on an ultrasound scan done for an unconnected reason. The vast majority are benign in nature, asymptomatic and require no treatment.  The RCOG Green Top guideline 63 from 2011 advises that the majority of asymptomatic incidental cysts should be managed conservatively reassuring us that “the overall incidence of a symptomatic ovarian cyst in a premenopausal female being malignant is approximately 1:1000”. Most of us remember the ovarian teratoma from our embryology and pathology lectures as undergraduates. Ovarian teratomas are almost always benign, though scary looking if well differentiated, and containing teeth or hair. This is in contrast to testicular teratomas which have a high risk of malignancy.

An ovarian cyst can rupture or can twist on its pedicle – leading to torsion of an ovarian cyst. Both can result in acute pelvic pain associated with peritonism and vomiting.  Diagnosis is usually be made on ultrasound scan though occasional a diagnostic laparoscopy is the only way to identify the situation. Management of a ruptured or torted cyst will usually be surgical though a small ruptured cyst in a haemodynamically stable patient may be managed conservatively with observation.

Ovarian torsion

Ovarian torsion occurs when an ovary twists on its ligamentous supports compromising the blood supply and presenting as acute pain. This is often associated with peritonism and vomiting. A rapid diagnosis is important in to save the ovary and conserve future fertility.  The twisted pedicle may be visualized on ultrasound scanning or may only be seen on diagnostic laparoscopy.  Treatment is always surgical and the ovary may not always be salvageable.

An urgent ultrasound scan reveals an enlarged left ovary, dopplers with minimal venous flow but preservation of arterial flow, and a twisted vascular pedicle referred to as the whirlpool sign, there is free fluid in the Pouch of Douglas. Alina is consented for a laparoscopy to include attempt to untwist and fix the ovary but with consent to perform oophorectomy if this is unsuccessful.  Unfortunately the surgeon is unable to save the ovary and an oophorectomy is required. Alina makes a good recovery and is discharged home 36 hours post operatively.

Selected references

NICE NG126 April 2019 – Ectopic Pregnancy and Miscarriage, initial presentation and management 

RCOG Green Top Guidelines on ectopic pregnancy 2016 

BASSH 2019 guideline update on PID 

https://www.aafp.org/afp/2010/0715/p141.html

Uterine (decidual) Casts

Cite this article as:
Tara George. Uterine (decidual) Casts, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32416

Lucy, 15, arrives in the ED sobbing hysterically clutching a wad of toilet paper. “I thought it was my period… only I had the worst period pains ever. I went to bed with a hot water bottle and it got worse and then… this came out”. She sobs, opening the tissue to show you a fleshy, pale triangular thing. approximately 5cm long.  “What is it? It’s disgusting. Have I got cancer? I’m not pregnant am I?”

Bodily secretions in tissues are rarely a source of delight but are common opening gambits. Vomit, faeces, sputum, vaginal discharge, worms, lice, blood clots and products of conception may be saved up and brought to the doctor to add colour to the history.    They present a challenge as often we don’t want to look. We don’t trust ourselves not to recoil or be disturbed and being presented with a “sample” early on can catch us off guard. It plays havoc with the “history, examination, management plan” structure we like to impose on our consultations.  In presentation terms, though, this is a gem of a presentation. We have an “Idea”, a “Concern” and it won’t be long before we elicit an “Expectation”.  Avoiding the enormous cue as it is thrust into your orbit, whilst tempting, risks dismissing the concerns. This can destroy any fledgling rapport and make the whole encounter even harder.  It is going to be necessary to take a history, but right now we have a distressed teenager, an unidentified object in a tissue and a lot of emotion. It may well be easiest to address this gift up front and just take a look. This is the time address the upset and the fear head on.

The “thing” looks like this:

Photo of uterine or decidual cast

A uterine or decidual cast occurs when the entire endometrial lining is shed in one piece. They are uncommon but frequently cause distress to the patient and can be extremely painful to pass.  A cast looks almost triangular in shape and if shed whole you can see the contours of the uterine cavity in a sort of fleshy model if you look closely.

Lucy tells you she had a Nexplanon contraceptive implant fitted about 6 weeks ago. She is not currently sexually active.  Her last period started the day before she had her implant fitted. She’s well otherwise with no past medical history. She had some light PV spotting yesterday and this morning but it has been light.  Since she passed the mass her pain has settled completely. Her observations are normal. She is happy to do a pregnancy test which is negative.  She just wants to know what it was, why it happened and if she can go home now.

The vast majority of uterine casts have no identifiable precipitating causes though there are case reports in association with Ectopic Pregnancy and they may be slightly more common in users of Hormonal Contraception though having had a cast is not a contraindication for continued use, nor are recurrent casts likely with continued use. The pain associated with passage of the cast is often severe – remember they are passing a 5cm mass through their cervix.

You reassure Lucy that this is not cancer, that she wasn’t pregnant and that this was a cast.  You explain what a cast is and that it is unlikely to recur.  She goes home much reassured and relieved.

You decide to send the cast to the lab for histology and a few days later a report lands in your in-tray which reads “extensively decidualized endometrial tissue with minimal glandular structures lined by low cuboidal epithelium, consistent with a uterine or decidual cast. No chorionic villi were identified.

References

Nunes, R.D. and Pissetti, V.C., 2015. Membranous Dysmenorrhea–Case Report. Obstet Gynecol Cases Rev2, p.042.

Strauss, L., 2018. Fleshy Mass Passed Vaginally by a Young Woman. American family physician98(7), pp.449-450.

Lost Tampons

Cite this article as:
Tara George. Lost Tampons, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32273

Maddy is 15. She presents with a one week history of a brown smelly discharge from the vagina. Her period ended eight days ago. At first, she thought it was just some spotting tailing off but now it’s heavier and smelly. Maddy is a gymnast and swimmer and has used tampons since she started her periods at 13. She has never been sexually active. Shyly, she admits that she “felt up inside” herself and thinks there might be a tampon up there. She’s not sure she removed the last one at the end of her last period, but she’s scared by the discharge and has come to see you for help.

Retained tampons are a common presentation to the emergency department and to GPs. Most GPs will tell you that the first retained tampon case they encounter is a rite of passage into the “real world of GP” and is usually a learning experience.

Here are some top tips for your first time

Classic Presentation

  • May or may not remember having “forgotten” a tampon
  • Foul smelling PV discharge, often watery and brownish
  • Usually well but embarrassed however don’t forget the risk of Toxic Shock Syndrome (TSS) – you will need to check observations/sepsis criteria and if scoring high consider this within your differential

Top Tips for Managing

There are no official published guidelines….

Management consensus from a group of GPs nationally:

  • Firstly encourage her to try and remove it herself by bearing down on the toilet slightly and using her fingers to grasp either the string or the tampon itself.
  • Have a look with a speculum +/- a bimanual exam (preferably in someone else’s room because the smell will linger).
  • Pull it down (with sponge-holding forceps) to where she can reach herself and send her to the toilet to remove and dispose of it.
  • If you must remove yourself have a specimen pot half full of water to put in in and shut the lid immediately.
  • It may be sensible to check that there are no more up there, especially if the patient reports that this has happened before, or if she tells you she habitually uses more than one tampon at a time. This is not advisable or safe, but sadly not uncommon especially in adults with menorrhagia.

In the context of the emergency department and Maddy:

  • Reassurance is key – she is embarrassed. If you are embarrassed too this is only going to end badly.
  • Reassure her that exploring her own body, including her vagina is completely normal.
  • Remind her that the string is sewn through the tampon so it is unlikely to have fallen off. Feeling inside for it and pulling it down is likely to be effective.
  • Encourage her to go to the patient toilet in private and to try to bear down and pull on whatever is up there to get it out. Lots of teenagers are embarrassed and ashamed to have touched their own vulva or vagina. Understanding that this is okay may be all you need to give her the confidence to solve her own problem.
  • If this is unsuccessful and you need to examine her and intervene, make sure you have all the kit you need. In some departments this may mean you have to refer to Gynae for them so it’s worth knowing what they will do.

What you need

  • A chaperone/assistant
  • A room with a lockable door
  • Disposable gloves
  • Speculum – probably a small/”virgin” size for Maddy
  • Lubricating jelly
  • A specimen pot, half full of water
  • Sponge-holding forceps
  • A decent light source

What to do

  • Examine externally first. If the tampon is just inside the vagina you may well see it and be able to easily remove it.
  • Pass the speculum and have a look – if you see the tampon then grasp it with sponge-holding forceps, pull it out and put it straight into a specimen pot with water in and dispose. 
  • If you insert the speculum and cannot see the tampon but can see the cervix clearly it is probably worth pulling back slightly and reinserting to ensure you visualise the posterior fornix too.
  • If she is unable to tolerate opening the speculum blades a gentle bimanual examination may allow you to feel the tampon and grasp it between your fingers to remove it.

Provided she is well and her observations are normal, she does not need antibiotics or any follow up other than reassurance and safety netting. If she is sexually active and/or the discharge is profuse or typical you may wish to consider swabs. If she has symptoms of TSS or Pelvic Inflammatory Disease you need to manage as per these conditions.

Maddy and her mum disappear to the toilet in the department. They return 10 minutes later. Maddy is tearful and says the tampon is definitely there but she’s too scared to pull it down. She says it feels really low down and uncomfortable. You take her to a quiet lockable room with one of the nurses and the kit list above. Explaining carefully what you are going to do you examine her vulva externally and can see the tampon just inside her vagina. You use some forceps to remove it, and having been well-educated by this article you put it straight into a pot of water and shut the lid tightly. You chat about whether there is a possibility there might be another tampon up there and Maddy assures you that this is not possible. You discharge her from the department, relieved, with some safety netting advice about remembering to remove future tampons and to come back if the discharge persists or if she becomes unwell.

Period Problems: Menorrhagia

Cite this article as:
Tara George. Period Problems: Menorrhagia, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32371

Period problems in teens are common. They can cause significant disruption and distress to adolescents and their parents but rarely have a significant or medically worrying underlying cause. In this first of a series of articles I’ll try to provide a logical and systematic approach to assessing and managing period problems in teenagers (recognizing that this may often be able to be extrapolated to adults too for those of you who do not only see children).

Eloise is 14. She attends with her father complaining she is tired all the time.  When she saw her GP last, they arranged some blood tests – a FBC, haematinics, TFTs and coeliac screen.  The notes from the previous consultation are very sparse. It appears that mood (normal) and bowel habit (also normal) were discussed. Eloise’s dad had mentioned she eats a broad range of foods and is not vegetarian or vegan and she eats red meat 2-3 times a week. Her periods were not brought up by the last doctor. One of her aunts has coeliac disease is noted and that is why the GP had organised bloods. Eloise has come in today for her results.

Blood results showing iron deficiency anaemia

Iron deficiency anaemia (IDA) is common in young women. Paediatricians may be much more comfortable assessing dietary intake and encouraging iron supplementation or increasing iron in the diet than they are in talking about periods. 20-30% of all cases of IDA are caused by menorrhagia. Both NICE and the British Society of Gastroenterology advocate a trial of iron for menstruating females with iron deficiency, as long as coeliac disease has been ruled out and there are no red flags for cancer. Prescribing iron and advising Eloise to “eat more steak” isn’t going to address WHY she might have IDA. This could mean that she ends up on long term iron supplements unnecessarily. If she has menorrhagia significant enough to cause anaemia, it is likely to be having an impact on her education and her social life.

Approaching the subject is probably easier than you think, remembering if you are embarrassed the patient may well think there’s something to be embarrassed about”.

So let’s talk about periods….

First a little bit of nomenclature revision.

Menorrhagia – heavy periods

Dysmenorrhoea – painful periods

Oligomenorrhoea – scanty/sparse/irregular periods

Amenorrhoea – absence of periods (primary: failure to attain menarche by the age of 15 with the development of normal secondary sexual characteristics or failure to attain menarche by 13 with no development of secondary sexual characteristics. Secondary: cessation of menstruation for 3-6 months in someone who has previously had regular periods)

Intermenstrual bleeding (sometimes called metrorrhagia) – irregular and unscheduled bleeding including unexpected bleeding between periods

Menarche – the onset of menstruation (the last stage of female puberty)

The symptoms of problematic periods are not always found in isolation. Menorrhagia and dysmenorrhoea are very common and frequently coexist. It is not uncommon for periods to be irregular, painful and heavy especially in the first few months after menarche. In the UK, the average age of menarche is 12.9 years. The average girl will be in Year 8 at secondary school when she starts her periods. Most women will menstruate every 28 days, though irregular and prolonged cycles are common in early menstrual life.

The average period lasts for 2-7 days and on average 80ml of blood will be lost during the period. In developed countries a number of sanitary products are available. The majority of girls are likely to start off with disposable sanitary towels, though environmental concerns mean period pants and washable pads are gaining popularity. Tampons are often the easiest option for girls who do a lot of sport, especially swimming, and can be used from the onset of menstruation. Menstrual cups have a much greater capacity but can be tricky to get the hang of especially for young teenagers.

Absorbency of different products

Absorbency of sanitary products for menorrhagia

What to ask in a history of menorrhagia

Start with an open question (recognising that lots of teenagers are much more comfortable with closed questions and giving specific answers): 

Tell me about your periods…

If you need to be more specific:

  • On average, how long do your periods last for?
  • How often do your periods happen?
  • Do you think they are heavy?
  • Does the bleeding change over the course of the period?
  • How often do you have to change your sanitary protection?
  • What sort of sanitary products do you use? (Pads or towels? Tampons? Period pants? Other?)
  • When did you start your periods?
  • Do you leak though your tampons/pads? If so, how often?
  • Do you pass clots? If so, how big are they?
  • How often do you need to change your pads/tampon at night?
  • Do you have to change your sheets/pyjamas?
  • Can you manage your period at school? How often do you need to leave lessons to change your sanitary product? Do you ever stay home from school because the bleeding is too heavy?
  • Are there activities you enjoy that you’ve had to stop doing because of your periods?

Eloise looks embarrassed and keeps looking at her dad. He is staring firmly at the floor looking as if he wishes it would open up and swallow him. You ask her if she would prefer to talk to you without her dad there and she nods. He takes his newspaper to the waiting area and you reassure him you’ll come and find him in a few minutes. 

Eloise tells you she started her periods at 11. They last 5-6 days on average and she has one around every 30-32 days. She uses tampons backed up with period pants as she often leaks. She uses SuperPlus tampons and on the first couple of days needs to change them every 45 minutes or so. This can be very difficult at school. She passes clots the size of grapes for a day or so each month. She has to set an alarm at night to wake her to change her protection every 2 hours but can end up with bloodstained sheets. She has stopped gymnastics and now only swims socially but not competitively. She was dropped from the squad because she wasn’t comfortable training when she had her period – the other girls had laughed when she had leaked during training. Worse still, when at a gala with lots of other teams, blood poured down her leg and she had been jeered by the crowd. She thinks her periods are heavy (heavier than all her friends) but her mum has told her this is normal and to stop making a fuss.

Whilst there is no truly objective “test” for menorrhagia, with this history and the marked iron deficiency anaemia, it is pretty straightforward to assume Eloise has menorrhagia. This is likely to be the cause for her IDA as well as affecting her sport participation, her sleep and her schooling. She had normal thyroid function tests (TFTs) as part of her tiredness workup (though it is worth noting that NICE do not recommend checking TFTs routinely in cases of simple menorrhagia). You might want to ask about other bleeding history like epistaxis, bleeding after dental extraction, family history and to consider testing for von Willebrand’s disease. NICE recommend this is for patients who have had menorrhagia from the start of their menstrual life. Most cases of menorrhagia at this age are, however, idiopathic.

Other factors to consider in your assessment

It is so important that Eloise feels listened to and heard. Her perspective is vital for compliance with any plan you make. You’ve already asked her if she thinks her periods are heavy. Now is a good time to continue to explore her ICE (“ideas, concerns and expectations”) by finding out how worried she is about her periods, whether she thinks they are a problem and if she has any ideas for what might be available to fix the problem.

Family history and past medical history are relevant here too in terms of management options as you might well want to consider the combined pill or tranexamic acid both of which are contraindicated if there is a first degree relative family history of venous thromboembolism or a known prothombotic mutation and the COCP is contraindicated if she has focal migraine. It is important to take into account the thoughts and feelings of Eloise’s parent as well during this assessment but remembering that at aged 14 she is likely to have capacity to make decisions some about her own care and be fully involved in the process.

Management of menorrhagia

The NICE guidelines on heavy menstrual bleeding contain a useful interactive flowchart for managing menorrhagia. The first line according to NICE is a levnorgestrel IUS (e.g. Mirena) but this is not always going to be the best tolerated or most suitable in a young teenager. Pragmatically in teenagers we are much more likely to opt for the second line options of tranexamic acid +/- NSAID or the combined pill.

Tranexamic acid (TXA) may be familiar to people who work in haematology or with major trauma patients as an antifibrinolytic. It is licensed for menorrhagia management to be taken as 1g three times daily for up to four days starting on the first day of the period. There are few contraindications but it cannot be taken if there is a history of VTE and should be used with caution if the patient is on the COCP because both increase thrombotic effect. TXA will reduce menstrual blood loss by up to 50%.

NSAIDs for managing menorrhagia often causes confusion as surely they make people bleed don’t they? It’s worth going back to basic pharmacophysiology and revising how NSAIDs act on prostaglandins.  NSAIDs are cyclo-oxygenase inhibitors and cyclo-oxygenase is the enzyme involved in production of prostaglandins. In menorrhagia most women will have increased levels of prostaglandins which, as you might remember, are powerful vasodilators. The local effect of prostaglandin on endometrial blood vessels causes increased bleeding. By reducing the level of prostaglandins using oral NSAIDs the blood loss volume will be reduced by up to 40%. NSAIDs will also have a significant effect on dysmenorrhoea which will frequently coexist with menorrhagia.

The COCP is frequently prescribed for menorrhagia. It is important to be familiar with the UKMEC guidelines when prescribing the COCP. Whilst the licensed regimen for COCP is to take for 21 days with a seven day break, the RCOG FSRH and most menorrhagia guidelines recommend using extended or tailored regimens. This allows for shorter pill free intervals and reduced numbers of bleeding days. Tailored regimens are associated with less frequent bleeds, and in many cases a reduced number of bleeding days.  Satisfaction with tailored regimens is high. 

Eloise seems delighted that you think her periods might not be something she simply has to “put up with”. As she isn’t sure about her family history you call dad back in and he confirms that he knows of no family history of clotting or bleeding disorders. Eloise has had several dental extractions for orthodontic work and has never bled much after these and has never had epistaxis. Eloise has never had a migraine. Her blood pressure and BMI are normal and after discussions of options you prescribe her the levest COCP using an extended tricyling regimen with a five day break after 63 pills to minimise the number of bleeds she experiences and the volume. You also prescribe oral iron and arrange a repeat haemoglobin and ferritin in 3 months, with follow up consultation in four months time.

Selected references

Heavy menstrual bleeding: assessment and management (2018, updated 2020) NICE guideline NG88

Goddard, A.F., James, M.W., McIntyre, A.S. and Scott, B.B., 2011. Guidelines for the management of iron deficiency anaemia. Gut60(10), pp.1309-1316.

Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(2):CD000400. 

Nash, Z., Thwaites, A. and Davies, M., 2020. Tailored regimens for combined hormonal contraceptives. BMJ368.

Emergency Contraception for teenagers

Cite this article as:
Tara George. Emergency Contraception for teenagers, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31958

Olivia presents to the children’s emergency department at 3:40 one Monday afternoon still in her school uniform and with her friend Annabel. Annabel does all the talking to start with and tells the receptionist her friend has “a gynae problem”. She is somewhat assertive with the triage nurse arguing that Olivia needs to be seen by a doctor, in a private room and not in a cubicle with curtains.  They disclose that they are both 15 years old.  When you arrive in the room, Olivia tells you she’s come to A&E to get “the morning after pill”.

Requests for emergency contraception (EC) are a common reason for presentating to GPs, sexual health services and the emergency department. As a children’s doctor it can be a bit of a shock to the system to recognise that adolescents are just as likely as adults to need emergency contraception. There is often a learning gap in the paediatric medicine curriculum. In the UK, around 7% of all women of childbearing age have used emergency contraception in the past 12 months. 10-20% of sexually active teenagers acknowledge they do not always use condoms when having sex.  A request for emergency contraception in a teenager signals that contraceptive and sexual health needs are not being met.

What do you need to cover in the history?

  • Why does she think she needs emergency contraception?
  • When did the unprotected sex (UPSI) occur? (i.e. how long ago)
  • Where is she in her cycle? (i.e when was her last menstrual period (LMP)?)
  • Is her cycle regular and predictable?
  • How many other episodes of UPSI have there been this cycle?
  • Who did she have sex with?
  • Was it consensual? Do you need to consider Sexual Assault Referral Centre (SARC) or forensic medicine input? STI risk? Childhood Sexual Exploitation risk.
  • Was he a regular partner? (STI risk especially)
  • Remember she is 15 – the Fraser Guidelines apply here – does she have capacity to consent to sex? And to the treatment she is seeking? The NSPCC have a brilliant summary of Gillick Competence and Fraser Guidelines.
  • What contraception, if any, does she normally use?
  • Does she have a preference for the form of emergency contraception?
  • What is her weight? And BMI?
  • Is she on any regular medication which might affect the efficacy of oral emergency contraception?
  • What plans has she got for ongoing contraception?

Olivia tells you she had sex on Saturday night at around 2am.  She was staying over at her boyfriend’s house  Her boyfriend, Jack, and she have been in a relationship for about a year. He told her this morning that he thinks the condom might have split.  Olivia says she is normally careful to use condoms so feels pretty embarrassed about this situation. You ask a bit more about Jack.  Annabel tells you Jack is her twin brother. They are all in the same year at school and have known each other for years.  Olivia says her LMP was 10 days ago, her periods are really regular – every 28 days.  This is the only time since her LMP that she has had sex.  Jack is her only sexual partner ever and she is pretty sure he is hers too. Her BMI is 19 and she has no past medical history and is on no medication.

Now it’s time for a revision session on menstrual physiology*

*and on the life span of eggs and sperm without a good understanding of which, providing emergency contraception is really confusing

In a 28 day cycle the first day of the period is always referred to as day 1.  Ovulation then occurs around day 14 of a 28/7 cycle.  If the ovum is not fertilised within 12-24 hours, menstruation will occur 14 days later. The first part of the cycle is called the follicular phase and the second part the luteal phase.  The luteal phase is fixed in length in all women, if the cycle length varies the follicular phase may be longer or shorter than 14 days but following ovulation, if the ovum does not meet a sperm and implant, menstruation will always follow 14 days later

Sperm released into the female genital tract can live for upto 120 hours meaning if unprotected sexual intercourse (UPSI) has occurred any time from 6 days before the earliest possible calculated ovulation to 24 hours after ovulation there is a risk of pregnancy. If an ovum is fertilized by a sperm, implantation will occur 5-6 days after ovulation.

There’s a brilliant diagram in the BJFM article linked in the references section which shows dates, phases, risks and times of action really effectively.

These dates and timelines are crucial in establishing pregnancy risk and in supplying emergency contraception.  If ovulation has already occurred, a method which acts by postponing ovulation will be ineffective.  A method which works by preventing implantation cannot be used after the earliest possible implantation because it is unlikely to be effective but more importantly because it could be considered to be providing a termination of pregnancy which is only legal in specific situations.

What are the options for emergency contraception for Olivia?

There are 3 options licensed for emergency contraception in the UK.  The Copper IUCD, oral levonorgestrel (Levonelle) and Ulipristal (Ella-One)

The flowcharts and decision-making algorithms from the RCOG FFPRHC provide a really clear guide to prescribing.

The Copper IUCD is considered the gold ctandard first choice for EC because it:

  • Is the only method which is effective post-ovulation.
  • Is unaffected by body weight.
  • Is unaffected by enzyme-inducing drugs.
  • Provides ongoing contraception if required.
  • Has a failure rate of only 0.09% when used for emergency contraception.
  • Can cover multiple episodes of UPSI provided early in cycle.

Any copper IUCD can be used for emergency contraception though the “gold standard” for ongoing use is a device with a minimum of 375mm of copper, for example the T-safe 380a.  It is probably worth emphasizing here that this is not a Mirena IUS which cannot be used for emergency contraception.  A copper IUCD for emergency contraception can be fitted any time up to 5 days after the earliest possible ovulation in a cycle (so up to day 19 in a 28 day cycle). Fitting a copper IUCD for emergency contraception can cover several episodes of unprotected sex earlier in the cycle provided it is now before day 19 of a 28 day regular cycle. If a patient has had a single episode of unprotected sex after day 19 a copper IUCD can still be fitted.

It is unlikely there is a service within your emergency department for fitting copper IUCDs. This means that if a copper IUCD is the chosen option you are going to have to arrange for Olivia to attend a contraception and sexual health clinic or her GP if they have a coil fitting enhanced service. She’s on day 10 of her cycle so this is possible as she doesn’t “need” it until day 19 but are you sure she will go there? Not having had children is NOT a contraindication to having a copper IUCD fitted but it can be extremely uncomfortable and she may need a cervical block or gas and air to tolerate the procedure.

Oral EC  in the form of Levonorgestrel and Ulipristal both work by delaying ovulation. This is an important piece of information to bear in mind because if your patient has already ovulated oral emergency contraception is not going to work. It is also worth being aware of for those patients who believe life begins at fertilisation and who may be ethically or religiously opposed to preventing implantation via the use of a copper IUCD but who would find the postponement of ovulation (as per other hormonal contraceptive measures also) acceptable.  The flowchart in the FFPRHC guidelines is really useful to consult every time you have a case of this sort.  

Ulipristal (Ella-One) is second-line after a copper IUCD for the majority of situations when emergency contraception is needed. It does have a number of interactions, most importantly with enzyme inducers and progestogens. It is contraindicated in asthma if the patient is taking oral steroids.  It is important to note that if a patient has taken a progestogen within the preceding 5 days ulipristal will not work. It is not suitable in the case of “missed pills” requiring emergency contraception and it is not possible to “quickstart” POP/COCP/depo progestogen/Nexplanon if you give ulipristal.

Levnorgestrel is the only emergency contraception available both over-the-counter from pharmacies and on prescription in the UK.  It should really only be used if the risk of pregnancy is low and copper IUCD and Ella-One are both not suitable/not available. It is given as a 1.5g stat dose (though this should be doubled to 3g if she weighs over 70kg or has a BMI over 26 and cannot have Ella-One). If levonorgestrel is given the clinician can (and if reviewing the FFPRHC gold standard and NICE CKS advice, should) “quickstart” alternative contraception immediately with condoms until the next period.  The patient should do a pregnancy test three weeks after use if she has not had a normal period.  If your patient is on an enzyme inducer and declines IUCD, levonorgestrel is unlicensed but is the only other option as she cannot use ulipristal.

What else do I need to consider?

Any teenager who has had unprotected sex is at risk of STIs as well as pregnancy. There is no role for doing swabs urgently as they will not pick up STIs contracted as a result of this episode of unprotected sex.  Your patient should be signposted to a Contraception and Sexual Health (CASH) Clinic or her GP surgery for swabs in 3 weeks. You may want to write some free-text on your discharge letter to ensure the surgery are aware of this, and if the department isn’t too busy you might even want to ring her GP surgery and book her in for an appointment with the practice nurse for swabs.

Every teenager presenting needing emergency contraception has unmet ongoing contraceptive needs.  Whilst provision of such contraception may well be outside the scope of your role in the Emergency Department, basic counselling about ongoing contraception with signposting to CASH/GP and some relevant patient information leaflets such as those from www.fpa.org.uk should be within the scope of all clinicians.

If you have any concerns about a young person’s sexual activity and think there is any risk of sexual exploitation, abuse or inability to consent to treatment or to the sexual activity they have disclosed you need to raise this with the safeguarding lead in your department before you let her leave

You supply Olivia with ullipristal and some written counselling information about reliable contraception. You phone her GP surgery and get her booked in for a telephone appointment with a GP to discuss contraception a few days later and an appointment with the practice nurse for triple swabs for an STI screen in three weeks. Olivia rings her mum whilst in A&E and tells her what has happened. Her mum comes to pick her up and is engaged with the suggestion for ongoing follow up and contraception.

References

https://cks.nice.org.uk/topics/contraception-emergency/

https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-emergency-contraception-march-2017/

https://www.bjfm.co.uk/emergency-contraception-which-option-when-part-1

https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines#heading-top

Burack, R., 1999. Teenage sexual behaviour: attitudes towards and declared sexual activity. The British journal of family planning24(4), pp.145-148.

Period management in young people with disabilities

Cite this article as:
Tara George. Period management in young people with disabilities, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31396

Ellie is 14 years old and she has athetoid cerebral palsy. She has limited use of her hands and is in a wheelchair. She started her periods 3 months ago and she finds them very distressing. She comes to see you with her mum to ask about options to help. Mum asks if “ she should go on the pill to help” because that’s what mum was given 30 years ago for her own menstrual problems.


Why might we be thinking about this topic?

Menstrual disorders are common (10% of all teens will need treatment for heavy menstrual bleeding for example). Dysmenorrhoea is very common in all young women and can be extremely disabling or frightening especially if an adolescent does not have the language skills to articulate the issue or the receptive understanding to have it explained to them. Periods and especially period products may be extremely difficult to manage for a young person with a physical or mental disability


Triple incontinence” (bowel/bladder/menstrual blood) can have serious consequences for skin integrity. There are a number of strategies to help but gynaecology is often not part of the paediatric curriculum. Here at DFTB we are going to try and fix this.


Sexuality and sexual behaviour are not the exclusive privileges of the neurotypical but, unfortunately, the risk of abuse, coercion, sexually transmitted infections (STIs) and pregnancy is higher in people with physical or learning disabilities.



What do we need to know from Ellie and her mum?

A clear menstrual history is key here but most important is focusing on their ideas, concerns and expectations. We’ve already heard from the mother that she thinks “the pill” could be the solution but we need to know more about what is happening, what is bothering them and what they think might help.

  • Is the issue simply periods per se and the manual dexterity challenges of managing pads/tampons independently?
  • Does she have heavy bleeding?
  • Are her periods significantly painful?
  • Are there concerns about relationships and sexual activity?

Remember Ellie is a teenager. She’s likely to have crushes, to fancy boys (or girls) and to be exploring her own sexual identity. This can be really hard to come to terms with as a parent of any child, but as the parent of a child with a disability, this can be particularly frightening. There is a huge taboo surrounding the idea of disabled people having sex (more to come in a future article).


Ellie tells you she has had three periods so far. She bleeds for 4-5 days each time and gets a bit of lower abdominal cramping. This settles with paracetamol or ibuprofen. She needs her sanitary pads changing every 3-4 hours and this is really upsetting as her hands won’t let her peel the sticky strips from the back of the pad and she has to get someone else to do it for her. She’s in a mainstream secondary school with some writing and mobility support but her 1:1 teaching assistant can’t help her with personal care so on period weeks her mum has to come into school 2-3 times in the day to change her pads. Ellie finds this humiliating as she is really independent with everything normally. Ellie knows about sex and relationships and has a bit of a thing for a boy in her French class. She’s open and aware of pregnancy and STIs having been to lots of PHSE lessons recently and does not want, or need, contraception currently.



What options are there for helping Ellie with her periods?


The key thing here is not to over medicalise the situation but to recognise that being a menstruating adolescent with physical disabilities can be challenging.

Consider period pants

Liaise directly with school nurses

Medication based approach

Progestogen only pill

  • Shouldn’t be used as a first line agent as erratic bleeding is common
  • It needs to be taken daily
  • 50% of young women will have amenorrhoea by six months with desogestrel

Combined Pill

  • Commonly used, such as the 150/30mcg Levest
  • Prescribers need to consider relative contraindications such as immobility, BMI and enzyme-inducing medication and absolute contraindications such as a history of migraines or family or personal history of venous thrombo-embolism
  • Targeted regimes (bi- or tri-cycling) may be used to induce the longest period of amenorrhoea
  • Loestrin can be crushed and flushed down a gastrostomy tube if swallowing is a challenge

Transdermal contraceptives

  • E.g. Evra
  • They have the same relative and absolute contra-indications as the combine oral contraceptive pill
  • Weekly application is easier than daily tablets
  • A sequentially tailored regime can be used to manage bleeding

Depo progestogen

  • 70% will have amenorrhoea by 12 months
  • This is the most commonly used method
  • Sayana-Press may be able to given by the carer – it is a subcut injection, that is less painful and easier for the teen.
  • Known side effects include weight gain, which may further impede mobility or challenge carer
  • If the teen is of lower BMI, and relatively immobile, it may increase the risk of osteoporosis necessitating the use of supplemental medication

Intra Uterine Devices (IUDs)

  • E.g the Mirena. It works by slowly releasing progestogen into the uterus
  • Licensed for 5 years
  • No drug interactions
  • Amenorrhoea common and dysmenorrhoea tends to improve
  • The uterine cavity needs to be at least 6cm
  • Needs a degree of mobility (and consent) to fit in a routine clinic
  • It may be more appropriate to fit under GA

Contraceptive implant

  • E.g. Nexplanon (etonogestrel)
  • Only a 20% amenorrhoea rate and erratic bleeding is common, though it is usually lighter and less painful
  • The 3-year license means better concordance
  • There is a risk of the teen picking at the implant site, so it may be better to implant in the dominant arm, by the triceps
  • Removal can be tricky so current guidelines suggest putting in a second implant and just leaving the old one in place



Ellie and her mum decided to try some period pants and to speak to the school nurse about changing facilities at school. After another two months she’s still struggling on days 1 and 2 with changing her pants but can manage a whole school day in one pair of “nighttime” pants on days 3-5. She opts to try the combined pill with a tailored regimen allowing day 1-2 of her bleed to be scheduled for weekend days.

Selected references

Dickson J, et al. Contraception for adolescents with disabilities: taking control of periods, cycles and conditions. BMJ Sex Reprod Health 2018;44:7-13