Epidemiology & Physiology
Epidemiology of Common Conditions
- Endometriosis: Affects ~1 in 7 females. 11.4% of females diagnosed by age 44. Significant burden on the ED (>3600 presentations in 2021-2022).
- Adenomyosis: Affects ~1 in 5 females. Often co-exists with endometriosis.
- PCOS: Affects 8-13% of women of reproductive age.
- Ovarian Cysts: 6.6% of pre-menopausal and 14% of post-menopausal women.
The Hypothalamic-Pituitary-Gonadal (HPG) Axis
The female reproductive cycle is driven by the HPG axis regulating two simultaneous cycles:
- Ovarian Cycle: Maturation of the egg.
- Follicular Phase: FSH stimulates follicle growth. Estrogen rises.
- Ovulation: LH surge triggers egg release.
- Luteal Phase: Corpus luteum secretes Progesterone to maintain lining.
- Uterine Cycle: Preparation of the endometrium.
- Menstrual: Shedding of functional layer.
- Proliferative: Rebuilding (Estrogen driven).
- Secretory: Enrichment/thickening (Progesterone driven).
History Taking & Assessment
Gynaecological History Framework
In addition to standard history (CHAMPSS/SOCRATES), specific areas must be covered:
1. Menstrual History
LMP: Last Menstrual Period (Start date? Normal flow?).
Cycle: Regularity? Length?
Terminology:
- Menorrhagia: Heavy/prolonged periods (>80mL or >7 days).
- Amenorrhoea: Absence of menstruation (Primary = never started; Secondary = cessation >6 months).
- Dysmenorrhoea: Painful menstruation.
- Oligomenorrhoea: Infrequent periods (<5 per year).
2. Obstetric History
Gravidity: Total number of pregnancies (regardless of outcome).
Parity: Number of births >20 weeks.
3. Sexual & Contraceptive History
Active? Partners (gender)? Dyspareunia (pain during sex)?
Contraception used? (IUD, pill, implant). Recent STI screening?
Physical Examination Principles
Paramedic Rule: Do NOT perform internal pelvic examinations (digital or speculum) in the pre-hospital setting.
Abdominal Exam:
- Inspect: Distension, surgical scars (Laparoscopy/Pfannenstiel).
- Palpate: From umbilicus down to pubic symphysis. Check for masses, peritonism (guarding/rigidity), and localized tenderness.
Ovarian Disorders
Ovarian Cysts
Pathophysiology: Fluid-filled sacs.
Functional: Follicle fails to rupture (Follicular) or Corpus Luteum fails to shrink.
Pathologic: Dermoid (teratomas with hair/teeth), Cystadenomas (mucous), Endometriomas ("chocolate cysts").
Ruptured Cyst: Fluid/blood released into peritoneal cavity -> Peritoneal irritation.
Symptoms: Sudden sharp pain (unilateral), bloating. Can mimic appendicitis or ectopic pregnancy.
Management: Analgesia, anti-emetics, transport (for ultrasound/diagnosis).
Ovarian Torsion (Emergency)
Pathophysiology: The ovary twists around the infundibulopelvic ligament (suspensory ligament). This initially compresses lymphatic/venous outflow causing massive ovarian edema. Eventually, arterial inflow is compromised leading to ischemia and necrosis. Time is tissue.
Risk Factors: Ovarian mass >5cm (cyst/tumour), pregnancy, IVF.
Presentation: Sudden onset severe unilateral pain. Nausea/Vomiting is very common (reflexive).
- Analgesia: Aggressive pain management (e.g., Fentanyl/Morphine).
- Anti-emetics: Ondansetron for N/V.
- Fluids: If signs of shock/dehydration.
- Transport: Urgent transport to a facility with surgical capability.
Polycystic Ovarian Syndrome (PCOS)
Pathophysiology: Metabolic/Endocrine disorder. Insulin resistance leads to hyperinsulinemia, which stimulates androgen production. High androgens prevent ovulation (anovulation), leading to multiple immature follicles ("cysts").
Features: Irregular periods, Hirsutism, Obesity, Infertility.
Paramedic Relevance: Patients have higher risks of metabolic syndrome, T2DM, hypertension, and endometrial cancer.
Uterine Disorders
| Condition | Pathophysiology | Clinical Features |
|---|---|---|
| Endometriosis | Endometrial-like tissue grows outside the uterus (ovaries, tubes, pelvis). This tissue responds to hormones and bleeds cyclically. Blood is trapped -> inflammation -> fibrosis/adhesions. | Chronic cyclical pain, dysmenorrhoea, dyspareunia, infertility, "endo belly" (bloating). |
| Adenomyosis | Endometrial tissue grows into the myometrium (muscle wall) of the uterus. The uterus becomes enlarged, tender, and "boggy". | Heavy menstrual bleeding (menorrhagia), severe cramping, chronic pelvic pain. |
- Manage acute exacerbations of chronic pain.
- Recognize that "chronic" pain can still be severe (10/10).
- Consider ruptured endometrioma (chocolate cyst) as a cause for acute deterioration.
Infections
Pelvic Inflammatory Disease (PID)
Pathophysiology: Ascending infection from the lower genital tract (vagina/cervix) to the sterile upper tract (uterus, tubes, ovaries).
Causes: STIs (Chlamydia/Gonorrhoea) or Non-STI (post-surgical, IUD insertion).
Sequelae: Inflammation -> Scarring -> Infertility / Ectopic Risk / Tubo-ovarian Abscess -> Sepsis.
Presentation: Bilateral lower abdo pain, fever, abnormal discharge (foul), deep dyspareunia, cervical motion tenderness ("chandelier sign").
- Sepsis Screen: Check Temp, HR, BP, RR.
- Analgesia: Paracetamol/NSAIDs/Opioids.
- Transport: Required if pregnant, septic, or severe pain.
Other Infections
- Bartholin's Cyst/Abscess: Blockage of gland at vaginal entrance. If infected (abscess), causes severe unilateral pain/swelling preventing walking/sitting. Requires drainage.
- Bacterial Vaginosis (BV): Bacterial imbalance (loss of lactobacilli). Fishy odour. Risk factor for PID.
- Thrush (Candida): Fungal. Thick white discharge, itching. Associated with diabetes/antibiotic use.
Early Pregnancy Complications (<20 Weeks)
Ectopic Pregnancy (Life Threat)
Pathophysiology: Implantation of blastocyst outside the uterine cavity (98% tubal). As the embryo grows, it stretches the tube causing pain. Rupture causes massive hemorrhage into the peritoneal cavity.
Risk Factors: Previous ectopic, PID, tubal surgery, IVF, IUD, Smoking.
Clinical Triad: 1. Amenorrhoea (missed period) 2. Vaginal Bleeding 3. Abdominal Pain.
Signs of Rupture: Shoulder tip pain (hemoperitoneum irritating diaphragm), peritonism, hypovolemic shock.
- Assume Ectopic: In any female of reproductive age with abdo pain until proven otherwise.
- Resuscitation: Large bore IV access. Fluid resuscitation (permissive hypotension considerations if ruptured).
- Transport: Rapid transport to hospital with surgical capability.
Miscarriage (Spontaneous Abortion)
Definition: Pregnancy loss before 20 weeks.
Causes: Chromosomal (50-60%), maternal health, infection.
| Type | Cervix | Bleeding/Pain |
|---|---|---|
| Threatened | Closed | Mild bleeding. Pregnancy may continue. |
| Inevitable | Open | Heavy bleeding/cramping. Loss unavoidable. |
| Incomplete | Open | Products partially passed. Ongoing bleeding. |
| Complete | Closed | Products passed. Symptoms subside. |
- Hemodynamics: Assess for shock. Fluid resuscitation if indicated.
- Analgesia: Safe to administer.
- Rhesus Status: Transport required for Anti-D if mother is Rh Negative.
- Empathy: Acknowledge the loss. Allow patient to stay home if stable and preferred (check local guidelines).
Sexual Assault
Paramedic Considerations
- Safety: Is the perpetrator still on scene? Do not enter until police secure if dangerous.
- Control: Restore control to the patient. Explain every move. Ask permission before touching.
- Evidence Preservation: Discourage showering, changing clothes, eating, or drinking (preserves DNA). Do not clean wounds unless necessary for bleeding control. Place clothing in paper bags (not plastic).
- Forensic Sensitivity: Do NOT examine genitals unless there is life-threatening hemorrhage.
- Reporting: Mandatory reporting for minors. For adults with capacity, respect their choice regarding police involvement.
- Disposition: Transport to a facility with forensic/sexual assault services or Sexual Assault Referral Centre (SARC).