5 Gynecologic Emergencies

Assess and stabilize first

Begin with airway, breathing, circulation, vital signs, mental status, and pain. Look for shock, ongoing heavy bleeding, peritonitis, fever or sepsis, and severe or rapidly worsening pain. If the patient is unstable, establish large-bore IV access, begin resuscitation, and arrange urgent gynecologic and surgical consultation; do not delay treatment for imaging.

For patients who could be pregnant, obtain a urine or serum pregnancy test early, even if contraception is used or the history makes pregnancy seem unlikely. A focused history covers pain onset and location, bleeding, last menstrual period, pregnancy possibility, discharge, fever, relevant sexual history, medications including anticoagulants, and prior gynecologic conditions or procedures.

Guide examination by consent and clinical need. This may include abdominal examination and, when appropriate, speculum and bimanual examination. Typical initial tests include a complete blood count, urinalysis, and targeted infection testing; obtain blood type and screen or crossmatch when bleeding is significant. Pelvic ultrasonography, often transvaginal, is the usual first imaging study for suspected gynecologic causes.

Evaluate acute pelvic pain

Acute pelvic pain can result from pregnancy-related causes, ovarian or tubal disease, pelvic infection, urinary disease, or gastrointestinal causes such as appendicitis. A pregnancy test and ultrasound help assess for ectopic pregnancy, but an early scan may not establish the pregnancy's location. If the patient is stable and pregnancy location remains uncertain, serial human chorionic gonadotropin (hCG) measurements and repeat ultrasound may be needed.

Severe pain, fainting, weakness, shoulder pain, or signs of shock in a patient who could be pregnant raise concern for a ruptured ectopic pregnancy and require emergency evaluation and treatment. Hemodynamic instability or peritoneal signs also require urgent assessment for internal bleeding or another surgical emergency.

Adnexal (ovarian) torsion commonly causes sudden, often one-sided pelvic pain with nausea or vomiting; the pain may come and go. It is a time-sensitive surgical emergency. Ultrasound can support the diagnosis, but normal Doppler blood flow does not reliably exclude torsion. When suspicion is significant, seek urgent gynecologic consultation rather than waiting for imaging to prove it; definitive diagnosis is surgical. Other important causes include a ruptured or bleeding ovarian cyst and tubo-ovarian abscess.

Respond to vaginal or uterine bleeding

First determine whether bleeding is causing hemodynamic compromise. Assess pulse, blood pressure, mental status, ongoing blood loss, and symptoms of anemia. Stabilize the patient and arrange urgent gynecologic care for instability or severe bleeding.

In reproductive-aged patients, exclude pregnancy before labeling bleeding as nonpregnancy-related abnormal uterine bleeding. Once the patient is stable, direct evaluation according to age, pregnancy status, bleeding pattern, examination, and likely cause. For acute abnormal uterine bleeding in a nonpregnant patient, medical therapy is often considered first when appropriate; persistent, severe, or medically uncontrolled bleeding may require a procedure or surgery.

Postmenopausal bleeding needs prompt evaluation because it may reflect endometrial disease, including cancer, even though benign causes are also common. The updated guidance described in the material recommends both transvaginal ultrasound and endometrial tissue sampling as part of the initial evaluation for most patients with postmenopausal bleeding.

Recognize and manage pelvic infection

Pelvic inflammatory disease (PID) may present with pelvic or lower-abdominal pain, abnormal bleeding, discharge, painful intercourse, or fever; symptoms can be mild. In a patient at risk for sexually transmitted infection (STI), consider empiric treatment when pelvic pain has no better explanation and examination shows at least one of cervical-motion, uterine, or adnexal tenderness. Do not wait for all three findings or for test results if clinical suspicion warrants treatment.

Assess for ectopic pregnancy, torsion, appendicitis, and other urgent causes as well. Hospital care is indicated when a surgical emergency cannot be excluded, a tubo-ovarian abscess or pregnancy is present, illness is severe (including vomiting or high fever), outpatient treatment cannot be followed or tolerated, or there is no response to outpatient therapy. Reassess patients treated as outpatients if they do not improve within 72 hours.

Test patients diagnosed with PID for gonorrhea, chlamydia, HIV, and syphilis. Arrange partner management and follow-up according to current guidance.

Provide consent-centered sexual-assault care

Address immediate injuries and safety first. Use a trauma-informed approach: listen without judgment, explain options, ask permission before each step, and let the patient decide whether to have an examination or forensic evidence collected. Medical care is available whether or not the patient reports to law enforcement. Offer access to a trained sexual-assault forensic examiner or advocate when available, without delaying urgent treatment.

With the patient's consent, assess pregnancy risk and offer emergency contraception when indicated. Options include a copper IUD or emergency contraceptive pills. They should be used as soon as possible and within five days of unprotected intercourse; emergency contraception does not prevent STIs.

Offer STI testing and discuss presumptive treatment, hepatitis B vaccination (and hepatitis B immune globulin when indicated), and HPV vaccination when appropriate. Assess HIV exposure promptly. When HIV nonoccupational postexposure prophylaxis (nPEP) is indicated, start it as soon as possible, ideally within 24 hours and no later than 72 hours, and continue it for 28 days. Do not delay the first dose while awaiting laboratory results. Arrange timely follow-up for test results, treatment, medication support, and ongoing safety or mental-health needs.

Integrate the urgent-care priorities

Prioritize stabilization when there is shock, major bleeding, sepsis, or peritonitis, and seek urgent specialist care when indicated. Check for pregnancy early in anyone who could be pregnant; ectopic pregnancy may be life-threatening even before its location is confirmed.

Consider torsion with sudden pelvic pain and nausea, recognizing that reassuring Doppler flow does not rule it out. Treat suspected PID promptly while assessing for surgical alternatives and arranging reassessment. Evaluate postmenopausal bleeding, and provide sexual-assault-related care with consent, privacy, and trauma-informed support.