A lady in her early 40s presents with heavy, painful bleeding, about 2 weeks later than normal. A thorough gynecologic history leads me to believe that she has just entered the peri-menopausal period, had her first anovulatory cycle, and is now sloughing the heavy endometrial buildup from an extra 2 weeks of hormonal influences. She had been married for 21 years, never pregant. THey had been unable to concieve early in their married years, and have since never used birth control. No condoms, no IUDs, no contraceptives. No other sexual partners, ever. No gynecologic infections, surgeries or abnormalities. Regular cycles, 28 days with 5 days of bleeding.

So far, nothing in the history to make me think any differently than to tell the couple that she was beginning, “The Change.” Yet one more stage of life to enter.

As usual, I preform a pelvic exam with the help of a nurse handing me supplies as needed. Insert speculum, search for cervix. I can’t find it. I poke and prod and redirect, finally having to reposition the patient on the table. Finally, it pops out at my like a giant, necrotic blue thumb. I supress the gasp that climbs out my throat at it’s appearance. I’m certain that she has cervical cancer.

There is a small growth at the tip of the cervix, and I grasp it with ring forceps, uncertain if it is a clot, or some piece of necrotic tissue. Gently I tug at it, not wanting to unleash a flood of new bleeding. But if it something stuck in the cervical opening, I feel compelled to try and remove it. I tug a second time. Suddenly I jump back about 3 feet from the table as the nurse gasps as well. I check my face, scrubs, pants and shoes for bodily fluids. Something…and I’m not sure what it was… erupted as I tugged, sending a stream of clear fluid straight back out at me.

“That’s not normal, is it?” the husband asked.

“No, it’s not.” I calmly said, trying not rid myself of the chills creeping down my spine.

I call the gynecologist, he of course wants me to get a pap smear, which we don’t carry supplies for in the ER. “Can you come and look at it?” I ask him. “Just have her see me in my office next week, we’ll have the pap results by then.” Sh*t. WHy won’t he just come and look at it. I’m pissed. I’m certain this lady has cancer, and I can’t get a gynecologist to see her today.

I go back ot the room and the nurse intercepts me. “I wanted to show you this,” she whispers, pointing to her urine pregnacy test that the nurses run by protocol. It was positive.

H*LY CR*P. What WAS that on her cervix? What WAS that fluid? My stomach sank and I became nauseated. I ran a serum pregnancy level, then ordered an ultrasound. I called the gynecologist back, with the updated information.

I pass the patient’s room and see the gynecologist’s black shoes on either side of the stool at the foot end of her bed, the room curtain pulled across the glass doorway. I pause to evesdrop and hear a small “PLUNK” as he pronouces, “Products of conception, send it to pathology please.” The nurse comes out of the room with the container of 5 week old gestational growth and mock sneers at me. She hates the gynecologist, thinks he’s rude. He’s just being factual, I think to myself.

I go back into the room while waiting for her Rh factor to get back from the lab. I summarize their visit to the ER. “I had initially thought that your cervix had a large fluid filled cyst on it, but your pregnancy test was positive. What I had thought was a cycst was the gestational sac of a pregnancy that had implanted just outside your cervix. There was no hope for survival of the fetus beyond a few weeks. The gynecologist removed what remained, and now your bleeding should slow down over the next few days. ” Her pain was gone, the bleeding had stopped, and the couple seemed satisfied. They weren’t planning on getting pregnant. I finally discharged them and he told me that it was their anniversary. “Congratulations,” I said, “what did you have planned for the night?”

“I think we’ll just go home and order a pizza,” he said.