13) Gynaecological Problems - Pain related Flashcards
Incidence of endometriosis
2-10% of women
What percentage of infertile women have endometriosis?
50%
What is gold standard diagnosis for endometriosis?
Laparoscopy and biopsy (but negative histology doesn’t exclude and positive laparoscopy without histology doesn’t confirm)
Indications for laparoscopy in endo
Patient wish for definitive diagnosis
Subfertility
Deep infiltrating disease
What types of endometriosis can TVUS detect?
Ovarian endometriomas.
Rectal endometriosis.
What other imaging is useful in endometriosis?
MRI useful for assessing ureter/bladder/bowel involvement and NICE recommend should be considered before surgery for deep endometriosis.
Treatment for endometriosis
Initial treatment: 3/12 trial (suitable in primary care) of simple analgesia + hormonal contraception (any method). (Recommended for 3-6m before laparoscopy by RCOG)
If this has failed:
- Consider need surgical treatment
- GnRH agonists with add back HRT
- Aromatase inhibitors (letrozole - for rectovaginal endometriosis only if all other therapies fail)
What surgical treatments are an option?
- Ablation or excision of peritoneal endometriosis
- Presacral neurectomy (effective for midline pain)
- Excision of endometriomas
- Surgical removal of deep endometriosis
- Hysterectomy and ovarian removal
Role of pre-surgical hormone treatment in endometriosis
Doesn’t improve surgical outcomes but can be used as interim pain control
(But NICE recommend GnRH for 3/12 pre-surgery for deep endo)
What can be used to prevent adhesions at time of surgery for endometriosis?
Oxidised regenerated cellulose (don’t recommend icodextrin)
What should be considered before surgery for deep endo?
GnRH 3/12
MRI
What can be used to reduce risk of recurrence after surgery for endometriosis?
Mirena/COCP for 18-24 months post-op
Treatments on fertility in endometriosis
- Hormonal treatment does not improve fertility
- Offer operative laparoscopy with CO2 laser vaporisation for stage 1/2 endometrial
- Excision of endometriomas
- Can consider surgery in stage 3/4 disease if it is thought it will improve pregnancy outcomes
ART in women with endometriosis
Stage 1/2: IUI with controlled ovarian stimulation increases birth rate.
GnRH agonists for 3-6m prior to ART can improve clinical pregnancy rates in infertile women with endometriosis.
What HRT to use in women after menopause (even if surgically induced) due to endo?
COMBINED (EVEN IF THEY DON’T HAVE A UTERUS)
Risks of cancer and endometriosis
Overall incidence of cancer unchanged
Ovarian cancer and non-Hodgkin’s lymphoma more common in people with endometriosis.
Cervical cancer less common.
Symptoms which are strongest predictors of deep endometriosis
Dyschezia during menstruation and deep dyspareunia
Correlation between pain symptoms and degree of endo
Pain increases as depth of invasion increases (but not stage of disease)
Mean latency to diagnosis of endometriosis
8 years
Comparison of COCP and GnRH analogues for treatment of endometriosis
As effective
Percentage loss of BMD after 6 months on GnRH analogues
13%
Ovarian failure rate after bilateral ovarian endometrioma cystectomies
2.4%
Rate of complications associated with surgery for deep infiltrating endometriosis
2% intra-operative complications
14% post-operative complications
Recurrence rates following colorectal endometriosis surgery
5-25%
Dietary changes with evidence for endometriosis
Omega 3 fish oil
Vitamin B12
Diet high in vegetables and low in animal fats
Vitamin E + C benefits
Incidence of IBS
10-15%
Incidence of IBS after gastroneteritis
7-30%
What type of foods exacerbate IBS?
FODMAP foods
Incidence of IBS in women with endometriosis
2.5 x higher
Management of IBS
- Avoid foods e.g. insoluble fibres, beans, fatty food, caffeine, chocolate and sugar substitutes and alcohol
- Moderate exercise
- 1st line: Antispasmodics
- 2nd line: TCAs/SSRIs
- Laxatives/antidiarrhoeals (ondansetron can control diarrhoea in pt with IBS)
- CBT, Hypnotherapy
- Pregabalin
How long does chronic pelvic pain have to have lasted for the definition?
6 months
Incidence of chronic pelvic pain
1 in 6 women
What is residual ovary syndrome?
Small amount of ovarian tissue left behind and gets trapped in adhesions
What is trapped ovary syndrome?
Retained ovary becomes buried in dense adhesions?
Rome III criteria for IBS
- COntinuous/recurrent abdo pain
- At least 3 days per month in last 3 months
- Onset at least 6 months previously
Associated with two of:
- Improvement with defaecation
- Onset associated with change in frequency of stool
- Onset associated with change in form of stool
Number of negative laparoscopies in patients with chronic pelvic pain
1/3-1/2
Incidence of bladder pain syndrome
2.5-6.5%
Definition of bladder pain syndrome
Pelvic pain, pressure or discomfort perceived to be related to the bladder, lasting for at least 6 months (new definition: 6 weeks) and accompanied by at least one other urinary symptom in the absence of other identifiable cause.
What makes bladder pain syndrome worse/better?
Worsens with certain food/drink
Worsens with bladder filling
Improves with urination
Diagnosis of bladder pain syndrome
- Diagnosis of exclusion.
- Bladder diary, food diary.
- Urine dipstick (consider testing ureaplasma/chlamydia if symptomatic sterile pyuria)
- Urine cytology and cystoscopy if suspect malignancy
- Bladder biopsy and hydrodistension NOT recommended to make diagnosis
Management of bladder pain syndrome
1st line: Analgesia, stress relief, diet, physical therapy
2nd line: Amitryptiline, Cimetidine (if fails refer MDT/pain team/psychologist)
3rd line: Intravesical DMSO, heparin, botox A, lidocaine chondroitin sulfate, hyaluronic acid.
4th line: Neuromodulation (posterior tibial N, sacral N), oral ciclosporin A
5th line: Cystoscopy and hydrodistension
Effect of pregnancy of BPS
Unkown
BPS treatments which are safe in pregnancy
Oral amitryptiline\
Intravesical heparin
One course of intravesical DMSO pre-pregnancy
Classification of BPS
Cystoscopy with hydrodistension:
- Not done: X
- Normal: 1
- Glomerulations: 2
- Hunner Lesions: 3
Biopsy:
- Not done: X
- Normal: A
- Inconclusive: B
- +ve: C
Incidence of pelvic congestion syndrome
3.8%
Who gets pelvic congestion syndrome?
Premenopausal multiparous women
What happens in pelvic congestion syndrome?
Ovarian plexus varicosities secondary to:
- Absence of ovarian vein valves allowing reflux
- Venous dilatation in pregnancy leading to valvular incompetence
- Compression of left renal vein (into which ovarian vein drains) between SMA and aorta (“nutcracker syndrome”)
Characteristic features of pelvic congestion syndrome
Pelvic pain which is worse premenstrually, in pregnancy and when standing.
Throbbing ache after intercourse.
Investigations for pelvic congestion syndrome
Gold standard is venography.
Can use USS/CT/MRI.
Management of pelvic congestion syndrome
Analgesia Responds to ovarian suppression Daflon is a vasoconstrictive drug with benefit Surgical Embolisation Psychotherapy
