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Chronic Pelvic Pain/Menstrual Abnormalities Flashcards

1
Q

Chronic pelvic pain definition

A

Noncyclic pain lasting for ***more than six months that localize to the anatomic pelvis, anterior abdominal wall, at or below the umbilicus, the lumbosacral back or buttocks
And is of sufficient **severity to cause, functional disability or lead to medical care

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2
Q

History in patient with chronic pelvic pain should include

A

Timing
Localization
Quality
Radiation
Intensity
Duration
Alleviating or aggravating factors
Patient perception

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3
Q

What do you want to know the relationship to in possible CPP

A

Relationship of pain to *Menstrual cycle
Bowel movements, intercourse, urination, physical activity

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4
Q

What physical exams do you want to perform for a patient with possible chronic pelvic pain

A

Abdominal exam to locate pain and determine radiation, peritoneal inflammation, etc.
Pelvic exam to localized pain and determine pathology
Back exam to determine skeletal or renal origin

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5
Q

What does every woman with abdominal pelvic pain must have

A

Pelvic and rectal exam

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6
Q

What further investigation steps do you want to do for a patient with possible CPP?

A

Labs- CBC, ESR, CMP to evaluate for infection, inflammation
Culture of vaginal discharge - rule out STI
HCG - rule out pregnancy, ectopic
Urine studies - rule out infection
Psychological evaluation - usually last resort if you can’t find a cause

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7
Q

What imaging studies can you perform for possible CPP?

A

Ultrasound- pelvic or transvaginal ultrasound can evaluate uterus, ovaries, and fallopian tubes
Plain film radiography (XR) - flat, an upright, abdominal radiographs to rule out intestinal obstruction or other G.I. disorders. Also want to look at pelvis to see if they’re passing a kidney stone
CT and MRI provide information on anatomic structures and differentiate abdominal from uterine mass
G.I. pathology may be evaluated with barium enema , colonoscopy, or proctoscopy

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8
Q

What imaging can you do to evaluate renal system?

A

Cystoscopy or pyelography
Need to have renal consultation

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9
Q

What is the ultimate method to diagnose etiologies of CPP?

A

Laparoscopy

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10
Q

What is the most common indication for laparoscopy?

A

CPP

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11
Q

Why are the three signs and symptoms(distinguishable) of endometriosis?

A

3 “Ds”
Dyspareunia, dysmenorrhea, dyschezia

Adhesions, scarring
Pain doesn’t let up after Cycle, severe pain

organic cause of CPP

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12
Q

What is the suspected cause of endometriosis?

A

Retrograde flow when women have menses and tissue can flow through fallopian tubes

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13
Q

18 to 35% of women status post what develop CPP

A

Chronic PID
Patients have adhesions and inflammation
Fitz Hugh curtis - adhesions between liver and diaphragm showing “violin string”

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14
Q

How can ovarian cysts cause chronic pelvic pain?

A

May result in pain from rapid distention of ovarian capsule or torsion of the ovary

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15
Q

What is adenomyosis?

A

Endometrial tissue within uterine musculature (myometrium)
Causes dysmenorrhea and dyspareunia

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16
Q

What are leiomyomas also known as

A

Fibroids

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17
Q

When do fibroids cause pain?

A

Leiomyomas do not cause pain unless degenerating, undergoing torsion, or pressing on nerves

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18
Q

What is pelvic congestion syndrome? What is the treatment?

A

Varicosities of pelvic veins and congested organs cause premenstrual pain, worse with fatigue, standing and intercourse
Veins are dilated and pressing on structures
Dx- Doppler US or laparoscopy
Tx- vasoconstrictors or hormones (progestins, GnRH agonists, embolotherapy, vein ligation, hysterectomy)

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19
Q

What are some genitourinary causes of chronic pelvic pain?

A

Urinary retention, cystitis, trigonitis

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20
Q

What are some symptoms of cystitis?

A

Frequency, urgency, dysuria, pelvic pain, blood in urine
This is chronic inflammation of the submucosal surface of the bladder
Can result from holding urine too long

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21
Q

Why can G.I. and GYN pain be difficult to distinguish?

A

Innervation of lower G.I. tract is the same as the uterus and fallopian tubes

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22
Q

What are some Gastro intestinal causes of CPP

A

Penetrating neoplasm of G.I. tract
Irritable bowel syndrome
Partial bowel obstruction
Diverticulitis
Hernia

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23
Q

How can neuromuscular pain cause CPP

A

Pain of neuromuscular origin presents as low back pain and increases with activity and stress
Can indicate radiating pain

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24
Q

Who is included in a multi disciplinary pain clinic for CPP

A

Gynecologist
Psychologist
Anesthesiologist
Acupuncturist

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25
Q

Physical Therapy management of chronic pelvic pain

A

Hot cold applications
Stretching
Ultrasound therapy
Transcutaneous electrical nerve stimulation(TENS)

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26
Q

Medical management of chronic pelvic pain

A

Trial of ovulation/ menstruation suppression with birth control pills, progestins, GnRH agonist can help if pain is related to menstrual cycle or ovarian pathology(cysts)
NSAIDs are useful
Antidepressants (increase norepinephrine, serotonin)

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27
Q

When do you manage CPP surgically?

A

Only if pathology is discovered

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28
Q

When is something considered an abnormality of menstruation?

A

When it occurs for more than three months

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29
Q

What is menorrhagia?

A

Prolonged or excessive uterine bleeding at regular intervals (>80 mL or longer than seven days)
A.k.a. Hypermenorrhea

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30
Q

What is metrorrhagia?

A

Irregular menstrual bleeding or bleeding between periods

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31
Q

What is menometrorrhagia?

A

Frequent menstruation bleeding that is excessive and irregular in amount and duration

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32
Q

What is oligomenorrhea?

A

Menstrual flow at intervals of over 35 days in frequency

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33
Q

What is polymenorrhea

A

Menstrual flow at intervals of less than 21 days

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34
Q

What can cause abnormal uterine bleeding in newborns?

A

Withdrawal bleeding
Newborn girls get withdrawal from hormones from mom - common within days after birth

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35
Q

Causes of abnormal uterine bleeding before menarche (before normal age range)

A

Malignancy
Trauma or sexual abuse
Foreign body
Urinary tract problems or irritation
Precocious puberty (early start of puberty before 9)

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36
Q

What age should the hypothalamic pituitary axis be matured?

A

18 to 21 years

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37
Q

When may periods be irregular?

A

For the first few months, may be up to a year

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38
Q

In childbearing years abnormal bleeding may be caused from this, so you have to rule it out first

A

Pregnancy and pregnancy related conditions (ectopic, abruptio placenta, spontaneous abortion)

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39
Q

Once pregnancy is ruled out what are other causes of abnormal bleeding in childbearing years

A

Medication’s- (anticoagulants, psych meds, corticosteroids, OC’s, Hormone Replacement Therapy (HRT)
Medical problems - thyroid, hematologic disorders, hepatic disorders (liver impacts platelet production), adrenal, pituitary, hypothalamic problems
IUD- usually when newly placed

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40
Q

GYN disorders that can cause abnormal bleeding in childbearing years

A

Anovulation
PCOS
Neoplasms , endometrial intraepithelial neoplasia, endometrial cancer
Trauma
Cervical polyps
STI’s
Leiomyomas (fibroids)

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41
Q

Palm-Coein Classification for Abnormal Uterine Bleeding

A

Abnormal uterine bleeding can be distinguish between structural and nonstructural causes

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42
Q

PALM CAUSES OF ABNORMAL UTERINE BLEEDING

A

Palm is structural

Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia

43
Q

COEIN causes of abnormal uterine bleeding

A

Non-structural causes

Coagulopathy
Ovulatory dysfunction (hormonal)
Endometrial
Iatrogenic
Not yet classified

44
Q

Evaluation of abnormal uterine bleeding in childbearing years

A

History
Specifics of bleeding, prior GYN problems, STI’s, abnormal paps, sexual history, contraceptives, medication’s

PE
Evaluate for coagulopathies, liver, thyroid disease
Pelvic exam to verify source of bleeding
Rectal exam

Diagnostic test-
HCG , CBC, platelet, bleeding time, thyroid, liver function, Pap smear(not in emergency setting), endometrial biopsy, ultrasound

45
Q

What is the average age for menopause in women in the US?

A

51 years

46
Q

abnormal bleeding in Perimenopause women

A

During perimenopause (up to five years before menopause) periods become irregular
Rule out, endometrial cancer and pregnancy

47
Q

What is postmenopausal bleeding considered unless proven otherwise

A

Cancer!

48
Q

Benign causes of bleeding after menopause

A

Atrophic vaginitis(thin vaginal walls)
Polyps
Endometrial hyperplasia

49
Q

Evaluation of abnormal bleeding after menopause

A

Transvaginal or abdominal ultrasound
Dilation and curettage (can you remove an entire section of abnormal tissue or can biopsy)
Endometrial biopsy

50
Q

In patients with mild bleeding like in asymptomatic or no blood changes what can you do to treat?

A

Oral contraceptives, maybe used to suppress the endometrium and establish regular predictable withdrawal cycles

51
Q

In severe endometrial hemorrhage what do you do first

A

Patient is hypotensive, anemic
Address bleeding quickly stabilize the patient first

52
Q

What can prolonged endometrial bleeding be caused by?

A

May be a result of denuded epithelial lining (very thin, can worsen bleeding

53
Q

If the patient is having a severe endometrial hemorrhage what do you do first? if successful what do you do?

A

High dose estrogen to support endometrium and stop bleeding
If successful, follow with low-dose estrogen +/- progestin- OC’s 3/day for a week

54
Q

If medical treatment feels of severe, endometrial hemorrhage, what can you do?

A

D&C, endometrial ablation, or hysterectomy may be necessary to control bleeding
Ablation or hysterectomy is usually used for patients who don’t want children

55
Q

What is dysfunctional uterine, bleeding considered

A

Diagnosis of exclusion

56
Q

DUB definition

A

Abnormal uterine bleeding in women between menarche and menopause that cannot be attributed to medications, blood disorders, systemic disease, trauma, uterine neoplasms, or pregnancy

57
Q

What is anovulatory bleeding most commonly caused by in adolescents

A

Problem or immaturity of the hypothalamic pituitary system
Check hormones

58
Q

What can cause anovulatory bleeding in perimenopausal women?

A

May result from declining function of the ovary

59
Q

Treatment of the DUB for younger, more mild cases

A

Maybe educated or treated with oral contraceptives for 21 days with 7 day withdrawal (28 day pack)
If withdrawal is positive (bleed) indicates it could be hormone related
This suppresses endometrial development and reestablishes normal patterns and decreases blood loss

60
Q

Treatment of DUB in a stable patient with moderate bleeding

A

Cyclic estrogens with progesterone added for the last 10-15 days of the 25 day cycle
expect withdraw bleeding for 5 to 7 days when you stop taking progesterone
Repeat each month for 3 to 6 months - normal pattern may be established

61
Q

Who should not receive oral contraceptives? why?

A

Should not be given to smokers >35 years (and increased BMI)
OCs increase the risk of blood clots, can lead to PE

62
Q

What can you do if Medical therapies fail to control DUB?

A

Endometrial biopsy, vaginal ultrasound, or saline infused sonohysterography for further Dx
If all else fails
Hysterectomy or endometrial ablation (allows new tissue (scar tissue) to grow back)
* results in infertility**

63
Q

What is primary amenorrhea?

A

No spontaneous uterine bleeding by the age of 15 with normal secondary characteristics (has all physical stages of development)
OR
13 years with abnormal secondary sexual characteristics (no development of breast bud, no coarse/fine hair on mons pubis, etc.)

64
Q

What is secondary amenorrhea?

A

Absence of menstrual periods for 3 to 6 months, or the duration of three typical menstrual cycles for the patient
* has already established bleeding*

65
Q

Amenorrhea may result from

A

Pregnancy (most common)
Hypothalamic pituitary causes (not making hormones)
Ovarian/ovulatory dysfunction (not responding to hormones)
Uterine causes

66
Q

Hypothalamic pituitary causes of amenorrhea

A

Congenital deficiency of GnRH
Hypothalamic pituitary dysfunction
Defect of GnRH transport
Defects of GnRH pulse production
Congenital absence of pituitary

67
Q

What is congenital deficiency of GnRH? Primary or secondary

A

No GnRH secretion from the hypothalamus, so the anterior pituitary is not told to secrete FSH or LH

Follicular recruitment an ovulation do not occur

Sexual maturation may be delayed or completely absent

  • primary amenorrhea*
68
Q

What is hypothalamic pituitary dysfunction? Primary or secondary

A

GnRH release occurs in pulsatile fashion normally. If disrupted, anterior pituitary is not stimulated to secrete FSH and LH

Follicles do not develop. Ovulation does not occur.

  • primary amenorrhea*
69
Q

What is can cause defect of GnRH transport?

A

Hypothalamic lesions (craniopharyngioma)
Benign brain tumor near pituitary

Prevents flow of GnRH from hypothalamus to pituitary

Want to recommend imaging to rule out tumor , can have neurological side effects

70
Q

What can cause defects of GnRH pulse production?

A

Anorexia nervosa (affects secretion of hormones)
Extreme weight loss (thyroid hormones)
Severe stress
Vigorous athletic exertion

LH , FSH not released, follicles do not develop no ovulation

71
Q

Congenital absence of pituitary causes what

A

Rare- lethal

72
Q

What is Sheehan’ syndrome?

A

Pituitary defect causing amenorrhea

Pituitary ischemic necrosis resulting from postpartum hemorrhage and severe hypotension

Not enough oxygen to pituitary almost like an ischemic stroke - permanent damage

73
Q

What are some ovarian causes of amenorrhea?

A

PCOS
Turner syndrome
Premature ovarian failure

74
Q

What is PCOS? Primary or secondary amenorrhea

A

Polycystic ovarian syndrome
Secondary amenorrhea
*This is not a problem with GnRH *
Cystic ovaries inhibit the follicles from doing what they’re supposed to (hormone imbalance)

75
Q

Signs and symptoms of PCOS

A

Insulin resistance (BGL high= eat more) and obesity
Anovulation
Hirsuitism (facial hair)
Androgen excess ( deepened voice)
Infertility
Clitoromegaly

76
Q

What is turner syndrome? Signs and symptoms?

A

Also called Gonadal dysgenesis

Abnormal X chromosome 45x (one X is missing or partially missing )
Webbed neck, increased carrying angle, streak (nonfunctional) ovaries, infertility, short stature, shield chest

Ovaries aren’t developed or are under developed so they don’t function
Some cases may have a little ovarian function with hormones

77
Q

What is premature ovarian failure?

A

Depletion of over before age of 40 (stop making estrogen or responding to GnRH)
Cause unknown
Signs and symptoms of menopause

78
Q

Uterine causes of amenorrhea

A

Congenital absence or malformation of the uterus
Unresponsive or a trophic endometrium

Ashermans Syndrome
Imperforate hymen

79
Q

What is Asherman syndrome?

A

Scarring adhesions of the uterine cavity as a result of D&C or ablation
May be treated with lysis of adhesions if mild estrogen after surgery to regenerate denuded areas of endometrium
Scar tissue prevents endometrium from shedding
For women who want to have kids- hormone therapy

80
Q

Imperforate hymens can cause

A

False amenorrhea
More common in peds
maybe bleeding but has no outlet
This is why physical exam is important

81
Q

Lab tests for amenorrhea

A

TSH
Estrogen
FSH
LH
Testosterone
Thyroid studies
Pregnancy test
MRI or CT of hypothalamus or pituitary
Genetic evaluation
Evaluate anatomy of uterus or service with ultrasound or MRI

82
Q

What are girls with permanent hypogonadism (turner syndrome) treated with?

A

Estrogen replacement therapy
May help secondary characteristics to develop, but still infertile

83
Q

What can be used for treatment of pituitary tumors?

A

Bromocriptine which inhibits the high prolactin secretion, surgical excision, radiation therapy

84
Q

Galactorrhea

A

Hyperprolactinemia
Ask about discharge from nipple (milk)

85
Q

What can estrogen deficiency reveal on physical exam?

A

Smooth vaginal, dry endocervix

86
Q

What is the progesterone challenge?

A

Progesterone given and if there’s withdraw bleeding indicates presence of estrogen
if no bleeding, low estrogen levels or problem with outflow tract

87
Q

Who does primary dysmenorrhea affect most? When does it occur? Etiology?

A

Usually affects women in late teens to early 20s
Occurs during ovulatory cycles
Etiology- excess prostaglandin production
Prostaglandins cause forceful uterine muscle contraction

88
Q

Clinical features of primary dysmenorrhea

A

Cramping starting several hours after onset of bleeding, lasting hours or days
Lower abdomen pain- may radiate to thighs, lower back
Pane may be associated with altered bowel habits, nausea, vomiting, fatigue, dizziness, headache, but not dyspareunia
PE/pelvic exam usually normal

89
Q

Treatment for primary dysmenorrhea

A

NSAIDs- ibuprofen(Motrin), naproxen(Naprosyn) to decrease prostaglandin production
Oral contraceptives, reduce menstrual flow and inhibit ovulation
Topical heat
Diet low in fat and meat decrease intensity of dysmenorrhea
DepoProvera and Mirena IUD (may) benefit
If no response considered secondary dysmenorrhea with further work up (ultrasound, laparoscopy) to exclude pelvic pathology

90
Q

What is secondary dysmenorrhea? When does it develop and what is a usually associated with?

A

Painful menstruation due to some underlying cause, prostaglandins may be involved
Develops in women in 30s and 40s
May occur before during or after menses
Usually associated with dyspareunia, infertility, or abnormal bleeding
Little or no response to NSAIDs or oral contraceptives

91
Q

Clinical findings in secondary dysmenorrhea

A

Pelvic pathology may be noted during pelvic exam
Adnexal tenderness
Pelvic masses or nodules

92
Q

What are some causes of secondary dysmenorrhea?

A

Endometriosis
Adenomyosis

93
Q

What are some clinical features of endometriosis causing secondary dysmenorrhea

A

Pane may be premenstrual postmenstrual or continuous WITH dyspareunia
Pre-menstrual spotting , on ultrasound you can see tender pelvic nodules
Onset in 20s or 30s but may start in teens

94
Q

Clinical features of secondary dysmenorrhea in fibroids and adenomyosis

A

Dysmenorrhea with dull pelvic dragging sensation
Uterus enlarged and may be tender

95
Q

Evaluation of secondary dysmenorrhea

A

Cervical c/x to rule out STI
WBC to r/o infection
HCG to rule out pregnancy
Pelvic US to evaluate intrauterine or ectopic pregnancy, pelvic mass, ovarian cysts
Hysterosalpingogram to r/o endometrial polyps, fibroids
Laparoscopy to determine pathology

96
Q

What is a hysterosalpingogram?

A

Die is injected, looking at patency of fallopian tubes

97
Q

What is premenstrual syndrome (PMS)

A

Emotional and physical symptoms occurring in luteal phase of menstrual cycle, which interfere with some aspects of a patient’s life
More severe dysmenorrhea

98
Q

What is more significant than PMS

A

Premenstrual Dysphoric Disorder (PMDD) symptoms are severe, and significantly disrupt daily functioning and relationships

99
Q

PMS causes

A

Exact is not known
Abnormal serotonin response from normal hormonal fluctuations
Altered levels of estrogen, progesterone, endorphins, catecholamines
Vitamin and mineral deficiencies

100
Q

Physical symptoms of PMS

A

Abdominal pain
Breast tenderness and swelling
Bloating
Weight gain
Edema
headache

101
Q

Diagnosing PMS

A

No specific lab test
Symptom diary over 2 to 3 menstrual periods to evaluate timing and symptoms

102
Q

Nonpharmacologic treatment of PMS

A

Reassurance
Adequate rest
Aerobic exercise
Diet, high in fruits and vegetables
**Low sodium sugar, caffeine chocolate, alcohol and fat

103
Q

Over the counter therapies for PMS

A

Midol, premsyn contain mild diuretics, analgesics, prostaglandin inhibitors, anti-histamines

104
Q

Pharmacologic treatment of PMS

A

Vitamin and mineral supplementation for electrolyte imbalance
Mild diuretics (Spironolactone)
SSRI antidepressants (fluoxetine- Prozac) in luteal phase
GnRH agonists (Lupron) Physical behavioral symptoms
NSAIDs for dysmenorrhea , breast pain, edema
Anti-anxiety meds - BuSpar(buspirone)
**Oral contraceptives may worsen symptoms of PMS/PMDD **

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