Disorders of Pelvis and Ovaries

Question 1

Chronic Pelvic Pain

• dx criteria
• causes
• risk factors

Answer 1

Dx criteria:

• pain of at least 6mo duration that occurs below the umbilicus
• significantly impacts a womans daily functioning and relationships
• episodic-cyclic or continuous non-cyclic

Causes:

• episodic:
• -dyspareunia
• -midcycle pelvic pain (mittelschmerz)
• -dysmenorrhea
• continuous:
• -endometriosis* (MC)
• -adenomyosis
• -chronic salpingitis (PID)
• -adhesions
• -loss of pelvic support

Risk factors:

• hx sexual abuse/trauma
• previous pelvic surgery
• hx of PID
• endometriosis
• Hx depression, chronic pain, alcohol or drug abuse, sexual dysfunction

Question 2

Chronic Pelvic Pain:

• PE
• dx tests
• tx

Answer 2

PE

• PE of abd, pelvic, and rectal areas focusing on the location and intensity of pain.
• attempt to reproduce the pain
• palpate scars for hernias
• speculum exam
• bimanual/rectal exam

Dx tests:

• selected as indicated by the findings of the H&P
• serum HCG
• UA
• wet prep KOH
• cervical cultures/GC and chlamydia
• CBC w/ diff
• ESR
• stool guiac
• US
• laparoscopy

Tx:

• treat the underlying cause
• psychosocial interventions
• meds: NSAIDS, antidepressants, oral contraceptives
• surgical interventions

Question 3

Pelvic Inflammatory Dz:

• what is this?
• risk factors
• MC pathogens
• describe spread

Answer 3

What: ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.
*encompasses spectrum of inflamm disordes such as endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

Risk factors:

• young age at onset of sexual activity
• new, multiple, or symptomatic partners
• unprotected sex
• hx of PID
• gonorrhea or chlamydia
• current vaginal douching
• insertion of IUD
• bacterial vaginosis
• sex during menses

MC pathogens:

• N. Gonorrhoeae
• C. Trachomatis

Spread:
-cervicitis—) endometritis, salpingitis/oophoritis/tubo-ovarian abscess,—) peritonitits

Question 4

Pelvic Inflamm Dz

• complications
• dx

Answer 4

Complications:

• ectopic pregnancy
• infertility
• tubo-ovarian abscess
• chronic pelvic pain
• fitz-hugh-curtis syndrome (perihepatitis)

Dx: 
Minimum criteria:
-uterine/adnexal tenderness 
-cervical motion tenderness 
Other criteria: 
-temp greater than 38.3C (101F) 
-abnormal cervical or vaginal mucopurulent discharge 
-presence of WBC on saline wet prep 
-elevated ESR &/or CRP 
- positive Gonorrhea or chlamydia test

More specific dx criteria:

• transvaginal US
• pelvic CT or MRI
• laparoscopy
• endometrial bx

Question 5

PID:

-tx

Answer 5

• need to treat sexual partners if GC/chlamydia +
• Rocephin 250mg IM x1 and azithromycin 1g PO once weekly x2wks
• -or Rocephin and Doxy
• -with or without flagyl

*Hospitilization with severe illness:
-pregnancy
-non-response to oral therapy
-HIV Infection with low CD4
-look septic
May use IV rocephin, clindamycin, or gentamicin

Question 6

PID

-prevention

Answer 6

Prevention:

• screen andd tx chlamydia (annual screening for sexually active women 25 and under)
• male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60days preceding the pts onset of sx

Question 7

Polycystic Ovarian Syndrome:

• MC cause of what?
• sx
• dx

Answer 7

MC cause of androgen excess and hirsutism in women

Sx:

• oligomenorrhea (light/infrequent) or amenorrhea, anovulation, obesity, acne, hirsutism, and infertility
• high association with insulin resistance

Dx:

• no definitive test b/c no exact cause has been established
• Rotterdam Criteria: need 2 of the following 3:
• -oligomenorrhea or anovulation
• clinical/biochemical signs of hyperandrogenism
• polycystic ovaries on US
• labs: testosterone, androstenedione, DHEAS, prolactin, TSH, HCG, fasting blood glucose, fasting insuline, LH/FSH

Question 8

PCOS:

• cause
• PE finding
• tx

Answer 8

cause; unknown, likely affects multiple systems:
-defect in hypothalmic-pituitary axis causing release of excessive LH leading to increased androgens thereby inhibiting ovulation.

• defect in ovaries leading to androgen overproduction
• defect in insulin sensitivity leading to hyperinsulinemia thereby stimulating androgen production
• genetic factors

PE findings:

• acanthosis nigricans (d/t increased insulin levels)
• fasting blood sugar to fasting insulin ratio should be greater than 4.5x in normal patient….anything below that is considered insulin resistant

Tx:

• as little as 10% weight reduction can be effective in restoring regular ovulation and menses
• diet and exercise
• oral contraceptive pills (suppress LH and therefore suppress androgens)
• spironolactone: acts as an anti-androgen (helps with hirsutism)
• metformin
• clomiphene(for those who are trying to become pregnant and are still anovulatory after diet, exercise, and meftformin)

Question 9

Ovarian cysts:

• what is this?
• sx

Answer 9

what: NOT neoplasm, fluid filled sac that develop in or on the ovary.

Sx: some women have pelvic pain and pressure while others may not.

Question 10

Follicular Cyst:

• cause
• sx
• PE findings
• tx

Answer 10

Cause:
-ovarian follicle fails to rupture during maturation and a cyst may develop.

Sx: may be asymptomatic

PE findings:
-mobile, cystic, adnexal mass

Tx:

• usually resolves spontaneously
• OCP may be given to supress gonadotropin stimulation of the cyst
• laparoscopy

Question 11

Corpus Luteum Cyst:

• cause
• sx
• PE
• tx

Answer 11

Cause:
-enlarged corpus luteum which often continues to produce progesterone for longer than 12 days.

Sx:
-dull Lower quadrant pain along with missed menstrual period.

PE: mobile, cystic, adnexal mass
-may rupture causing blood and pain

Tx:

• may resolve on its own
• cyclic OCP therapy

Question 12

Ovarian Tumors:

• what are the benign neoplasms
• -tx
• malignant neoplasms
• sx
• MC age
• MC type?

Answer 12

Benign:

• benign epithelial cell tumors
• benign germ cell tumors
• benign stromal cell tumors

Tx:
-surgery

Malignant;
-Sx: rarely symptomatic in early stages of dz

MC in the 5th and 6th decade of life

MC type are of epithelial cell type.

Question 13

Ovarian CA:

• risk factors
• screening

Answer 13

Risk factors:

• aging (45-60YO)
• postmenopause
• periods of prolonged ovulation without pregnancy
• 1st degree with ovarian, colon, or breast CA
• BRCA 1 and 2 gene mutation

Screening:

• no effective method of mass screening
• ACOG recommends annual bimanual exam

Question 14

Ovarian Torsion:

• what is this?
• cause
• which ovary is MC affected?
• sx
• dx
• tx

Answer 14

What: complete or partial rotation of the ovary on its ligamentous supports; often resulting in impedance of its blood supply.
*adnexal torsion = when fallopian tube twists along with the ovary

Cause:
-2ndry to ovarian mass

MC ovary is the right.

Sx:

• acute, severe, unilateral lower abd and pelvic pain
• nausea and vomiting

Dx: color flow doppler US

Tx:
-w/ early dx pt managed with conservative surgery, if necrosis = unilateral salpingooopherectomy is tx of choice.