Endometriosis and Pelvic Pain Flashcards
chronic pain is not ______ _____ over a prolonged time; it has its own ________ ________ and feedback pathway
acute pain; independent mechanism
chronic pain pathway: what happens in periphery, DRG neurons, dorsal horn neurons
periphery- inflammation or nerve injury, then DRG neurons inc inflammatory mediators, inc/dec miRNAs, inc/dec pain related genes, inc excitability, then dorsal horn neurons have central sensitization, and you then get chronic pain
first question to ask if pt has pelvic pain?
does she have any pelvic organs?
if a patient has pelvic pain and HAS pelvic organs, whats the next question to consider?
is she premenopausal or postmenopausal?
if a premenopause pt has pelvic pain AND pelvic organs, what sources are you most likely looking at for her pelvic pain?
GYN causes + non GYN causes
if a postmenopause pt has pelvic organs AND has pelvic pain, what sources are you most likely looking at for her pain?
non gyn causes: GI, Uro, MS, neuropathic, mass/tumor, adhesions, psych
if a pt has pelvic pain but NO pelvic organs, what sources are you looking at for her pelvic pain?
on gyn causes: GI, Uro, MS, neuropathic, mass/tumor, adhesions, psych
general things to ask in hx of a patient with pelvic pain (8)
chronology, pattern, aggravating/relieving activities , previous evaluations/treatements, bowel function, bladder function, dyspareunia, pt thoughts
most important factor when evaluating a pt for pelvic pain?
history
if a cyst is less than __ cm, it is unlikely to be a source of persistent pain
under 4 cm
______ ovaries will not torse; most _____ will not torse
PCOS; cysts
__________ is the best imaging modality for adnexa
transvaginal pelvic US
__-__% of ALL women will have at least one fibroid
70-80%
fibroids are mostly __________; ______ and _____ are key
asymptomatic; location and size
bulk symptoms are uncommon with a uterus
10; subserosal or pedunculated
__% of all reproductive age females get endometriosis
10%
what is endometriosis? what three places is it most common?
persistent endometrial tissue anywhere outside the endometrial lining; most common in ovary, peritoneal wall and uterine serosa (bowel, bladder, diaphragm, previous incisions)
how does endometriosis cause pain? what does it lead to?
endometrial glands cause cyclic changes of estrogen and proliferate/shed similar to endometrium; leads to internal bleeding, scar tissue formations, inflammation and chronic pain
whats the only way to confirm diagnosis of endometriosis?
surgical excision of tissue (but we often tx without this)
amount of endometriosis seen is OR is not directly correlated with pain symptoms?
IS NOT
is recurrence common with endometriosis?
yes
most women with dysmenorrhea do OR do not have endometriosis?
DO NOT; 90% of pop has dysmenorrhea but only 5-10% of population has endometriosis
how do you tx assumed endometriosis (no laparoscopy)?
1) . hormonal therapies
2) . tx other contributors
3) . consider L/S excision
what are some hormonal therapies used to tx assumed endometriosis pts? (5)
OCPs, progesterone only therapies, GnRH agonist (leuprolide), Danazol, Aromatase inhibitors
what should be done on an endometriosis pt before deciding on intensive medical therapy/surgery?
diagnostic laparoscopy
surgical treatment of endometriosis can help with _______ and _____ _______
fertility and pain relief
_________ is associated with improved pain and decreased re-operation rates in endometriosis pt compared to conservation surgical tx
hysterectomy
Surgical: how to defnitively tx a fibroid? how about conservative tx?
hysterectomy; myomectomy
Uterine artery embolization for fibroid tx: best for _____, ____ myomas, no future _______, usually _______ relief
large, few; fertility; temporary relief (20-25% of pts require more surgery within 1-2 yrs)
how to tx chronic endometritis?
confirm with cultures
doxycycline 100 mg BID for 14 days
most effective tx for post-tubal/post ablation syndrome?
hysterectomy (also, stop menses, salpingectomy, uterine evacuation)
gold standard to tx pelvic floor problems
pelvic floor PT (muscle relaxers rarely work)
general guidelines to tx adhesion pain
tx all other pain first, avoid surgery if possible
if pain did not progress from cyclic to constant, endometriosis treatment is ____ ________ and unlikely to be found in ______
less successful; surgery
not all endometriosis is _________; medical therapy will not resolve ____________
symptomatic; endometriomas
excision of endometriosis is _________ to ablation
superior
cysts: ________ pain for about ___ days that resolves
mid cycle; 2 days
most cysts are ____________ and removed due to ____/__________
asymptomatic; size and complexity
________ ____ muscles are located at clock positions 4 & 8; same positions but with external rotation is _________ muscle
levator ani; piriformis
_______ _______ muscles are at clock positions 10 and 2
obturator internus
for abdomen exam of pelvic pain, what is the carnett test?
carnett test is you touch an area of abdominal pain while the patient does a crunch; tells you if pain is musculoskeletal or intrabdominal pain (visceral)
