Endometriosis and Pelvic Pain

Question 1

chronic pain is not ______ _____ over a prolonged time; it has its own ________ ________ and feedback pathway

Answer 1

acute pain; independent mechanism

Question 2

chronic pain pathway: what happens in periphery, DRG neurons, dorsal horn neurons

Answer 2

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

Question 3

first question to ask if pt has pelvic pain?

Answer 3

does she have any pelvic organs?

Question 4

if a patient has pelvic pain and HAS pelvic organs, whats the next question to consider?

Answer 4

is she premenopausal or postmenopausal?

Question 5

if a premenopause pt has pelvic pain AND pelvic organs, what sources are you most likely looking at for her pelvic pain?

Answer 5

GYN causes + non GYN causes

Question 6

if a postmenopause pt has pelvic organs AND has pelvic pain, what sources are you most likely looking at for her pain?

Answer 6

non gyn causes: GI, Uro, MS, neuropathic, mass/tumor, adhesions, psych

Question 7

if a pt has pelvic pain but NO pelvic organs, what sources are you looking at for her pelvic pain?

Answer 7

on gyn causes: GI, Uro, MS, neuropathic, mass/tumor, adhesions, psych

Question 8

general things to ask in hx of a patient with pelvic pain (8)

Answer 8

chronology, pattern, aggravating/relieving activities , previous evaluations/treatements, bowel function, bladder function, dyspareunia, pt thoughts

Question 9

most important factor when evaluating a pt for pelvic pain?

Answer 9

history

Question 10

if a cyst is less than __ cm, it is unlikely to be a source of persistent pain

Answer 10

under 4 cm

Question 11

______ ovaries will not torse; most _____ will not torse

Answer 11

PCOS; cysts

Question 12

__________ is the best imaging modality for adnexa

Answer 12

transvaginal pelvic US

Question 13

__-__% of ALL women will have at least one fibroid

Answer 13

70-80%

Question 14

fibroids are mostly __________; ______ and _____ are key

Answer 14

asymptomatic; location and size

Question 15

bulk symptoms are uncommon with a uterus

Answer 15

10; subserosal or pedunculated

Question 16

__% of all reproductive age females get endometriosis

Answer 16

10%

Question 17

what is endometriosis? what three places is it most common?

Answer 17

persistent endometrial tissue anywhere outside the endometrial lining; most common in ovary, peritoneal wall and uterine serosa (bowel, bladder, diaphragm, previous incisions)

Question 18

how does endometriosis cause pain? what does it lead to?

Answer 18

endometrial glands cause cyclic changes of estrogen and proliferate/shed similar to endometrium; leads to internal bleeding, scar tissue formations, inflammation and chronic pain

Question 19

whats the only way to confirm diagnosis of endometriosis?

Answer 19

surgical excision of tissue (but we often tx without this)

Question 20

amount of endometriosis seen is OR is not directly correlated with pain symptoms?

Answer 20

IS NOT

Question 21

is recurrence common with endometriosis?

Answer 21

yes

Question 22

most women with dysmenorrhea do OR do not have endometriosis?

Answer 22

DO NOT; 90% of pop has dysmenorrhea but only 5-10% of population has endometriosis

Question 23

how do you tx assumed endometriosis (no laparoscopy)?

Answer 23

1) . hormonal therapies
2) . tx other contributors
3) . consider L/S excision

Question 24

what are some hormonal therapies used to tx assumed endometriosis pts? (5)

Answer 24

OCPs, progesterone only therapies, GnRH agonist (leuprolide), Danazol, Aromatase inhibitors

Question 25

what should be done on an endometriosis pt before deciding on intensive medical therapy/surgery?

Answer 25

diagnostic laparoscopy

Question 26

surgical treatment of endometriosis can help with _______ and _____ _______

Answer 26

fertility and pain relief

Question 27

_________ is associated with improved pain and decreased re-operation rates in endometriosis pt compared to conservation surgical tx

Answer 27

hysterectomy

Question 28

Surgical: how to defnitively tx a fibroid? how about conservative tx?

Answer 28

hysterectomy; myomectomy

Question 29

Uterine artery embolization for fibroid tx: best for _____, ____ myomas, no future _______, usually _______ relief

Answer 29

large, few; fertility; temporary relief (20-25% of pts require more surgery within 1-2 yrs)

Question 30

how to tx chronic endometritis?

Answer 30

confirm with cultures

doxycycline 100 mg BID for 14 days

Question 31

most effective tx for post-tubal/post ablation syndrome?

Answer 31

hysterectomy (also, stop menses, salpingectomy, uterine evacuation)

Question 32

gold standard to tx pelvic floor problems

Answer 32

pelvic floor PT (muscle relaxers rarely work)

Question 33

general guidelines to tx adhesion pain

Answer 33

tx all other pain first, avoid surgery if possible

Question 34

if pain did not progress from cyclic to constant, endometriosis treatment is ____ ________ and unlikely to be found in ______

Answer 34

less successful; surgery

Question 35

not all endometriosis is _________; medical therapy will not resolve ____________

Answer 35

symptomatic; endometriomas

Question 36

excision of endometriosis is _________ to ablation

Answer 36

superior

Question 37

cysts: ________ pain for about ___ days that resolves

Answer 37

mid cycle; 2 days

Question 38

most cysts are ____________ and removed due to ____/__________

Answer 38

asymptomatic; size and complexity

Question 39

________ ____ muscles are located at clock positions 4 & 8; same positions but with external rotation is _________ muscle

Answer 39

levator ani; piriformis

Question 40

_______ _______ muscles are at clock positions 10 and 2

Answer 40

obturator internus

Question 41

for abdomen exam of pelvic pain, what is the carnett test?

Answer 41

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)