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OB/GYN > Menstruation and Uterine Disorders > Flashcards

Menstruation and Uterine Disorders Flashcards

1
Q

What is primary amenhorrhea?

A

no hx of any menses:

  • by age 15 in presence of normal growth and secondary sexual characteristics
  • at age 13 in absence of secondary sexual characteristics
  • at age 12-13 evaluate cyclic menstural pain (imperforate hymen?)
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2
Q

Etiology of primary amenorrhea?

A
  • x’somal abnormality (gonadal dysgenesis, Turner’s syndrome) 50%
  • hypothalamic hypogonadism 20%
  • mullerian agenesis (absence of uterus, cervix and vagina 15%)
  • transverse vaginal septum or imperforate hymen 15%
  • other: CAH, PCOS, androgen insensitivity
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3
Q

Dx eval of primary amenorrhea - H and P?

A
  • hx:
    cyclic pelvic pain, other stages of puberty, HAs, virilization, galactorrhea, meds, stressors, wt change or illness
    FH of delayed puberty
  • exam:
    tanner staging (breast development is marker for estrogen = ovary), pelvic exam to confirm patent hymen and presence of vagina, signs of turners (low hairline, web neck, widely spaced nipples with shield chest)
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4
Q

Labs for primary amenorrhea?

A
  • initial: FSH (if elevated - ovarian failure)
  • further lab based upon FSH and presence or absence of breast development and uterus: could include karyotype, testosterone, TSH, prolactin, and pregnancy test
  • initial imaging: US to confirm uterus
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5
Q

Causes of secondary amenorrhea?

A
  • rule out pregnancy!
  • ovarian (40%): PCOS 20%, PCO (less than 40 yo)
  • hypothalamic:
    fxnl (decreasd GnRH): wt loss, exercise
    nutritional deficiences: low body fat, celiac
    emotional stress or illness
    infiltrative tumors: rare
  • pituitary:
    hyperprolactioma
    other causes of elev prolactin
    injury to pituitary (sheehan’s syndrome, radiation, hemochromatosis)
    hypothyroidism
  • uterine: asherman’s syndrome: acquired scarring of cavity, TB
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6
Q

Hx ?s to ask pt with secondary amenorrhea?

A
  • menstrual hx
  • exercise and eating patterns
  • meds that may increase prolactin
  • stress
  • post partum hemorrhage
  • radiation to head
  • HAs
  • hot flashes
  • uterine surgeries
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7
Q

Exam for secondary amenorrhea?

A
  • BMI
  • hirsutism (PCOS)
  • galactorrhea
  • uterine size
  • initial labs: pregnancy test, FSH, TSH, prolactin, possible testosterone and DHEA-S
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8
Q

Causes of primary dysmenorrhea (painful periods)?

Secondary?

A
  • primary: no obvious cause, typically begins in adolescence as crampy, midline lower abdominal pain assoc with onset of menses
  • secondary: sxs attributed to specific problem like endometriosis, adenomyosis or fibroids or PID
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9
Q

RFs for primary dysmenorrhea?

A
  • younger than 30
  • BMI less than 20
  • smoking
  • menarche b/f 12
  • irregular/prolonged/heavy menses
  • hx of sexual assault
  • family hx
  • younger age of first child and higher parity lower risk
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10
Q

Pathogenesis of primary dysmenorrhea?

A
  • prostaglandins released with endometrial sloughing induce contractions
  • uterine ischemia result in anaerobic metabolites which stimulates type C pain neurons
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11
Q

Presentation of primary dysmenorrhea?

A
  • pain begins after ovulatory cycle established
  • may start 1-2 days b/f menses, gradually diminishes over 12-72 hrs
  • unilateral pain or non-cyclic pain suggests other dx
  • nausea, diarrhea, HA may be present
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12
Q

Dx of primary dysmenorrhea?

A
  • no PE findings
  • no lab abnormalities
  • no imaging study findings
  • dx by hx and normal exam
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13
Q

What sxs wouldn’t line up with primary dysmenorrhea?

A
  • need to focus on exclusion of secondary dysmenorrhea:
    onset of sxs after 25
    nonmidline pain
    dyspareunia
    progression of sxs
    abnorm. uterine bleeding suggest secondary causes
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14
Q

1st tx of primary dysmenorrhea?

A
  • self-care, heating pad, exercise, relaxation techniques
  • NSAIDs (not if allergic to ASA)
  • suppression of menses with contraceptive hormones
  • limited data and small studies report reduced cramps with diet and supplements: low fat vegetarian diet; 3-4 dairy servings/day, vit E 2 days b/f through 1st 3 days of menses, 1-2 g fish oil/day, vit B1 100 mg/day, vit B6 mg/day
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15
Q

Causes of secondary dysmenorrhea?

A
  • endometriosis
  • fibroids
  • intrauterine/pelvic adhesions
  • obstructive endometrial polyps
  • obstructive mullerian anomalies
  • cervical stenosis
  • pelvic congestion syndrome
  • Adenomyosis
  • ovarian cysts
  • IUD
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16
Q

PALM-COEIN is used for?

A
  • abnormal uterine bleeding (AUB) this replaced dysfunctional uterine bleeding
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17
Q

Basic labs for AUB?

A
  • CBC (anemia, platelets)
  • prolactin
  • TSH
  • pregnancy test
  • chlamydia testing when indicated (inflamed cervix, post-coital bleeding)
  • other lab and imaging studies as indicated by exam or hx
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18
Q

PALM-COEIN?

A 
P= polyp
A= adenomyosis
L= leiomyoma
M= malignancy
C= coagulation
O= ovulatory dysfxn
E= endometrial
I= iatrogenic
N= not yet classified
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19
Q

What is polymenorrhea?

Oligomenorrhea?

A
  • have cycles less than 24 days

- have cycles that are longer than 35 days

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20
Q

What is menorrhagia? Metrorrhagia?

A
  • menorrhagia: heavy menstrual bleeding

- metrorrhagia: bleeding b/t periods

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21
Q

What % of women presenting with heavy menstrual bleeding have underlying bleeding disorder? What is MC disorder?

A
  • 20%

- VonWillebrands is MC (will have early hx of menorrhagia)

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22
Q

When should you refer a pt with ABU on for heme eval?

A 
in addition to heavy menstrual periods plus -
have hx of one of the following:
-hx of postpartum hemorrhage
-hx of unexplained bleeding with surgery
-hx of bleeding with dental work

refer with 2 of following:

  • frequent gum bleeding
  • epistaxis or unexplained bruising 2x a month
  • family hx of bleeding
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23
Q

Ovulatory causes of AUB?

A

caused by chronic unopposed estrogen influence as a result of anovulation or oligo-ovulation:

  • hyperandrogenic (PCOS)
  • hypothalamic dysfxn (anorexia)
  • thyroid disease
  • elevated prolactin
  • meds
  • iatrogenic
  • premature ovarian insufficiency
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24
Q

What is PMS and PMDD?

A
  • PMS= premenstrual syndrome
  • PMDD= premenstrual dysphoric disorder
  • cyclic physical and/or behavioral sxs that recur in luteal phase and first few days of menses (present for at least 3 months)
  • severity of sxs are disruptive at home/social situations/at work
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25
Q

RFs for PMS and PMDD?

A
  • genetics: variation of estrogen receptor alpha gene
  • hx of traumatic events/anxiety disorder/ highly daily hassle scores
  • lower education
  • smoking
  • PMS 3-8% with regular cycles
  • PMDD 2% with regular cycles
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26
Q

PP of PMS and PMDD?

A
  • unknown
  • abnormal response to normal concentrations of estrogen and progesterone
  • cyclic changes in circulating estrogen and progesterone trigger an abnormal serotonin (NT) response?
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27
Q

When do Sxs of PMS and PMDD usually start? What must these interfere with?

A
  • usually starts in 20s

- must cause significant distress and interference with normal activities

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28
Q

Physical sxs of PMS and PMDD?

A
  • abdominal bloating
  • extreme fatigue
  • breast pain
  • HA
  • hot flashes
  • dizziness
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29
Q

Behavioral sxs of PMS and PMDD?

A
  • mood swings
  • irritability/anger
  • depression
    /hopelessness/self-critical
  • anxiety/tension/ feeling on edge
  • for dx of PMDD must have at least one of the above and total of 5 sxs, 4 of which can be from expanded DSM-5 criteria. These sxs should have been present for most of the preceding year in a cyclic pattern with menses
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30
Q

Eval of PMS and PMDD?

A
  • confirm regular menses and cyclic pattern of sxs
  • lab: no specific test, consider TSH and CBC
  • have pt complete a prospective sx inventory
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31
Q

Tx for mild PMS and PMDD?

A
  • exercise and relaxation techniques

- no strong data that vitamins or supplements exceed the placebo response

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32
Q

Tx for moderate-severe PMS and PMDD?

A
  • SSRIs: fluoxetine, sertraline, extended release paroxetine all have FDA approval
  • 60-70% response, try different SSRI
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33
Q

Tx for PMS and PMDD that is refractory to SSRI?

A
  • induce anovulation with: continuous/short pill free interval OC - evidence strongest for drospirenone, GnRH agonist
  • surgery with BSO (and hysterectomy)
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34
Q

What is endometriosis?

A
  • cells that behave like lining of the uterus grow in other areas of the body, causing pain, irregular bleeding and possbile infertility
  • common, poorly understood, and extemely debilitating benign gyn condition
  • psychological impact of the severe pain experienced by the patient is compounded by the possiblity of infertility (endometriosis has prevalence rate of 20-50% in infertile women and as high as 80% in women with chronic pelvic pain
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35
Q

Who does endometriosis affect?

A
  • menstruating women
  • postmenopausal endometriosis may be encountered in women who are on ERT: occasionally if ERT is admin after total abdominal hysterectomy endometriosis can be stimulated in an ovarian remnant
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36
Q

Etiology and PP of endometriosis?

A
  • not well understood
  • retrograde menstruation: endometrial cells loosened during menstruation may back up through the fallopian tubes into the pelvis, once there they implant and grow in the pelvic or abdominal cavities
  • Halban theory: vascular and lymphatic dissemination
  • meyer theory: metaplasia of multipotential cells
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37
Q

What occurs in endometriosis?

A
  • each month ovaries produce hormones that stimulate cells of endometrium to multiply and prepare for a fertilized egg. The lining swells and gets thicker
  • if these cells are outside of the uterus endometriosis results -
  • unlkike cells normally found in uterus that are shed during menstruation, the ones outside the uterus stay in place - the cells bleed a little bit but they heal and are stimulated again durig the next cycle
  • ongoing process leads to sxs of endometriosis and can cause adhesions on the tubes, ovaries, and surrounding structures in the pelvis
38
Q

RFs for endometriosis?

A
  • FHx: women have mother or sister with endometriosis are 6x more likely to develop endometriosis
  • starting menstruation at an early age
  • never having any kids ( no increased levels of progesterone that you would normally have during pregnancy)
  • frequent menstrual cycles
  • periods that last 7 or more days
  • imperforate hymen, which blocks the flow of menstrual blood
39
Q

Main sx of endometriosis?

A
  • pain
  • degree of visible endometriosis has no correlation with degree of pain or other sx impairment
  • pain doesn’t correlate with depth of tissue infiltration
  • midline disease is generally more painful than lateral
  • this pain usually starts as secondary menorrhea
40
Q

Pain sxs of endometriosis?

A
  • painful periods
  • pain in lower abdomen or pelvic cramps that can be felt for a wk or 2 b/f menstruation
  • pain in lower abdomen felt during menstruation (pain and cramps may be steady and dull or severe)
  • pain during or following sex (dyspareunia)
  • have acute exacerbations - believed to be caused by chemical peritonitis due to leakage of old blood from an endometriotic cyst
41
Q

Anatomic spread of endometriosis? Lesion characteristics?

A
  • ovary is MC site: spread to ovary is believed to be lymphatic, although superficial implants may be due to retrograde menstrual flow b/c ovaries are in dependent part of pelvis
  • lesions can vary in size from spots to large endometriomas: classic lesion is chocolate cyst of ovary that contains old blood that has undergone hemolysis
    intracystic pressure rises, the cyst perforates, spilling its contents w/in the peritoneal cavity causing the severe abdominal pain typically assoc with endometriosis exacerbations
  • inflammatory response causes adhesions that further increase morbidity of the disease
42
Q

Complications of endometriosis?

A
  • infertility
  • chronic or long term pelvic pain that interferes with social and work activities
  • large cysts in pelvis (endometriomas)
  • depression (secondary to chronic pain and infertility)
43
Q

Pelvic exam of pt with endometriosis?

A
  • tenderness upon exam is best detected at time of menses
  • nodularity of uterosacral ligaments and cul-de-sac may be found
  • uterus may be fixed in retroversion, owing to adhesions
  • occasionally a bluish nodule may be seen in vagina due to infiltration from posterior vaginal wall
44
Q

US and MRI findings of endometriosis?

A
  • US: transvaginal songography is useful method of ID classic chocolate cyst of ovary - typical appearance is that of a cyst containing low level homogenous internal echoes consistent with old blood
  • MRI: cost-effectiveness of this imaging for endometriosis has yet to be justified for use as a routine tool
45
Q

What is considered the primary dx modality for endometriosis? What will be seen?

A
  • Pelvic laparoscopy
  • classic lesions are blue-black or have powder burned appearance
  • can be read, white or nonpigmented, peritoneal defects and adhesions are also indicative
46
Q

Tx depends on what factors for endometriosis?

A
  • age
  • severity of sxs
  • severity of disease
  • desire to maintain the uterus
47
Q

Tx for endometriosis?

A
  • GnRH analogs: use for 6months to suppress ovulation - Lupron
  • CPs: used for 6mo to suppress ovulation -OCPs, vaginal ring, patch
  • medroxyprogesterone acetate: used for 6-9mo, may need oral estrogen for breakthrough bleedings - provera, depo-provera
  • danazol (pts don’t like this b/c SEs): used for 4-6 months, lowest dose necessary to suppress ovulation - SEs: wt gain, hirsutism, acne
  • aromatase inhibitors: block synthesis of estrogen, used if endometriosis is resistant to other cancers - Letrozole
48
Q

Epidemiology of endometrial cancer?

A
  • MC gyn cancer in US: 70% are stage 1 at dx with 5 yr survival of 90%
  • mean age at dx 63
49
Q

Type 1 endometrial cancer? Precursor?

A
  • Endometriod adenocarcinoma - MC 75%
  • low grade and usually confined to uterus at dx
  • precursor: endometrial intraepithelial neoplasia (atypical endometrial hyperplasia): 30-50% undx, coexisting cancer
50
Q

Type 2 endometrial cancer? Prognosis?

A
  • papillary serous/clear cell
  • poorer prognosis - high grade, likely to have spread beyond uterus at time of dx
  • more common in black women and smokers
51
Q

Risk factors for endometrial cancer?

A
  • *Unopposed estrogen- chronic anovulation: PCOS, obesity (conversion of androgens to estrone in fat cells)
  • nulliparity or low parity
  • exogenous use of estrogen w/o progesterone: risk increases with duration, RR as high as 20
    • type 2 Dm or HTN - independent of obesity
    • age: 85% are 50 and older (only 5% younger than 40)
  • *SERM: tamoxifen (prophylaxis or tx of breast cancer) - 50 and older have RR 4.01
  • smoking: Type 2
  • genetics
52
Q

Endometrial cancer - what genetic syndromes increase risk of endometrial cancer?

A
  • lynch syndrome (HNPCC): increased risk of colon, ovarian, and type 1 endometrial cancer (up to 61% risk by age 70), 10% dx with endometrial under age 50 have lynch syndrome
  • cowden syndrome: 13-19% lifetime risk
  • consider referral for genetic testing
53
Q

What is assoc with decreased risk of endometrial cancer?

A
  • use of combo OCPs, medroxyprogesterone acetate or levonorgestrel IUD
54
Q

Signs and sxs of endometrial cancer?

A
  • abnormal bleeding: 80% of cases - postmenopausal bleeding, irregular menses or intermenstrual bleeding
  • advanced disease: abndominal pain/bloating/early satiety/change in bowel or bladder habits
  • Recommended routine screening: none
55
Q

Hx and PE of endometrial cancer?

A
  • hx: review for RFs (obesity, smoking, unopposed estrogen, genetics)
  • exam: eval for any other site of bleeding, abdominal, pelvic and lymph node exam
56
Q

Dx of endometrial cancer - what tests is method of choice for histologic eval?

A
  • initial eval doesn’t reqr both bx and US unless pelvic exam warrants
  • further eval needed if bleeding persists after negative endometrial bx or acceptable sono
  • endometrial bx is method of choice for histologic evalf (office procedure)
  • vaginal probe US to measure endometrial thickness (there is no dx value in premenopausal women)
    but
    in postmenopausal women: enodmetrial stripe (EMS) of 4 or less no bx is needed
    if EMS is greater than 4 need bx
57
Q

Tx of endometrial cancer?

A
  • total abdominal hysterectomy and bilateral salpingo-oophorectomy with surgical staging:
    peritoneal washings for cytology, pelvic and para-aortic lymph node sampling (may eliminate need for adjuvant tx)
  • adjuvant chemo with advanced cancer
  • adjuvant vaginal brachytherapy if if high risk for recurrence
58
Q

Prognosis of endometrial cancer?

A
  • based on surgical staging - depth of myometrial invasion, tumor type and grade, tumor spread to include lymph nodes
59
Q

Detection and prevention of endometrial cancer?

A
  • early detection: eval abnormal menstrual bleeding and all postmenopausal uterine bleeding (need bx)
  • prevention: younger women with chronic anovulation are at risk for endometrial hyperplasia - OCPs or cyclic progestin therapy can reduce risk
60
Q

What is the MC pelvic tumor in women? These are dependent on?

A
  • Uterine fibroids: leiomyoma or myomas
  • by age 50: 70% white and 80% black women, most women have no sxs or need for surgery but fibroids are MC cause for hysterectomy**
  • benign, monoclonal smooth muscle tumors of myometrium
  • dependent on estrogen: rarely occur b/f menarche or after menopause - usually shrink after menopause, grow larger during pregnancy
61
Q

RFs for uterine fibroids?

A
  • race: more common in blakcs and present with sxs earlier
  • family hx
  • menarche b/f 10
  • nulliparity
  • sig. red meat or ham consumption
62
Q

Signs and sxs of uterine fibroids?

A
  • heavy/prolonged menstrual flows: postmenopausal bleeding and intermenstrual bleeding not expected, location of fibroid influences bleeding: submucosal
  • pelvic pain/pressure/prolapse: size and location, urethral obstruction with hydronephrosis, degeneration or torsion
  • infertility/miscarriage or preterm labor
63
Q

Pelvic exam findings of uterine fibroids?

A
  • uterus usually irregularly enlarged and somewhat asymmetric
  • may be tender
  • unlike adenomyosis, the fibroid uterus is firm
  • may be mistaken for adnexal mass if situated laterally
  • if mass moves with uterus - likely to be leiomyoma
64
Q

DDx of uterine fibroids?

A 
- enlarged uterus:
pregnancy
adenomyosis (soft, tender not as bumpy)
uterine neoplasm: uterine sarcoma is rare
- asymmetric uterus or pelvic mass: 
tubo-ovarian inflammatory mass
diverticular inflammatory mass (L side)
ovarian tumor
65
Q

Lab and imaging studies for eval of suspected uterine fibroids?

A
  • lab:
    eval for anemia
    UA if has urinary sxs
    pregnancy test if appropriate
  • imaging studies:
    usually complete pelvic sono (not just vaginal probe) - consider saline-enhanced sono or hysteroscopy if submucosal fibroid suspected
  • histologic confirmation usually not needed
66
Q

What is a hysteroscopy used for?

A
  • can be done in office
  • allows for excellent visualization of inside of uterus
  • it is possible to remove some polyps during the procedure, and to take a sample of the lining of the uterus
67
Q

Management of heavy bleeding from uterine fibroids?

A
  • trial of OCPs, progestin implants or levonorgestrel IUD (latter not with distortion of endometrial cavity)
  • tranexamic acid (Lysteda) an antifibrinolytic: use up to 5 days during menses, don’t combine with combined OCPs
  • endometrial ablation
  • uterine artery ablation (fibroids will become necrotic)
68
Q

Size reduction of uterine fibroids?

A
  • presurgical reduction in size
  • surgical risk high:
    GnRH agonist (leuprolide or Lupron) - creates temporary menopause - b/c of bone loss use limited for 3-6 months
  • selective progesterone receptor modulators (SPRMs) - ulipristal or mifepristone
  • aromatase inhibitors (blocks conversion of androgen to estrogen) - anastrozole
69
Q

Less invasive procedures of uterine fibroids?

A
  • uterine artery ablation

- endometrial ablation

70
Q

More invasive surgical options for uterine fibroids?

A
  • myomectomy: desire to preserve fertility, esp for solitary pedunculated myoma, or myoma protruding into uterine cavity, location of myoma appears to be interfering with fertilty or pregnancy loss
  • hysterectomy indications:
    rapid enlargement of the uterus may mean possible malignancy, heavy uterine bleeding or pain not responding to medical methods or minimally invasive procedures, completed childbearing and have significant sxs with desire for definitive tx, uterine growth after menopause
71
Q

Epidemiology and RFs of adenomyosis?

A
  • little is known
  • More common in parous women
  • often coexists with endometriosis (11%) or fibroids (50%)
72
Q

PP of adenomyosis?

A
  • presence of endometrial glands and stroma in the myometrium
  • induction of hypertrophy and hyperplasia of myometrium:
    generalized - uniform uterine enlargement
    focal or nodular: uterus may be normal size but asymmetric
73
Q

Signs and sxs of adenomyosis? When do they generally present?

A
  • generally present 35-50
  • severity of sxs proportional to depth and volume of myometrial involvement
  • secondary (acquired) dysmenorrhea (25%)
  • menorrhagia (60%)
  • uterine enlargement, generally symmetric and no larger than 12-14 wk uterus
  • uterine tenderness b/f and during menses
74
Q

Dx of adenomyosis?

A
  • definitive dx with hysterectomy
  • MRI
  • US (best test to eval ovaries)
75
Q

Tx of adenomyosis?

A
  • hormone manipulation: progestins, aromatase inhibitors, continuous oral contraception
  • uterine artery embolization (painful)
  • hysterectomy
  • no specific meds are given, rather sxs tx - NSAIDs are helpful
  • hysterectomy is indicated for:
    severe, sx adenomyosis
    severe dysmenorrhea
    menorrhagia
    enlarged uterus greater than 10 wks size
76
Q

Epidemiology, pathology and RFs of endometrial polyps?

A
  • frequency increases with age
  • localized hyperplastic overgrowth of endometrial glands and stroma around a vascular core - may contain smooth muscle
  • increased estrogen:
    Tamoxifen (SERM)
    obesity
    menopausal hormone tx
77
Q

Signs and sxs of endometrial polyps?

A
  • abnormal bleeding: 64-88% of women with polyps
  • incidental finding on imaging (US)
  • 12-14% of women with benign endometrial cells on pap smear
78
Q

Eval of endometrial polyps? How is this dx?

A
  • on exam, no specific findings unless prolapsed thru external os of cervix
  • transvaginal sono: consider saline infused sonogram
  • dx is by histology
79
Q

DDx of endometrial polyps?

A
  • fibroid (submucosal)

- endometrial hyperplasia or cancer (thickened endometrial stripe)

80
Q

Tx of endometrial polyps?

A 
- hysteroscopic removal:
of all sx polyps (bleeding)
- removal in premenopausal if:
-RFs for hyperplasia/endometrial cancer
- mult or greater than 1.5 cm diameter (unlikely to regress)
- infertility

removal in all postmenopausal women since higher risk for malignancy

81
Q

Why does uterine prolapse occur?

A
  • weakening of pelvic floor muscles and ligaments creating inadequate support for the uterus and/or vaginal tissues
82
Q

RFs for uterine prolapse?

A
  • multiple vaginal deliveries, particularly large infants, prolonged second stage or instrument delivery
  • family hx
  • postmenopausal (age)
  • obesity, chronic cough, frequent straining with BM
  • repetitive heavy lifting
83
Q

Eval of uterine prolapse?

A
  • pelvic exam
  • pelvic US only if uterine enlargement or adnexal mass warrants
  • urologic eval if indicated
84
Q

Sxs of uterine prolapse?

A
  • sensation of heaviness or pressure in the pelvis
  • tissue bulging at introitus/protruding from vagina is only sx specific to prolapse**
  • urinary difficulties such as urine leakage or urine retention
  • trouble having a BM
  • low back pain
  • sensation of sitting on small ball
  • sexual concerns: difficulty with penetration, awareness of decreased vaginal tone
  • sxs often less bothersome in morning and increase with prolonged standing or activity
85
Q

Sequela of uterine prolapse?

A
  • ulcers: friction of exposed tissue on underwear may lead to ulceration of tissue and spotting/bleeding, rarely infection
  • prolapse of other pelvic organs: cystocele - bulges into vagina and can lead to difficulty in urinating/urinary retention/increased risk of urinary tract infections
    rectocele - resulting from weakness of CT overlying rectum may lead to difficulty having BMs
86
Q

Questions to ask pt who has suspected uterine prolapse?

A
  • what sxs are you experiencing?
  • when did you first notice these sxs, are they increasing?
  • are you having any pain? if yes, how severe?
  • do you have urinary leakage, frequency, or sensation of not emptying your bladder well?
  • have you had a chronic or severe cough?
  • does your work or daily activities involve heavy lifting?
  • do you strain during BMs?
  • is there family hx of prolapse?
  • did you have children born vaginally? How large was your largest? Any difficulties?
  • do you plan on having children in your future?
  • do you have any other concerns?
87
Q

Eval of uterine prolapse?

A
  • look and feel for position of uterus in vagina: describe location in relation to hymen
  • ask pt to bear down/cough - observe for further drop of cervix or vaginal tissues as well as urinary incontinence.
    If tissues not bulging dramatically as pt describes have pt stand
  • eval for uterine enlargement or adnexal mass
  • perform rectovaginal exam to eval for rectocele
88
Q

Tx of uterine prolapse?

A
  • education and reassurance
  • lifestyle changes:
    achieve and maintain a healthy wt:
    to minimize the effects of being overweight on supportive pelvic structures
  • perform kegel exercises
  • avoid heavy lifting and straining
  • address factors contributing to valsalva - chronic cough, constipation
  • role of estrogen replacement not well established
89
Q

What are pessaries?

A
  • vaginal pessary generally made of silicone that is designed to hold the prolapsed tissue in place
  • should be offered to all sx women
  • fitting can be successful regardless of degree of prolapse
  • need to remove the device and clean with soap and water periodically
90
Q

Drawbacks to pessaries?

A
  • inability to get a good fit
  • woman’s comfort or ability to insert and remove may be limited
  • irritation/ulceration of vaginal tissues
  • odor/d/c develops if not regularly removed and cleansed
  • pessary may interfere with sexual intercourse
91
Q

Approach to surgery for uterine prolapse is influenced by what factors?

A
  • desire to maintain uterus
  • desire to maintain abilty to have intercourse
  • surgical risk
  • presence of urinary
  • degree of vaginal prolapse
  • hx of prior procedures
  • approach to address underlying problem of apical support
92
Q

Diff in hysterectomies?

A
  • partial - is just uterus excluding the cervix
  • total: all of the uterus including the cervix
  • radical: removal of everything (fallopian tubes, ovaries, vagina)

OB/GYN (17 decks)

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