Pelvic and Ovarian Disorders Flashcards
What is chronic pelvic pain?
5
- Pain of at least 6 months’ duration that occurs below the umbilicus
- Significantly impacts a woman’s daily functioning and relationships
- Episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
- Continuous non-cyclic pain
- Many times etiology not found or treatment of presumed etiology fails: pain becomes the illness
Six major sources need to be considered for pelvic pain?
6
- Gynecological
- Gastrointestinal
- Urological
- Psychological
- Musculoskeletal
- Neurological
Etiologies of Chronic Pelvic Pain
- episodic? 3
- Continuous? 5
- Episodic
- dyspareunia
- midcycle pelvic pain (Mittelschmerz)
- dysmenorrhea - Continuous
- Endometriosis (mostly cyclic pain)
- adenomyosis
- chronic salpingitis (PID)
- adhesions
- loss of pelvic support
- What is the most common gynecological cause of CPP?
2. What are other gynecological causes? 6
- Endometriosis
- PID: 30% of women w/ PID develop CPP
- Dysmenorrhea
- Adenomyosis
- Adhesions
- Ovarian cysts
- Ovarian cancer
Risk Factors for
Chronic Pelvic Pain
8
- History of sexual abuse or trauma
- Previous pelvic surgery
- History of PID
- Endometriosis
- Personal or family history of depression
- History of other chronic pain syndromes
- History of alcohol and drug abuse
- Sexual dysfunction
Chronic Pelvic Pain: History findings
9
- Pain duration > 6 months
- Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics
- Significantly impaired functioning at home or work
- Signs of depression such as early morning awakening, weight loss, and anorexia
- Pain out of proportion to pathology
- History of childhood abuse, rape or other sexual trauma
- History of substance abuse
- Current sexual dysfunction
- Previous consultation with one or more health care providers and dissatisfaction with their management of her condition
Chronic Pelvic Pain: Physical Exam
7
- Systematic PE of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain
- Attempt to reproduce the pain
- Note general appearance, demeanor, and gait… may suggest the severity of the pain and possible neuromuscular etiology.
- inspect & note any well healed scars
- palpate scars for incisional hernias
- Palpate for femoral and inguinal hernias
- Palpate for any unsuspected masses
Chronic Pelvic Pain: Physical Exam
-Abdominal symptoms of more acute process? 5
- rebound tenderness (peritoneal irritation)
- increased abdominal pain on palpation with tension of the rectus muscles
- straight leg raise
- Decrease…. pelvic origin
- increase …. abdominal wall or myofascial origin - Fever?…acute process
- Vomiting?…acute process.
Chronic Pelvic Pain: Physical Exam
1. Speculum exam: What would be the source of parametrial irritation?
- Bimanual/rectal exam: What may be findings for this? 5
- If you see these symptoms what should you think? 3
- Palpate the ________, both internally and externally
- Cervicitis
- tender pelvic or
- adnexal mass,
- abnormal bleeding,
- tender uterine fundus,
- cervical motion tenderness
- Think acute process such as
- PID,
- ectopic pregnancy, or
- ruptured ovarian cyst - coccyx
What would the following findingd on bimanual/rectal exam show:
- Non-mobility of uterus?
- Cul-de-sac nodularities?
- Identify any areas that reproduce what?
- Cerival motion tenderness also called?
- presence of pelvic adhesions
- endometriosis
- deep dyspareunia
- Chandelier sign
Diagnostic Tests for Chronic Pelvic Pain
8
- Should be selected discriminately as indicated by the findings of the H & P
- Avoid unnecessary and repetitive diagnostic testing
- Serum HCG
- UA
- Wet prep/KOH
- Cervical cultures/GC and chlamydia
- CBC with diff
- ESR
- Stool guaiac…if + do GI w/u
- Ultrasound to identify pelvic masses
CPP: Diagnostic laparascopy may identify?
8
- acute or chronic salpingitis
- ectopic pregnancy
- hydrosalpinx
- endometriosis
- ovarian tumors and cysts
- torsion
- appendicitis
- adhesions
Treatment of Chronic Pelvic Pain
3
May have a surgical interventions? 2
- Treat underlying cause
- Psychosocial interventions
- Medications
- diagnostic and therapeutic laparoscopy
- hysterectomy
Medications for CPP? 3
Avoid what? 1
- NSAIDs
- antidepressants
- oral contraceptives
- Avoid long-term narcotic use
CPP: Alternative interventions
8
- biofeedback
- stress management techniques
- self-hypnosis
- relaxation therapy
- transcutaneous nerve stimulation (TNS)
- trigger-point injections
- spinal anesthesia
- nerve blocks
Pelvic Inflammatory Disease
1. What is it?
- Comprises a spectrum of inflammatory disorders including any combination of what? 4
- Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.
Comprises a spectrum of inflammatory disorders including any combination of:
- endometritis,
- salpingitis,
- tubo-ovarian abscess, and
- pelvic peritonitis.
PID Risk Factors
9
- Young age at onset of sexual activity
- New, multiple, or symptomatic partners
- Unprotected sexual intercourse
- History of PID
- Gonorrhea or chlamydia, or a history of gonorrhea or chlamydia
- Current vaginal douching
- Insertion of IUD (within 1st 3 weeks)
- Bacterial vaginosis
- Sex during menses
PID Microbial Etiology
2
- Overgrowth of microorganisms that comprise the vaginal flora such as? 6
- N. gonorrhoeae: recovered from cervix in 30%-40% of women with PID
- C. trachomatis: recovered from cervix in 20%-40% of women with PID
- streptococci,
- staphylococci,
- Enterobacteriaceae,
- anerobes,
- gardenella vaginalis,
- strep. agalactiae.
PID: Pathway of Ascendant infection?
4
- Cervicitis
- Endometritis
- Salpingitis/ oophoritis/ tubo-ovarian abscess
- Peritonitis
Complications of PID
5
Approximately 10-20% of women with a single episode of PID will experience sequelae, including:
1. ectopic pregnancy
2. Infertility
3. Tubo-ovarian abscess
chronic pelvic pain
4. Fitz-hugh-curtis syndrome (perihepatitis)
5. Tubal infertility occurs in 50% of women after three episodes of PID
Minimum Criteria in the Diagnosis of PID
2
- Uterine/adnexal tenderness or
2. Cervical motion tenderness (positive Chandelier Sign)
Additional Criteria to Increase Specificity of Diagnosis
6
More Specific Criteria 4
- Temperature >38.3°C (101°F)
- Abnormal cervical or vaginal mucopurulent discharge
- Presence of WBCs on saline wet prep
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein (CRP)
- Gonorrhea or chlamydia test positive
- Transvaginal ultrasound
- Pelvic CT or MRI
- Laparoscopy
- Endometrial biopsy
General PID Considerations
1. Treatment should be instituted when?
- Need to treat sexual partners if what?
- Educate patient to avoid what?
- as early as possible to prevent long term sequelae
- +GC/Chlamydia
- sexual activity until she and partner complete treatment.
- Need close f/u to ensure cure.
PID Treatment
1. Regimens must provide coverage of what? 5
- Outpatient first line therapy?
(3 combinations) + (may add what?)
- N. gonorrhoeae,
- C. trachomatis,
- anaerobes,
- Gram-negative bacteria, and
- streptococci
- Ceftriaxone 250 mg IM in a single dose, AND azithromycin 1 g PO once weekly x 2 weeks
- Ceftriaxone 250 mg IM in a single dose AND doxycycline 100 mg orally 2 times a day for 14 days
- Cefoxitin 2 g IM in a single dose AND Probenecid 1 g orally in a single dose, AND Doxycycline 100 mg orally 2 times a day for 14 days
-WITH OR WITHOUT
Metronidazole 500 mg orally 2 times a day for 14 days
Follow-Up
1. Patients should demonstrate substantial improvement within __ hours.
- Patients who do not improve usually require what? 3
- Some experts recommend rescreening for what 4-6 weeks after completion of therapy in women with documented infection with these pathogens? 2
- 72
- hospitalization,
- additional diagnostic tests, and
- surgical intervention.
- C. trachomatis and
- N. gonorrhoeae
PID Criteria for Hospitalization
6
- Inability to exclude surgical emergencies
- Pregnancy
- Non-response to oral therapy
- Inability to tolerate an outpatient oral regimen
- Severe illness, looks septic, nausea and vomiting, high fever or tubo-ovarian abscess
- HIV infection with low CD4 count
Parenteral Regimens: PID
CDC-recommended parenteral regimen A? 3
CDC-recommended parenteral regimen B? 2
Continue either of these regimens for at least 24 hours after substantial clinical improvement, then what? 2
CDC-recommended parenteral regimen A
- Cefotetan 2 g IV every 12 hours, OR
- Cefoxitin 2 g IV every 6 hours
- PLUS doxycycline 100 mg orally or IV every 12 hours
CDC-recommended parenteral regimen B
- Clindamycin 900 mg IV every 8 hours
- PLUS gentamicin loading dose IV of IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be used.
Complete a total of 14 days therapy with
- Doxycycline (100 mg orally twice a day) with regimen A or with
- Doxycycline or Clindamycin (450 mg orally 4 times a day), if using regimen B
Screening
1. To reduce the incidence of PID, screen and treat for _______?
- chlamydia.
PID: Annual chlamydia screening is recommended for:
- Sexually active women = age?
- Sexually active women >___ that are high risk?
- Screen pregnant women in the ___ trimester.
- 25 and under
- 25
- 1st
Report cases of PID to the local STI program (RSH) in states where reporting is mandated.
Which STIs are reportable in all states?
2
Gonorrhea and chlamydia
Patient Counseling and Education
5
- Nature of the infection
- Transmission
- Assess patient’s behavior-change potential
- Discuss prevention strategies
- Develop individualized risk-reduction plans
What is the most common cause of androgen excess and hirsutism in women?
Polycystic Ovarian Syndrome (PCOS)
-Most common hormonal disorder among women of reproductive age
PCOS: Typical symptoms include?
7
Highly associated with what?
- oligomenorrhea or
- amenorrhea,
- anovulation,
- obesity,
- acne,
- hirsutism, and
- infertility.
Highly associated with insulin resistance (many patients have impaired glucose tolerance or frank DM2)
PCOS Dx?
3
Diagnosis: no single definitive test for PCOS because no exact cause of the condition has been established (remember, this is a syndrome)
Rotterdam Criteria (est. 2003): a diagnosis of PCOS can be made with
2 out of the following 3 features (***once related disorders have been excluded):
-Oligomenorrhea (light or infrequent flow)or anovulation
-Clinical and/or biochemical signs of hyperandrogenism (acne and hirsutism)
-Polycystic ovaries on US
PCOS possible PP and etiology? 4
- Defect in hypothalmic-pituitary axis causing the release of excessive LH by the anterior pituitary which cause increased androgen production in the ovary making local concentrations of androgens elevated thus inhibiting ovulation
- Defects of ovaries which cause androgen overproduction (testosterone, androstenedione, DHEAS, DHA, 17 hydroxyprogesterone and estrone)
- Defect in insulin sensitivity, leads to insulin resistance and compensatory hyperinsulinemia; Increased insulin levels, can stimulate androgen production by the stromal cells of the ovary.
- Genetic factors contribute
- Acanthosis Nigricans can be present in these patients because of the what?
- Fasting blood sugar to fasting insulin ratio should be greater than ___ in a normal patient… anything below that is considered insulin resistant
- 70% of women with PCOS have what?
- Results in what?
- Insulin stimulates storage of glucose in the liver and muscle cells as _______?
- Once the maximum amount of glycogen has been reached, insulin next converts excess glucose into ___?
- As little as ___% weight reduction can be effective in restoring regular ovulation and menses
- elevated insulin levels
- 4.5
- insulin resistance
- elevated blood glucose level
- glycogen
- fat
- 10
Ultrasound findings of PCOS
Multiple follicles around the periphery of the ovary (this is a finding not the cause-25% of normal women can have this finding, and not all PCOS patient’s will have cystic ovaries)
Ultrasound is not necessary to make the diagnosis
Lab tests for PCOS
10
- Testosterone
- Androstenedione
- DHEAS (dehydroepiandrosterone)
- 17 hydroxyprogesterone
- Prolactin
- TSH
- HCG
- Fasting Blood sugar
- Fasting Insulin level
- LH/FSH
Why treat PCOS?
4
- Decrease risk of endometrial hyperplasia and cancer,
- possibly decrease risk of breast CA,
- decrease all sequella that occur with DM
- Patient satisfaction
PCOS therapeutic options?
5
- ***Diet and Exercise!!:
- OCPs:
- Spironolactone:
- Metformin (Glucophage)
- Clomiphene (Clomid)
- How does Spironolactone work for PCOS?
2. Make sure to monitor what?
- acts as an antiandrogen (will help with hirsutism in conjunction with OCPs) (Well, it happens to bind with androgen receptors and block the effects of dihydrotestosterone as well)
- Pregnancy cat. D, monitor for hyperkalemia, may be tumorigenic.
How do OCPs work to help PCOS?
2
- these suppress LH and therefore suppress circulating androgens.
- Also regulates periods (but not so good if you want to have children, right?)
How does metformin help with PCOS?
this helps with insulin resistance as well as weight loss
- Clomid helps with which PCOS pts?
2. How does this work to help PCOS?
- for those trying to become pregnant and are still anovulatory after diet, exercise, and Metformin have been tried
- binds to estrogen receptors in the hypothalamus to create a state of hypoestrogenicity, thereby causing an enhanced Gonadotropin-releasing hormone (GnRH) release followed by an increased secretion of gonadotropins which induces ovulation.
Ovarian Disease
1. Often the key to evaluating ovarian disease is with what?
- The ovaries should NOT be palpable when? 2
- When can it be palpable?
- Ovaries are palpable less frequently in reproductive age women taking what?
- The older the woman, the more likely a tumor is what?
- excellent history and physical exam
- The ovaries should NOT be palpable in the premenarchal group, nor should they be palpable in the postmenopausal group
- Ovary is palpable about half the time in the reproductive age group
- OCPs
- malignant versus benign
- How does an ovarian cyst arise?
- What are they?
- Ovarian cysts occur commonly in women of what ages?
- How does it present? 2
- An Ovarian cyst is NOT a neoplasm, but arises as a result of normal ovarian physiology.
- Ovarian cysts are fluid-filled sacs that develop in or on the ovary.
- all ages
- Some women with ovarian cysts have pain or pelvic pressure, while others have no symptoms
- What is a follicular cyst?
- How may it present?
- WHen do they become clinically significant?
- What are the characteristics you may find on a clinical exam? 3
- Prognosis?
- Management? 3
- Rupture may produce what?
- If an ovarian follicle fails to rupture during maturation, ovulation does NOT occur, and a follicular cyst may develop.
- May be symptomatic or asymptomatic
- Clinically significant if large enough to cause pain or if it persists beyond one menstrual interval
- Characteristics on physical exam:
- mobile,
- cystic,
- adnexal mass - Usually spontaneously resolves
- Management:
- Reevaluation in six to eight weeks to ensure the cyst has resolved.
- May order transvaginal US as needed on a case by case basis
- OCP may be given to suppress gonadotroin stimulation of the cyst - Note: rupture of a follicular cyst may produce transient acute pelvic pain
- What is a Corpus Luteum Cyst?
- Presentation? 3
- Rupture may cause what?
- What do you think this is confused with most of the time?
- What simple test can help to rule out the more dangerous pathology?
- Enlarged corpus luteum, which often continues to produce progesterone for longer than the standard 12 days.
- Often the presentation is of
- dull lower quadrant pain
- along with a missed menstrual period
- Physical exam findings usually the same as that of a follicular cyst - Cyst may rupture and hemorrhage with blood causing paiin
- Pregnancy
- US
Corpus Luteum Cyst
Management
3
- May reevaluate this patient as well to make sure cyst has resolved.
- Patients may benefit from cyclic OCP therapy.
- May use transvaginal US on a case by case basis
Ovarian Cysts
Always make sure to F/U if what?
Always make sure to follow up if palpating a mass
Some cysts can be persistent for some time and may benefit from laparoscopy
Ovarian Tumors Benign Neoplasms: 1. Tumors coming from where? 4 2. 80% occur in what ages? 3. Often produce tumors markers such as? 2
- -Benign Epithelial Cell Tumors
-Benign Germ Cell Tumors
(-Ever heard of a benign cystic teratoma …also called a dermoid cyst)
-Benign Stromal Cell Tumors - 80% of these occur during reproductive years
- Often produce tumor markers such as HCG or AFP
Benign Neoplasms: The following information is important to understand with regards to Benign Ovarian Neoplasms?
4
- More common than malignant tumors of the ovary in all age groups
- Chance for malignancy transformation increases with age
- Warrant surgical treatment because of their potential for transformation to malignancy
- Surgical treatment may be conservative for benign tumors, especially if future pregnancy is desired
Ovarian tumors-
Malignant Neoplasms:
1. What dramatically increases the risk that an ovarian enlargement is malignant?
- How critical is it for an aging woman to have a yearly well-woman exam even if they don’t necessarily have to have a pap smear?
- increasing age
2. Should still have physical and bimanual exam annually. Educate your patients about this.
Ovarian Cancer: Malignant Neoplasms:
- Describe the early stages of this cancer?
- Presents most commonly in what ages?
- What gene is associated with this?
- What tends to have a protective effect?
- Rarely symptomatic in the early stages of disease
- Presents most commonly in the fifth and sixth decade of life
- BRCA1 gene has been found to be associated with ovarian cancers in approximately 5% of cases
- Suppression of ovulation tends to have a protective effect
- use of OCPs for five years decreased lifetime risk of ovarian cancer in half
Risk Factors for Ovarian Cancer
5
- aging (especially 45-60 year old women)
- postmenopause
- periods of prolonged ovulation without pregnancy
- having a 1st degree relative with ovarian, colon, or breast cancer
- BRCA1 and BRCA2 gene mutation
Ovarian Cancer Screening
no effective method of mass screening has yet been developed. Neither is recommended but what are your options? 2
What is reccomended by the ACOG?
routine ultrasound and CA-125
annual bimanual exam
90% of ovarian malignancies are of what?
epithelial cell type
What is ovarian Torsion?
Complete or partial rotation of the ovary on its ligamentous supports
-the ovary typically rotates around both the infundibulopelvic ligament and the utero-ovarian ligament
- Ovarian Torsion often results in what?
2. What is adnexal torsion?
- Often resulting in impedance of its blood supply.
2. The fallopian tube often twists along with the ovary; when this occurs, it is referred to as adnexal torsion.
Ovarian Torsion
1. Secondary to ___________ in approximately 50-60% of patients 2. Which side more often that the other?
- ovarian mass
- Right more often than left (3:2)
- possibly because the right utero-ovarian ligament is longer than the left and/or that the presence of the sigmoid colon in the left side of the colon may help to prevent torsion
Ovarian Torsion
Presentation?
5
- Abrupt onset of acute, severe, unilateral, lower abdominal and pelvic pain often
- associated with nausea and vomiting.
- Often the severe pain will come on suddenly with a change of position.
- A unilateral, extremely tender adnexal mass is found in more than 90% of patients
- Many patients have noted intermittent previous episodes of similar pain for several days to several weeks
- Ovarian Torsion Dx?
2. Rx? 2
- Color flow Doppler US can help with diagnosis.
- With early diagnosis, patients often managed with conservative surgery
- If necrosis developing, unilateral salpingo-oopherectomy is treatment of choice
