Pelvic and Ovarian disorders Flashcards
1
Q
What is chronic pelvic pain?
A
- pain of at least 6 months duration that occurs below the umbillicus
- significantly impacts a woman’s daily fxning and relationships
- episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
- continuous non-cyclic pain
- frustrates both pt and her clinician
- many times etiology not found or tx of presumed etiology fails: pain becomes the illness
2
Q
How common is it to have no obvious pathology in chronic pelvic pain? Procedures used in these pts?
A
- 1/3 have no obvious pelvic pathology
- comprises of up to 10% of outpt gyn visits
- accounts for 40% of GYN laparoscopies
- accounts for 20% of hysterectomies
- approx 70,000 hysterectomies are performed annually due to chronic pelvic pain
3
Q
Differential of chronic pelvic pain?
A
- 6 major sources: gyn GI urological psych musculoskeletal neuor - complete hx of pt's pain and good ROS
4
Q
Etiologies of chronic pelvic pain?
A
episodic:
- dyspareunia
- midcycle pelvic pain (mittelschmerz)
- dysmenorrhea
continuous:
- endometriosis (mostly cyclic pain)
- adenomyosis
- chronic salpingitis (PID)
- adhesions
- loss of pelvic support
5
Q
MC gyn etiologies of chronic pelvic pain?
A
- endometriosis is MC (1/3 CPP)
- PID 30% of women with PID develop CPP
- dysmenorrhea
- adenomyosis
- adhesions
- ovarian cysts
- ovarian cancer
6
Q
RFs for CPP?
A
- hx of sexual abuse or trauma
- previous pelvic surgery
- hx of PID
- endometriosis
- personal or family hx of depression
- hx of other chronic pain syndromes
- hx of alcohol or drug abuse
- sexual dysfxn
7
Q
Hx of pt with CPP?
A
- pain duration greater than 6 mo
- incomplete relief by most previous tx, including surgery and non-narcotic analgesics
- significantly impaired fxning at home or work
- signs of depression such as early morning awakening, wt loss, and anorexia
- pain out of proportion to pathology
- hx of childhood abuse, rape or other sexual trauma
- hx of sexual abuse
- current sexual dysfxn
- previous consultation with one or more health care providers and dissatisfaction with their management of her condition
8
Q
PE of pt with CPP?
A
- systematic PE of abdominal, pelvic and rectal areas focusing on location and intensity of pain
- attempt to reproduce the pain
- note general appearance, demeanor, and gait..may suggest severity of pain and possible neuromusc. etiology
- if a fever: acute process
- if vomiting: acute process
- inspect and note any well healed scars
- palpate scars for incisional hernias
- palpate for femoral and inguinal hernias
- palpate for any unsuspected masses
9
Q
What are abdominal sxs of a more acute process of pelvic pain?
A
- rebound tenderness (peritoneal irritation)
- increased abdominal pain on palpation with tension of rectus muscles
- straight leg raise:
decreases - pelvic origin
increases - abdominal wall or myofascial origin
10
Q
What may be seen on speculum and bimanual/rectum exam in pt with CPP?
A
speculum: cervicitis - source of parametrial irritation
bimanual/rectal:
-tender pelvic or adnexal mass, abnormal bleeding, tender uterine fundus, cervical motion tenderness - then think acute process such as PID, ectopic pregnancy, or ruptured ovarian cyst
-non-mobility of uterus - presence of pelvic adhesions
- existence of adnexal mass, fullness, tenderness
- cul-de-sac nodularities = endometriosis
- ID any areas that reproduce deep dyspareunia
- palpate the coccyx, both internally and externally (rectal exam)
11
Q
Dx tests for CPP?
A
- should be selected discriminately as indicated by findings of H&P
- avoid unecessary and repetitive dx testing
- serum HCG
- UA
- wet prep/KOH
- cervical cultures/GC and chlamydia
- CBC with diff
- ESR
-stool guaiac if + then do GI w/u - US to ID pelvic masses
- dx laparascopy may ID:
acute or chronic salpingitis, ectopic pregnancy, hydrosalpinc, endometriosis, ovarian tumors and cysts, torsion, appendicitis, adhesions
12
Q
Tx of CPP?
A
- tx underlying cause
- psychosocial interventions
- meds:
avoid long term narcotic use
NSAIDs
antidepressants
OCPs - surgical interventions: dx and therapeutic laparoscopy
hysterectomy
13
Q
Alt interventions for CPP?
A
- biofeedback
- stress management techniques
- self-hypnosis
- relaxation therapy
- transcutaneous nerve stimulation (TNS)
- trigger pt injections
- spinal anesthesia
- nerve blocks
14
Q
What is PID?
A
- clinical syndrome assoc with ascending spread of microorganisms from vagina or cervix to endometrium, fallopian tubes, ovaries, and contiguous structures
- comprises of spectrum of inflammatory disorders including any combo of: endometritis, salpingitis, turbo-ovarian abscess, and pelvic peritonitis
15
Q
PID: incidence and prevalence?
A
- occurs in approx 1 mill US women annually
- annual cost approx: $2 bill
- hospitalizations for acute PID steadily declined from approx 70,000 cases/yr in 1998 to 38,000 cases/yr in 2010
- outpt visits for PID also have declined primarily due to aggressive pop. based chlamydia screening and tx programs nationwide
16
Q
RFs for PID?
A
- young age at onset of sexual activity
- new, multiple or sx partners
- unprotected sexual intercourse
- hx of PID
- gonorrhea or chlamydia or a hx of gonorrhea or chlamydia
- current vaginal douching
- insertion of IUD (w/in fist 3 wks)
- bacterial vaginosis
- sex during menses
17
Q
Etiology of PID microbiology?
A
- most cases are polymicrobial
- MC pathogens:
N. gonorrhoeae - recovered from cervix in 30-40% of women with PID
C. trachomatis - recovered from cervix in 20-40% of women with PID - overgrowth of microorganisms that comprise vaginal flora: streptococci, staph, enterobacteriacea, anerobes, gardenella vaginalis, strep. agalactiae
18
Q
Pathway of ascendant infection to PID?
A
go from cervicitis to endometritis to salpingitis/oophoritis/tubo-ovarian abscess to peritonitis
19
Q
Complications of PID?
A
- approx 10-20% of women with a single episode of PID will experience sequela including:
ectopic preg.
infertility
tubo-ovarian abscess
chronic pelvic pain
fitz-hugh-curtis syndrome (perihepatitis) - tubal infertility occurs in 50% of women after 3 episodes of PID
20
Q
What is the minimum criteria for dx of PID?
A
- uterine/adnexal tenderness or
- cervical motion tenderness (Positive chandelier sign)
21
Q
Additional criteria to increase specificity of dx of PID?
A
- temp over 101F
- abnormal cervical or vaginal mucopurulent d/c (positive swab test)
- presence of WBCs on saline wet prep
- elevated ESR
- elevated CRP
- gonorrhea or chlamydia test positive
22
Q
More specific criteria for dx PID?
A
- transvaginal US
- pelvic CT or MRI
- laparoscopy
- endometrial bx
23
Q
PID tx considerations?
A
- tx should be instituted as early as possible to prevent long term sequelae
- need to tx sexual partners if +GC/chlamydia
- educate pt to avoid sexual activity until she and partner complete tx
- need close f/u to ensure cure
24
Q
Tx for PID?
A
Regimens must provide coverage for N. gonorrhpeae, C. trachomatis, anaerobes, gram - bacteria and streptococci
- outpt first line:
ceftriaxone 250 mg IM single dose, and azithro 1 g PO once wkly x 2 wks
or
ceftriaxone and doxy 100 mg orally bid for 14 days
or
cefoxitin 2 g IM in single dose and probenecid 1 g orally in single dose and doxy 100 mg orally 2x a day for 14 days
- any of the above regimens with or w/o
metronidazole 500 mg orally bid for 14 days
25
Q
F/U care for pt with PID?
A
- pts should demonstrate substantial improvement w/in 72 hrs
- pts who don’t improve usually reqr hospitalization, additional dx tests, and surgical intervention
- some experts recommend rescreening for C. trachomatis and N. gonorrhoeae 4-6 wks after completion of therapy in women with documented infection with these pathogens
26
Q
PID criteria for hospitaliziaton?
A
- inability to exclude surgical emergencies
- pregnancy
- non-response to oral therapy
- inability to tolerate an outpt oral regimen
- severe illness, looks septic, N/V, high fever or tubo-ovarian abscess
- HIV infection w/ low CD4 count
27
Q
Parenteral regimens for PID?
A
- A:
cefotetan 2 g IV q 12 hrs, or
cefoxitin 2 g IV q 6 hrs
plus doxy 100 mg orally or IV q 12 hrs - B:
clindamycin 900 mg IV q 8 hrs plus gentamicin loading dose IV or IM followed by maintenance dose q 8 hrs, single gentamicin dosing may be used - continue either of these regimens for at least 24 hrs after substantial clinical improvement then complete a total of 14 days therapy with:
doxy 100 mg PO bid with regimen A or
doxy or clindamycin (450 mg PO qid) if using regimen B
28
Q
Screening - for prevention of PID?
A
- to reduce incidence of PID, screen and tx for chlamydia
- annual chlamydia screening is recommended for:
sexually active women 25 and under and sexually active women who are older than 25 at high risk - screen pregnant women in 1st trimester
29
Q
Tx of partners with PID?
A
- male sex partners of women with PID should be examined and tx if they had sexual contact with pt during 60 days preceding the pt’s onset of sxs
- male partners of women who have PID caused by C. trachomatis or N. gonorrhoeae are oftne asx
- sex partners should be tx empirically with regimens effective against both C. trachomatis and N. gonorrhoeae, regardless of apparent etiology of PID or pathogens isolated from infected woman
30
Q
Reporting PID cases?
A
- report cases of PID to local STI program in states where reporting is mandated
- gonorrhea and chlamydia are reportable in all states
31
Q
Pt counseling and education of PID?
A
- nature of infection
- transmission
- risk reduction:
assess pt’s behavioral- change potential, discuss prevention strategies, develop individualized risk-reduction plans
32
Q
PCOS is MC cause of what?
A
- of androgen excess and hirutism in women
- most common hormonal disorder among women of reproductive age (6-8% in US approx 5 mill)
33
Q
Typical sxs of PCOS? Highly assoc with?
A
- oligomenorrhea or amenorrhea, anovulation, obesity, acne, hirsutism and infertility
- highly assoc with insulin resistance (many pts have impaired glucose tolerance or frank DM2)
34
Q
Dx of PCOS? What is the criteria?
A
- dx: no single definitive test for PCOS b/c no exact cause of condition has been est. (this is a syndrome)
- rotterdam criteria: a dx of PCOS can be made with 2 out of the 3 following features (once related disorders have been excluded):
- oligomenorrhea (light or infrequent flow) or anovulation
- clinic and/or biochemical signs of hyperadrenogenism (acne and hirsutism)
- polycystic ovaries in US
35
Q
PCOS possible etiologies?
A
likely multiple systems are affected:
- defect in HPA: causing release of excessive LH by anterior pituitary which cause increased androgen production in ovary making local concentrations of androgens elevated thus inhibiting ovulation
- defects in 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 stromal cells of the ovary
- genetic factors: contribute
36
Q
Signs of PCOS? What could help restore regular fxn of ovulation and menses?
A
- acanthosis nigricans can be present in these pts b/c of elevated insulin levels
- fasting blood sugar to fasting insulin ratio should be greater than 4.5 in normal pt - anything below that is considered insulin resistnat
- 70% of women with PCOS have insulin resistance - results in elevated blood glucose level, insulin stimulates storage of glucose in liver and muscle cells as glycogen
- once max amt of glycogen has been reached, insulin next converts excess glucose to fat
- as little as 10% of wt reduction can be effective in restoring regular ovulation and menses
37
Q
US findings of PCOS?
A
- multiple follicles around periphery of ovary (this is a finding not the cause - 25% of normal women can have this finding, and not all PCOS pts will have cystic ovaries)
- US isn’t necessary to make dx
38
Q
Lab tests for PCOS?
A
- testosterone
- androstenedione
- DHEAS
- 17 hydroxyprogesterone
- prolactin
- TSH
- HCG
- fasting blood sugar
- fasting insulin level
- LH/FSH
39
Q
Why should we tx PCOS?
A
- decrease risk of endometrial hyperplasia and cancer, possible decrease risk of breast CA, decrease all sequela that occurs with DM
- pt satisfaction
40
Q
What factors go into deciding on what therapy is right for pt with PCOS?
A
- how much hirsutism does pt have?
- does pt desire to become pregnant
- how willing is pt to exercise and reduce her wt?
41
Q
Therapeutic options for PCOS?
A
- diet and exercise: wt loss of 7-10% can regulate periods of a woman with PCOS
- OCPs: these suppress LH and therefore suppress circulating androgens. Also regulates periods
- spironolactone: act as antiandrogen (helps with hirsutism in conjunction with OCPs) - binds with androgen receptors and blocks the effects of dihydrotestosterone as well (preg D, monitor for hyperkalemia, may be tumorigenic)
- metformin - heps with insulin resistance and wt loss
- clomiphene (clomid): those trying to get pregnant and are still anovulatroy after diet, exercise, and metformin have been tried - binds estrogen receptors in hypothalamus to create state of hypoestrogenicity, thereby causing an enhanced GnRH release followed by increase secretion of gonadotropins which induces ovulation
42
Q
Key to eval ovarian disease?
A
- with excellent hx and physical
- ovaries shouldn’t be palpable in premenarchal group, nor should they be palpable in postmenopausal group
- ovary is palpable less frequently in reproductive age women taking OCPs
- older the woman the more likely tumor is malignant vs. benign
43
Q
What are ovarian cysts? Sxs?
A
- 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
- they occur commonly in women of all ages
- some women have pelvic pain or pressure, while others have no sxs
44
Q
What is a follicular cyst?PE findings?
A
- if an ovarian follicle fails to rupture during maturation, ovulation doesn’t occur, and a follicular cyst may defelop, these may be sx or asx
- clinically significant if large enough to cause pain or if it persists beyond the menstrual interval
- PE characteristics: mobile, cystic, adnexal mass
45
Q
Management of follicular cysts?
A
- usually spontaneously resolves
- management: reeval in 6-8 wks to ensure the cyst has resolved. May order transvaginal US as needed on a case by case basis
- OCP may be given to suppress gonadotoin stimulation of cyst
- Rupture of follicular cyst may produce transient acute pelvic pain
46
Q
What is a corpeus luteum cyst? Presentation?
A
- enlarged corpus luteum, which often continues to produce progesterone for longer than standard 12 days
- often presentation is of dull lower quadrant pain along with a missed menstrual period: (gets confused with pregnancy - so rule this out with test)
- PE findings: same as follicular cyst - mobile, cystic, adnexal mass
- cyst may rupture and hemorrhage with blood causing pain
47
Q
Management for corpus luteum cyst?
A
- may reevaluate this pt to make sure cyst has resolved
- pts may benefit from cyclic OCP therapy
- may use tranvaginal US on a case by case basis
48
Q
What should you do after palpating a mass on ovaries?
A
- f/u - some cysts can persist for some time and may benefit from a laparoscopy
49
Q
Other names for follicular cyst and corpus luteum cyst?
A
- fxnl ovarian cyst
- physiologic cyst
50
Q
Diff benign neoplasms of the ovaries?
A
- benign epithelial cell tumors
- benign germ cell tumors ( can create benign cystic teratoma aka dermoid cyst)
80% of these occur during reproductive years, often produce tumor markers such as HCG or AFP - benign stromal cell tumors: common one of these is called sertoli-leydig cell tumor
51
Q
Benign vs malignant tumors of the ovaries? Do they need surgery?
A
- benign tumors are more common than malignant tumors in all age groups
- chance for malignancy goes up with age
- warrant surgical tx b.c of potential for transformation to malignancy
- surgical tx may be conservative for benign tumors, especially if future pregnancy is desired
52
Q
Main RF of malignant ovarian tumors? When are these discovered?
A
- increasing age dramatically increases risk that ovarian enlargement is malignant
- 1st time many are discovered is at time of routine pelvic exam
- Aging women should still have physical and bimanual exam annually (even if they don’t have to have a pap)
53
Q
Numbers of ovarian cancer in US? How common is it? Mortality?
A
- 20,000 cases anually in US
- incidence increases with age: 1.4/100,000 under 40, 38/100,000 over 60
- rarely sx in early stages of disease
- late dx and early mets usually signify a poor prognosis and low survival rate
- 5th MC of all cancers in women
- mortality rate is higher than that of any other gyn cancer (presents in late stage)
54
Q
When does ovarian cancer most commonly present? What gene has been found to be assoc with ovarian cancer?
What has protective effect?
A
- rarely sx in early stages
- presents MC in 50s, and 60s
- BRCA1 gene has been found to be assoc with ovarian cancers in approx 5% of cases
- suppression of ovulation tends to have a protective effect: use of OCPs for 5 yrs decreased lifetime risk of ovarian cancer in half
55
Q
RFs for ovarian cancer?
A
- aging (esp 45-60)
- postmenopause
- periods of prolonged ovulation w/o pregnancy
- having a 1st degree relative with ovarian, colon or breast cancer
- BRCA1 and BRCA2 gene mutation
56
Q
Is there screening for ovarian cancer?
A
- no effective method of mass screening has yet been developed
- routine US and CA-125 but neither is recommended for routine screening, it is really expensive and has poor sensitivity and reliabilty
- annual bimanual exam is recommended by ACOG
57
Q
What pts should be followed up with further eval if palpable ovary or mass found?
A
- any postmenopausal pt with palpable ovary or mass should be refered on for further eval
58
Q
MC type of ovarian malignant neoplasms?
A
- 90% of ovarian malignancies are of epithelial cell type
- but still can arise from germ cell, and stromal neoplasms
59
Q
What is ovarian torsion?
A
- complete or partial rotation of ovary on ints ligamentous supports: the ovary typically rotates around both the infundibulopelvic ligament and the utero-ovarian ligament
- often resulting in imepedance of its blood supply
- the fallopian tube often twists along with the ovary; when this occurs it is referred to as an adnexal torsion
60
Q
Causes of ovarian torsion?
A
- rare event, reported with both normal and pathologic fallopian tubes
- secondary to ovarian mass in approx 50-60% of pts (another reason why we follow up on masses and one of main reasons that benign ovarian tumors are removed)
- R more often than L (3:2): possibly b/c the right utero-ovarian ligament is longer than the left and/or that the presence of sigmoid colon in left side may help prevent torsion
61
Q
Presentation of ovarian torsion?
A
- abrupt onset of acute, severe, unilateral, lower abdominal and pelvic pain often assoc with N/V. Often the severe pain will come on suddenly with a change of position (can be confused with appendicitis)
- a unilateral, extremely tender adnexal mass is found in more than 90% of pts
- many pts have noted intermittent previous episodes of similar pain for several days to several weeks
62
Q
Dx and Tx of ovarian torsion?
A
- color flow doppler US can help
- with early dx, pts often managed with conservative surgery: if necrosis developing, unilateral salpingooopherectomy is TOC
63
Q
Severe complications of PID?
A
- peritonitis, sepsis, and infertility
64
Q
What can happen to ovarian cysts if they become too large?
A
- esp follicular cysts - if they become larger than 5 cm they are at high risk of becoming torsed and need a laparoscopy
- always f/u on ovarian mass!
