PELVIC & OVARIAN DISORDERS Flashcards
ovarian torsion
complete or partial rotation of ovary on its ligamentous supports
- often impedes blood supply
⦁ ovary typically rotates around both the infundibulopelvic ligament & utero-ovarian ligament
when fallopian tube twists along with the ovary - torsion = called
adnexal torsion
- 50-60% of patient’s ovarian torsion = was secondary to an
ovarian mass
_______ ovarian torsion more common
right more common than left
why is right ovarian torsion more common than left
perhaps because right utero-ovarian ligament is longer than the left, or that presence of sigmoid colon on left side helps prevent it
presentation of ovarian torsion
⦁ abrupt onset of acute, severe, unilateral, lower abdominal & pelvic pain
⦁ often associated with N/V
⦁ often the severe pain comes on suddenly with a change in position
⦁ a unilateral, extremely tender adnexal mass is found in > 90% of patients
⦁ many patients noted intermittent previous episodes of similar pain for several days to several weeks
- often confused with appendicitis
Diagnosis of ovarian torsion
color flow Doppler US
Treatment for ovarian torsion
⦁ early diagnosis = can often be managed with conservative surgery
⦁ if necrosis is developing = need unilateral salpingo-oophorectomy = TOC (removal of FT & ovary)
what is chronic pelvic pain (CPP)?
Pain of AT LEAST 6 MONTHS duration that occurs below the umbilicus
CPP = chronic pelvic pain is Pain of AT LEAST __________ duration that occurs below the umbilicus
6 MONTHS
Chronic Pelvic Pain
- episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
- or continuous non-cyclic pain
often times the etiology is not found or the treatment of the presumed etiology fails: and pain becomes the illness
most common gynecological cause of chronic pelvic pain
ENDOMETRIOSIS
ETIOLOGIES OF CPP
ETIOLOGIES OF CPP o EPISODIC ⦁ dysparuenia ⦁ midcycle pelvic pain (Mittelschmerz) ⦁ dysmenorrhea
o CONTINUOUS ⦁ Endometriosis (mostly cyclic pain) ⦁ Adenomyosis ⦁ Chronic salpingitis (PID) ⦁ Adhesions ⦁ Loss of pelvic support
RISK FACTORS FOR CPP
⦁ hx of sexual abuse/trauma ⦁ previous pelvic surgery ⦁ hx of PID ⦁ endometriosis ⦁ personal or family hx of depression ⦁ hx of other chronic pain syndromes (fibromyalgia) ⦁ hx of alcohol / drug abuse ⦁ sexual dysfunction
HISTORY OF CPP
- pain duration > 6 months
- incomplete relief from most treatments - including surgery & non-narcotic analgesics
- significantly impairs work/home
- signs of depression such as early morning awakening, weight loss, anorexia
- pain out of proportion to pathology
- hx of childhood abuse/rape/sexual trauma
- hx of substance abuse
- current sexual dysfunction
- previous consultation with 1+ providers & dissatisfaction with treatment/management
more of an acute process and not CPP
- fever
- vomiting
- rebound tenderness
- increased abdominal pain on palpation with tension of rectus muscles
straight leg raise on PE with CPP
⦁ decreased pain = think pelvic origin
⦁ increased pain = think abdominal wall or myofascial origin
PE for CPP
- inspect & note any well healed scars (may be CPP from surgery)
- palpate for any hernias (incisional, femoral, inguinal) & masses
o Do speculum exam; cervicitis?
o Bimanual / rectal exam - any masses, abnormal bleeding, tender
⦁ cervical motion tenderness = think acute process - such as PID, ectopic, or ruptured ovarian cyst
⦁ nonmobility of uterus = presence of pelvic adhesions
⦁ cul-de-sac nodularities = endometriosis
labs for CPP
⦁ serum hcg
⦁ UA
⦁ wet prep/KOH
⦁ cervical cultures / Gonorrhea & chlamydia
⦁ CBC with diff
⦁ ESR
⦁ Stool guiac - if positive = do GI workup
imaging for CPP
⦁ ULTRASOUND - to identify pelvic masses
⦁ Diagnostic Laparoscopy - may identify: acute or chronic salpingitis, ectopic pregnancy, hydrosalpinx, endometriosis, ovarian tumors/cysts, torsion, appendicitis, adhesions
CPP TREATMENT
- treat the underlying cause = #1 treatment
- psychosocial interventions
- Meds
⦁ avoid long-term narcotic use
⦁ NSAIDS
⦁ antidepressants
⦁ oral contraceptives
o Surgical Interventions
⦁ diagnostic & therapeutic laparoscopy
⦁ hysterectomy
PID
- **ASCENDING spread of bugs - spread of micro-organisms from vagina or cervix to the endometrium / fallopian tubes / ovaries & contiguous structures
- **ASCENDING spread of bugs - spread of micro-organisms from vagina or cervix to the endometrium / fallopian tubes / ovaries & contiguous structures
PID
Pain of AT LEAST 6 MONTHS duration that occurs below the umbilicus
CHRONIC PELVIC PAIN
Outpatient visits for PID have declined, primarily due to aggressive __________ screening
chlamydia
RISK FACTORS FOR PID
⦁ young age at onset of sexual activity ⦁ new, multiple, or symptomatic partners ⦁ unprotected sex ⦁ hx of PID ⦁ gonorrhea/chlamydia or hx of gonorrhea/chlamydia ⦁ current vaginal douching ⦁ insertion of IUD (within first 3 weeks) ⦁ BV ⦁ sex during menses
most cases of PID are _______
polymicrobial
MOST COMMON PID PATHOGENS
⦁ N. gonorrhoeae - 30-40%
⦁ C. trachomatis - 20-40%
⦁ others = streptococci, staphylococci, enterobacteria, anaerobes, gardnerella vaginalis, strep agalactiae
PATHWAY OF ASCENDING INFECTION (PID)
- cervicitis –> endometritis –> salpingitis / oophoritis / tubo-ovarian abscess –> peritonitis
COMPLICATIONS WITH PID
- approx 10-20% of women with a single PID episode will experience sequelae, including
⦁ ectopic pregnancy
⦁ infertility
⦁ tubo-ovarian abscess
⦁ chronic pelvic pain
⦁ Fitz-Hugh-Curtis syndrome (perihepatitis)
Tubal infertility occurs in 50% of women after ________________ episodes of PID
3
____________ occurs in 50% of women after 3 episodes of PID
tubal infertility
MINIMUM CRITERIA FOR DIAGNOSIS OF PID
- uterine/adnexal tenderness
or
- cervical motion tenderness (positive chandelier sign)
DIAGNOSING PID
- uterine/adnexal tenderness or…
- cervical motion tenderness (positive chandelier sign) - throw hands up from pain
OTHERS
- fever
- abnormal cervical or vaginal mucopurulent discharge
- WBC presence on saline wet prep
- elevated ESR & CRP
- gonorrhea or chlamydia test positive
- have fever, adnexal/cervical tenderness, mucopurulent vaginal or cervical discharge, WBCs on saline wet mount, gonorrhea or chlamydia test is positive, elevated ESR/CRP
PID
cervical motion tenderness / chandelier sign
PID
treatment for PID
⦁ Ceftriaxone 250mg IM (gonorrhea) + Azithromycin 1g qw x 2 weeks (chlamydia)
or
⦁ Ceftriaxone 250mg IM (gonorrhea) + Doxycycline 200mg BID x 14 days (chlamyd)
- treatment should be done ASAP to prevent long term sequelae
- need to treat sexual partners if + for Gonorrhea/chlamydia
- educate pt to avoid sexual activity until she & partner complete treatment
- close follow up to ensure clearance
follow up for PID
- patients should have substantial improvement within 72 hours
- pts who don’t improve usually require hospitalization, additional diagnostic tests, and surgery
- some recommendations to rescreen for chlamydia & gonorrhea 4-6 weeks after completing therapy
PID CRITERIA FOR HOSPITALIZATION
⦁ 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 FOR PID
⦁ Cefotetan or Cefoxitin PLUS Doxycycline (A)
⦁ Clindamycin + Gentamycin (B)
parenteral regimen A for PID
Cefotetan or Cefoxitin PLUS Doxycycline = IV
- continue this regimen for at least 24 hours after substantial clinical improvement
- then take doxy x 14 days
parenteral regimen B for PID
Clindamycin + Gentamycin (B) = IV
- continue this regimen for at least 24 hours after substantial clinical improvement
- then take doxy or clinda x 14 days
treating male partners of women with PID
- male sex partners of women with PID should be examined/treated if they had sexual contact with pt during 60 days preceding patient’s onset of symptoms
- male partners of women with PID from gonorrhea or chlamydia = often asymptomatic
⦁ should be treated empirically against both gonorrhea & chlamydia, regardless of apparent etiology of PID or pathogens isolated from infected woman
SCREENING FOR CHLAMYDIA IN PID PREVENTION
- to reduce incidence of PID = screen & treat for chlamydia!
- annual chlamydia screening recommended for
⦁ sexually active women 25 and under
⦁ sexually active women > 25 at high risk - screen pregnant women in the 1st trimester
Most common cause of androgen excess and hirsutism in women
PCOS
Most common hormonal disorder among women of reproductive age
PCOS
Highly associated with insulin resistance
PCOS
PCOS is highly associated with
insulin resistance
PCOS SYMPTOMS
⦁ oligomenorrhea (infrequent menses) or amenorrhea ⦁ anovulation ⦁ obesity ⦁ acne ⦁ hirsutism ⦁ infertility
DIAGNOSIS OF PCOS
no single definitive test for PCOS because no exact cause of the condition has been established (remember, this is a syndrome)
o ROTTERDAM CRITERIA = diagnosis of PCOS can be made with 2/3 features (once related disorders have been excluded)
⦁ Oligomenorrhea or anovulation
⦁ clinical and or biochemical signs of hyperandrogenism (acne & hirsutism)
⦁ Polycystic ovaries on US
PANCE PEARLS SAYS PCOS TRIAD =
1) amenorrhea
2) hirsutism/acne
3) obesity
ROTTERDAM CRITERIA
to diagnose PCOS = need 2/3 features (once related disorders have been excluded)
⦁ Oligomenorrhea or anovulation
⦁ clinical and or biochemical signs of hyperandrogenism (acne & hirsutism)
⦁ Polycystic ovaries on US
what does insulin resistance have to do with PCOS
insulin resistance leads to compensatory hyperinsulinemia
increased insulin levels can stimulate androgen production by stromal cells in the ovaries
ETIOLOGY OF PCOS
Precise etiology unknown, likely multiple systems affected:
1) Defect in hypothalmic-pituitary axis
⦁ causing the release of excessive LH by anterior pituitary –> increased androgen production in the ovary –> elevated local concentrations of androgens –> inhibits ovulation
2) Defects of ovaries –> androgen overproduction
3) Defect in insulin sensitivity –> leads to insulin resistance and compensatory hyperinsulinemia
⦁ Increased insulin levels can stimulate androgen production by stromal cells of the ovary.
4) Genetic factors can also contribute
PCOS & insulin resistance = presence of
acanthosis nigricans
Fasting blood sugar to fasting insulin ratio should be greater than 4.5 in a normal patient… anything below that is considered insulin resistant
70% of women with PCOS have
insulin resistance
in PCOS: As little as ____% weight reduction can be effective in restoring regular ovulation and menses
10%
ULTRASOUND FINDINGS IN PCOS
- multiple follicles around the periphery of the ovary (this is a finding, not a cause) - because 25% of normal women can have this, and not all women with PCOS have cystic ovaries
- ultrasound is NOT necessary to make a PCOS diagnosis
is an ultrasound necessary to diagnose PCOS
no
multiple follicles around the periphery of the ovary on ultrasound
PCOS
“string of pearls”
lab tests for PCOS
⦁ testosterone ⦁ androstenedione ⦁ DHEAS ⦁ 17 hydroxyprogesterone ⦁ prolactin ⦁ TSH ⦁ HCG
FITZ-HUGH-CURTIS SYNDROME
perihepatitis
complication of PID
LABS FOR PCOS
⦁ testosterone ⦁ androstenedione ⦁ DHEAS ⦁ 17 hydroxyprogesterone ⦁ prolactin (elevated prolactin prevents ovulation) ⦁ TSH ⦁ HCG ⦁ fasting blood sugar ⦁ fasting insulin level ⦁ LH/FSH
WHY TREAT PCOS
⦁ Decrease risk of endometrial hyperplasia and cancer
⦁ Possibly decrease risk of breast CA
⦁ Decrease all sequella that occur with DM
⦁ Patient satisfaction***
PCOS TREATMENT
1) diet & exercise
2) OCPs
3) Spiro
4) Metformin
5) Clomiphene (Clomid)
OCPS = suppress LH and therefore suppress circulating androgens.
Also regulates periods (but not so good if you want to have children)
SPIRO = antiandrogen (helps with hirsutism) - diuretic but also blocks effects of dihydrotestosterone too
⦁ pregnancy category D
⦁ monitor for hyperkalemia
⦁ may be tumorigenic
METFORMIN = helps with insulin resistance & weight loss
CLOMIPHENE = for those trying to become pregnant and are still anovulatory after diet, exercise & metformin have been tried**
⦁ binds to estrogen receptors in hypothalamus - creates a state of hypoestrogenicity –> enhanced GnRH release –> increased gonadotropin release –> stimualtes ovulation
treatment for women with PCOS who are trying to get pregnant and are still anovulatory after diet, exercise, and metformin
Clomiphene (Clomid)
MOA OF CLOMID (CLOMIPHENE)
binds to estrogen receptors in hypothalamus - creates a state of hypoestrogenicity –> enhanced GnRH release –> increased gonadotropin release –> stimualtes ovulation
⦁ Ovaries are palpable less frequently in reproductive age women taking
OCPs
⦁ The older the woman, the more likely a tumor is
malignant
⦁ The ovaries should NOT be palpable in the ___________ group, nor should they be palpable in the _________ group
premenarchal
postmenopausal
arises as a result of normal ovarian physiology
ovarian cysts
OVARIAN CYSTS
- fluid-filled sacs that develop in or on the ovary
- ovarian cysts occur commonly in women of all ages
- some women with ovarian cysts have pain or pelvic pressure, while others have no symptoms
HOW DOES A FOLLICULAR CYST FORM
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
MANAGEMENT OF FOLLICULAR CYST
- follicular cysts usually spontaneously resolve
MANAGEMENT = reevaluation in 6-8 weeks to ensure the cyst has resolved. May order transvaginal US as needed
- OCP may be given to suppress gonadotropin stimulation of the cyst
BENIGN OVARIAN TUMORS ex:
⦁ Benign epithelial cell tumors
⦁ Benign germ cell tumors (benign cystic teratoma = dermoid cyst)
⦁ Benign Stromal cell tumors = sertoli-leydig cell tumor
BENIGN OVARIAN NEOPLASMS
**benign ovarian neoplasms are more common than malignant tumors of the ovary in ALL AGE GROUPS.
The chance for malignancy transformation increases with age –> warrants surgical treatment because of their potential to transform to malignancy.
Surgical treatment may be conservative for benign tumors, especially if future pregnancy is desired
The mortality rate from _________ cancer is higher than that of all other gynecologic cancers
ovarian
why? - because they’re found late!
ovarian cancer happens in the ________ decades
5th-6th decades most often
Use of ______ x _______ years decreases lifetime risk of ovarian cancer by half
OCPs x 5 years
The suppression of ovulation tends to have a protective effect
RISK FACTORS FOR OVARIAN CANCER
⦁ aging
⦁ postmenopause
⦁ periods of prolonged ovulation without pregnancy (so no kids)
⦁ having 1st degree relative with ovarian, colon or breast cancer
⦁ BRCA 1 or BRCA 2 gene mutation
OVARIAN CANCER SCREENING GUIDELINES
- no effective method of mass screening has been developed yet
- routine ultrasound & CA-125?
⦁ neither is recommended routinely
⦁ high expense, poor sensitivity & reliability
ANNUAL BIMANUAL EXAM is recommended by ACOG
*****90% of ovarian malignancies are of the
EPITHELIAL CELL TYPE*****
