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MD3: Women's > Pelvic pain > Flashcards

Pelvic pain Flashcards

1
Q

What is/are features of dysmenorrhoea?

A

Pelvic pain occurring peri-menstruation

May be lower abdominal pain (usually midline), back pain, groin pain or radiate to groin/flanks

Includes dyschezia (pain on defecation), pain with full rectum (sharp, shooting pain), dysuria, dysparaunia

Typically occurs ~24hrs prior to menses and increases in severity for 2-3 days and then improves

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2
Q

What are the definitions of acute and chronic pelvic pain?

A

Acute = pelvic/lower abdominal pain lasting <3mths

Chronic = pelvic/lower abdominal pain lasting >6m, intermittent or constant, but not occuring exclusively with menstruation, intercourse or pregnancy

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3
Q

What are DDx for dyspareunia?

A

Superficial

  • Thrush
  • Skin - atrophic vaginitis, lichen sclerosis or dermatitis of vulva
  • vestibulodynia, vaganismus

Deep

  • endometriosis
  • PID
  • adenomyosis
  • adhesions
  • ovarian cysts

*psychosocial

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4
Q

What are the clinical features of endometriosis?

A 
Dysmenorrhoea 
Dyschezia and other bowel symptoms
Dysuria 
Deep dyspareunia 
Subfertility 
Lower abdominal tenderness 
Nodules - vaginal or in POD on VE
Cervical motion tenderness
Immobile uterus - adhesions
Adnexal mass/tenderness - endometrioma
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5
Q

How is endometriosis diagnosed?

A

Mainly clinically

Laparoscopy gold standard for diagnosis - visualisation + histology

U/S - deep infiltrative lesions can be detected, endometriomas (chocolate cysts, ground glass appearance, on ovaries), bowel prep increases visibility (reduces shadowing), quality is user dependent (specialist training)

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6
Q

What are the pharmacological management options for endometriosis?

A

Pharmacological

  • Analgesia
    1. Cyclical NSAIDs (naproxen, ibuprofen, mefenamic acid)
  • Suppress hormonal activity
    1. Continuous COCP - effective in long term but takes time to become as effective as GnRH-analogues
    2. Progestins - high dose oral/systemic progestins can be used esp. when C/I to oestrogen (i.e. depot proveria), thin endometrium and reduce prostaglandins
    3. GnRH-analogues - only used for 6/12 due to bone loss, very effective but usually use as prelude to surgery, can help ‘break cycle’ and allow other Rx to be more effective

*usually combine NSAIDs + hormonal contraceptive

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7
Q

What are the theories for causes of endometriosis?

A

Sampson’s theory = menstrual reflux

  • Reflux of menstrual blood leads to deposition and development of endometriosis
  • Many women have this and no endo - therefore other contributing factors

Transformation = Coelomic metaplasia
-Hormonal influence and factors released during menstration/with menstrual reflux induce cellular changes

Embryological implantation

Mechanical transplantation i.e. with surgery

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8
Q

What are the surgical Rx options for endometriosis?

A

Laparoscopic surgery

  • Ablate - superficial lesions
  • Mainstay = resection of lesions and removal of endometriomas
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9
Q

What is the natural hx of endometriosis?

A

Affects ~10-15% women
Peak age 25 - 35 yrs
Symptoms resolve with menopause

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10
Q

What are the surgical Rx options for endometriosis?

A

Laparoscopic surgery

  • Ablate - superficial lesions
  • Mainstay = resection of lesions and removal of endometriomas
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11
Q

Where does endometriosis most commonly occur?

A

Uretosacral ligaments
POD
Ovaries

Can occur ‘anywhere’ but usually confined to pelvis - ureters, bladder, bowel, peritoneal wall etc

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12
Q

What are the clinical features of adenomyosis?

A

Menorrphagia, dysmenorrhoea

Bulky, tender uterus

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13
Q

How can adenomyosis be diagnosed?

A

U/S - asymmetrical thickening, venetian blind shadowing

Definitive diagnosis requires hysterectomy + histology

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14
Q

What are the risk factors for adenomyosis?

A 
Increasing age (ceases after menopause)
Increasing parity/gravidy
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15
Q

What are the treatment options for adenomyosis?

A

Same as per endo - NSAIDs, COCP, high dose systemic progestins, GnRH analogues

Surgical - Endometrial ablation, myomectomy, hysterectomy

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16
Q

What is primary dysmenorrhoea and general features?

A

Pain occurring with periods from onset (generally commences 1-2 years after menarche)

Dull, crampy pai in the low abdomen/pelvic area which can radiate to groin or back, may be associated with N+V, headachesm syncope and flushing

No pathological cause found

Pain will reduce with increasing age, parity and use of the OCP

17
Q

What is the mechanism for primary dysmenorrhoea?

A

Local production of prostaglandins which cause increased uterine contractions
Both lead to transient uterine ischaemia - pain

18
Q

What examination and Ix should be performed in primary dysmenorrhoea?

A

Abdominal exam
Pelvic examination - do not perform in adolescence who have not been sexually active

TV U/S - exclude endometriosis

STI screen

Pap smear

19
Q

What are the management options for primary dysmenorrhoea?

A

Expectant/do nothing

Heat packs, B1 and Mg daily may have some effect

Cyclical NSAIDs (menefamic acid, naproxen) +/- COCP, progestin’s, mirena – reduce prostoglandin production

Definitive - hysterectomy

20
Q

What is secondary dysmenorrhoea and general features?

A

Menstrual pain that commences years after onset of menarche

Typically starts >30yr

Pain typically begins 3-4 days before menses and becomes more severe during menstruation

21
Q

What are the ddx for secondary dysmenorrhoea?

A

Endometriosis, adenomyosis

Polyps

PID

22
Q

What are key history features to be elicited with patient presenting with dysmenorrhoea?

A
  • Age
  • Age of menstruation, normal menstruation cycle
  • Current menstruation pattern
  • Onset of dysmenorrhoea and chronicity - primary vs. secondary dysmenorrhoea, acute vs. chronic
  • Define pain - quality, severity, cyclical vs. constant vs. exclusively with period, location & radiation (abdo midline, low abdo, pelvic, rectal, groin, back)
  • Relationship and timing with cycle - before/after onset of bleeding, improves or worsens during period
  • Other pain - dyschezia, dysuria, dyspareunia (deep vs. superficial)
  • Abnormal bleeding - IMB, PCB
  • other bowel/bladder symptoms - IBS, incontinence, storage or voiding symptoms, bleeding
  • Associated features - pelvic mass, distention/bloating, weight loss, night sweats, fevers, discharge
  • Sexual hx risk factors
  • Gynaecological hx - previous diagnoses or Ix, pap smear history, STI hx

MD3: Women's (19 decks)

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