Pelvic Pain Flashcards
Dysmenorrhea/ dyspareunia/ dyschesia / PMS & PMDD
the “gold standard” diagnostic method of endometriosis is
laparoscopy, with or without biopsy for histologic diagnosis
endometriosis prevalence rates lie between - to - percent in infertility, and In those with chronic pelvic pain (CPP), it ranges from - to - percent
endometriosis prevalence rates lie between 20 to 50 percent in infertility, and In those with chronic pelvic pain (CPP), it ranges from 40 to 50 percent
Endometriosis risk factors,
lower body mass appears to positively correlate with endometriosis risk.
Early menarche, especially before age 14, carries increased risk for endometriosis.
nulliparas have a higher risk that likely is secondary to a greater number of ovulatory cycles.
The commonest site of endometriosis
Left ovary
Approximately – percent of all reproductive-aged women are affected by endometriosis
Approximately 10 percent of all reproductive-aged women are affected by endometriosis
definition of deep infiltrating endometriosis DIE also quantify invasion as >– mm
definition of deep infiltrating endometriosis DIE also quantify invasion as >5 mm
Endometriotic lesions also arc morphologically categorized as white, red, or black. In American Society for Reproductive Medicine (ASRM) system, endometriosis is classified as
stage I (minimal), stage II (mild), stage III (moderate). and stage IV (severe).
Symptoms such as dysuria, suprapubic pain, urinary frequency, urgency, and hematuria are more common with bladder involvement by endometriosis. Costovertebral angle pain may reflect ureteral endometriosis with obstruction and hydronephrosis that can progress eventually to loss of kidney function
Endometriosis should be considered if urinary tract symptoms persist despite negative urine culture results.Cystoscopy with biopsy also can help clarify the diagnosis.
thoracic endometriosis defines implants inside the thoracic cavity that lead to symptoms described as menstrual or synonymowly called
catamenial. These include cyclic chest or shoulder pain, hemoptysis, or pneumothorax, which predominantly occurs on the right.
Endometrioma resection (cystectomy vs. aspiration coupled with cyst wall ablation)
Endometriomas typically are treated surgically to exclude malignancy. To determine the best technique, both total ovarian cystectomy and aspiration coupled with cyst wall ablation have been compared. Of the two, cystectomy lowers endometrioma recurrence rates and pain symptoms and improves sub-sequent spontaneous pregnancy rates
recurrence rate of endometrioma
Despite cystectomy, endometriomas may recur. Liu and coworkers (2007) found an approximately 15 percent recurrence rate at 2 years following initial surgery. Importantly, women who undergo endometrioma excision may subsequently have reduced ovarian reserve, that is, the capacity to provide ova capable of fertilization. Additionally, surgery also raises the risk for adhesion formation. Both effects may diminish future fertility.
Endometrioma diagnosis and surveillance
Following initial diagnosis, repeat TVS is recommended 6 to 12 weeks later to exclude a hemorrhagic cyst. Endometriomas then may be sonographically surveilled in asymptomatic women yearly or sooner, at the clinician’s discre-tion (Levine, 2010). The main disadvantage to observation is an inability to exclude ovarian malignancy, and thus patient counseling is essential.
This procedure is the definitive and most effective therapy for women with endometriosis who do not wish to retain fertility.
Hysterectomy
those with hysterectomy and bilateral salpingo-oophorectomy (BSO), 10 percent had recurrent CPP and 4 percent required reoperation. Compared with these women, those choosing ovarian conservation had a sixfold greater risk of recurrent pain and an eightfold greater risk of requiring additional surgery
What is the 1st line of treating endometriosis associated dysmenorrhea?
Both norethindrone acetate and dienogest (Visanne) have regulatory approval for treating endometriosis and may be better than OCPs as a first-line therapy.
If you use leuprolide (GnRH agonist) how would you prevent possible side effects from using it more than 6 mon (osteoporosis, dementia, CVD, …)?
Add back therapy
Using hormonal replacement therapy (like clemen(white pills only+ Duphaston)
Endometrioma Recurrence Rate
recurrence rateis between 11.0% and 30.4% after ≥2 years of observation. The results of Busacca et al11showed arecurrenceof ovarianendometriomasin 24.6% at 4 years after surgery.
Allen-Masters Syndrome
defined asdefects in the broad ligament that result in peritoneal pockets. Classically, it was described in relationship to congenital defects and birth or operative trauma.
Causes of Secondary dysmenorrhea:
Common and less common
Common:
• Endometriosis • Chronic pelvic inflammatory disease • Adenomyosis • Intrauterine polyps • Submucosal fibroids • Intrauterine contraceptive devices
Less common:
• Allen-Masters syndrome • Congenital uterine abnormalities • Cervical stenosis • Asherman syndrome • Uterine retroversion • Pelvic congestion syndrome • Ovarian cysts
The pathogenesis of dysmenorrhea
Arachidonic acid is converted to PGF2α, PGE2, and leukotrienes, which are involved in increasing myometrial contractions. During menses, these contractions decrease uterine blood flow and cause ischemia and sensitization of pain fibers, PGF2α and PGE2 affect other organs such as the bowel and result in nausea, vomiting, and diarrhea.
Causes of Secondary Dysmenorrhea
Gynecological and non-Gynecological
◇ Gynecologic Pathology: Cervical stenosis Endometriosis and adenomyosis Pelvic infection and adhesions Uterine polyps or fibroids Ovarian cyst or mass Pelvic congestion Congenital obstructed müllerian malformations
◇ Nongynecologic Disorders Causing Pelvic Pain Mental health issues/disorders Somatization Depression Drug-seeking behavior and opioid dependency History of physical or sexual abuse Bowel disease Irritable bowel syndrome Inflammatory bowel disease Celiac sprue Lactose intolerance Urinary tract disease Ureteral obstruction Interstitial cystitis Nephrolithiasis.
secondary dysmenorrhea
associated with pelvic conditions or pathology that causes pelvic pain in conjunction with the menses.
occur in women younger than 20, but it is most often seen in women older than 20.
primary dysmenorrhea refers to
pain with no obvious pathologic pelvic disease. It is currently recognized that these patients are suffering from the effects of endogenous prostaglandins.Primary dysmenorrhea almost always first occurs in women younger than 20.
Endometriosis stages
