Repro CIS Handout Flashcards
What is endometriosis?
Ectopic endometrial tissue
DDx of acute pelvic pain in a female
Ectopic pregnancy Appendicitis Pelvic inflammatory disease Adnexal torsion Ruptured corpus luteum Endometrioma rupture Adhesions (—> obstruction)
DDx of chronic pelvic pain in a female
Chronic PID Adhesions Mesonephroma Endosalpingosis Adenomyosis Interstitial cystitis Pelvic congestion syndrome Endometrioma
______, _______, and/or ______ are causes of chronic pelvic pain in females that can co-exist with endometriosis
Adenomyosis; interstitial cystitis; pelvic congestion syndrome
_______ = cause of chronic pelvic pain in a female in which only endometrial glands (no stroma) are present
Endosalpingiosis
_____________ are frequently the product of segmental muscle contraction that results from a viscerosomatic reflex and should prompt the search for visceral disease and dysfunction
Extended lumbar type II dysfunctions
In a patient with endometriosis, the abrupt increase in severity and radiation indicates a possible _____
Endometrioma rupture
T/F: hemorrhage due to rupture of endometriotic cysts with subsequent peritoneal irritation will lead to the production of reactive exudates
True
Ruptured ovarian endometriotic cysts can sometimes mimic ovarian malignancy because of the extremely elevated __________
Serum CA 125 concentration
What is the best imaging modality in a pt suspected of having hemoperitoneum due to endometrioma rupture?
CT scan w/contrast is better than pelvic sonogram or MRI
CT shows active arterial extravasation of IV contrast with a measured attenuation value higher than that of free or clotted blood indicative of need for prompt surgical intervention
Signs and symptoms of endometriosis
Dysmenorrhea Pelvic pain Menorrhagia Hormone-dependent Dyspareunia Lumbago Rectal pain Dyschezia Infertility Increased allergic reactions Positive family hx
MAY BE ASYMPTOMATIC!
T/F: the genetic predisposition for endometriosis is more consistent with polygenic and multifactorial inheritance than with a single mutant gene
True
What causes the pelvic pain associated with endometriosis?
Intrapelvic bleeding and periuterine adhesions
When is the best time to examine a pt with suspected endometriosis?
During early menses
Exam findings in pts with endometriosis
Pelvic tenderness
Nodules on bimanual exam — on uterosacral ligament and/or in posterior cul-de-sac
Decreased uterine mobility/retroversion
Tender/fixed nodular adnexal masses
Osteopathic findings — somatic dysfunction lumbar spine, chapmans points
Less common — hemorrhagic cysts observed on cervix
Besides CA-125, what other labs should be done in pt with suspected endometriosis?
Quantitative HCG — rule out pregnancy
UA and culture (if UTI is in DDx)
CBC
CMP
STD testing to r/o chlamydia and gonorrhea; consider cervical gram staining and culture
First imaging modality for the evaluation of abdominal and pelvic pain of unknown etiology
CT scan
[contrast this with US and MRI which are the primary imaging modalities for assessing women with suspected gynecologic pathologies]
What type of ultrasound is used to look at endometriomas — which will look like homogenous cysts
Transvaginal ultrasound
It is often very difficult to diagnose endometriosis without surgical confirmation. What are typical laparascopic and biopsy findings?
Visual lesions — black powder burns are classic finding while red/white lesions are non-classic
Biopsy histology shows endometrial glands and stroma
[note: poor correlation between clinical and surgical findings]
Potnetial complications of endometriosis
Progressively worsening course — implants spread to pelvis, GI tract, urinary tract, iliopsoas muscle, lumbar spine
Etiologies of endometriosis
Retrograde menstruation
Vascular/lymphatic dissemination
Coelomic metaplasia of multipotential cells in peritoneal cavity
Metaplastic
Extrauterine stem/progenitor cell (HSCs from bone marrow differentiate into endometrial tissue)
Presence of abnormal factors (proinflammatory factors, increased estrogen production by stromal cells, endometrioid cancer, clear cell ovarian cancer, gene mutations in PTEN, ARID1A, etc.)
Coelomic metaplasia of multipotential cells in peritoneal cavity is cited as a possible etiology of endometriosis. What is the coelom?
Cavity between splanchnic and somatic mesoderm in the embryo that forms the lining of the general body cavity in the adult
Derives from mesothelium. A single layer of flattened cells forms an epithelium that lines serous cavities; from which mullerian ducts and endometrium originate
Describe metaplastic changes as a potential etiology of endometriosis
Mesonephric remnants may undergo endometrial differentiation and give rise to ectopic endometrial tissue
Fate of mesonephros
mesonephros is an embryonic excretory organ; in a young embryo is well developed and briefly functional. In older embryo, undergoes regression. Becomes epididymis and ductus deferens in males
Fate of mullerian ducts (aka ductus paramesonephricus, paramesonephric duct, muellers duct)
In the female: upper parts of uterine tubes, lower parts form uterus and upper vagina
In the male vestigial: vagina masculina, appendix testis
[Mullerian ducts = Either of 2 paired embryonic tubes extending along the mesonephros roughly parallel to the mesonephric duct and emptying into the cloaca]
One factor that may contribute to endometriosis is increased estrogen production by stromal cells. This may be due to abnormally high levels of the steroidgenic enzyme ________ which contributes to survival of ectopic endometrial tissue
Aromatase
One factor that may contribute to endometriosis is an assocation with what 2 types of cancer?
Endometrioid cancer
Clear cell ovarian cancer
What 2 shared gene mutations may contribute to development of endometriosis?
PTEN
ARID1A
Rule of 3s for thoracic spine location of spinous process
T1-3 — SP is in same plane as TP and vertebral body
T4-6 — SP is in a plane halfway between its own TP and the TP of the vertebrae below
T7-9 — SP in the plane of TP of vertebrae one level below
T10 — like T7-9
T11 — like T4-6
T12 — like T1-3
ROM for thoracic sidebending vs. thoracic rotation
T SB — up to 40 degrees
T R — 90 degrees
For the lumbar spine, the spinous processes are in the same plane as the transverse processes. The most superior portion of the iliac crests corresponds with the spinous process of ____
L4
DTRs of lower extremities and corresponding nerve roots
L4 nerve root — patellar reflex
S1 nerve root — achilles reflex
What nerve root would be affected by L3-4 disc herniation?
L4
What nerve roots are tested on motor exam of ankle dorsiflexion, great toe dorsiflexion, and ankle plantarflexion?
Ankle dorsiflexion = L4/L5 nerve root
Great toe dorsiflexion = L5 nerve root
Ankle plantar flexion = S1 nerve root
Lumbar ROM with forward flexion, backward extension, SB, and Rot
Forward flexion = 40-90 degrees
Backward extension = 20-45 degrees
Sidebending = 15-30 degrees
Rotation = 90 degrees
Describe the hip drop test and what a positive result would be
Hip drop test assesses lumbar sidebending. The pt is standing and instructed to bend one knee, keeping both feet on the ground but displacing weight to the leg that is not bending at the knee. This causes a compensatory shift in body weight. Repeat on contralateral side and compare
Physician notes the amount of lumbar sidebending created by the drop in iliac crest height in degrees (normal is 15-30 deg)
If the hip does NOT drop 15 degrees, it is a positive side on the unsupported side
[ex: right iliac crest drops 10 degrees = positive right hip drop test —> problem with left sidebending]
Describe straight leg raise test (lasegue test)
Tests for sciatic nerve irritation by stretching the dura.
Pt is placed in the supine position. With knee extended, medially rotate and adduct the pt’s hip then flex the hip while maintaining knee extension
Continue hip flexion until the pt experiences pain in the BACK of the symptomatic leg.
Symptoms should not be felt in the lower leg until the leg is raised 30-35 degrees. If pain is felt at lesser angle or in opposite leg, may indicate a disc protrusion or rupture or radiculopathy. The dura starts stretching at 30 degrees. Pain above this angle may indicate nerve root irritation, but >70 degrees may be related to mechanical low back pain secondary to muscle strain or joint disease.
Check seated and supine for consistency
Osteopathic findings in endometriosis pts may include somatic dysfunctions in lower thoracic and lumbar spine, as well as viscerosomatics, chapmans points, lumbar/sacral/pelvic tender points, and in extreme cases psoas spasm.
What are the sympathetic and parasympathetic viscerosomatics associated with endometriosis?
Sympathetic: T10-L2
Parasympathetic: S2-S4
Anterior and posterior Chapman’s points associated with endometriosis
Anterior: ascending ramus of the pubis
Posterior: transverse process of L5
OMT techniques utilized in endometriosis pts
Soft tissue, MFR, BLT, FPR to lower thoracic/lumbar spine [indirect techniques are better; HVLA is less indicated]
Counterstrain, paraspinal inhibition, sacral rocking/inhibition, self-stretches and education
Absolute and relative contraindications to OMT in endometriosis
No absolute contraindications to OMT for endometriosis
Relative contraindication is increased pain with treatment
