Review: Repro CIS Handout Flashcards by Monika Eszterhazy

What is endometriosis?

Ectopic endometrial tissue

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DDx of acute pelvic pain in a female

Ectopic pregnancy
Appendicitis
Pelvic inflammatory disease
Adnexal torsion
Ruptured corpus luteum
Endometrioma rupture
Adhesions (—> obstruction)

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DDx of chronic pelvic pain in a female

Chronic PID
Adhesions
Mesonephroma
Endosalpingosis
Adenomyosis
Interstitial cystitis
Pelvic congestion syndrome
Endometrioma

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______, _______, and/or ______ are causes of chronic pelvic pain in females that can co-exist with endometriosis

Adenomyosis; interstitial cystitis; pelvic congestion syndrome

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_______ = cause of chronic pelvic pain in a female in which only endometrial glands (no stroma) are present

Endosalpingiosis

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_____________ 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

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In a patient with endometriosis, the abrupt increase in severity and radiation indicates a possible _____

Endometrioma rupture

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T/F: hemorrhage due to rupture of endometriotic cysts with subsequent peritoneal irritation will lead to the production of reactive exudates

True

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Ruptured ovarian endometriotic cysts can sometimes mimic ovarian malignancy because of the extremely elevated __________

Serum CA 125 concentration

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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

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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!

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T/F: the genetic predisposition for endometriosis is more consistent with polygenic and multifactorial inheritance than with a single mutant gene

True

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What causes the pelvic pain associated with endometriosis?

Intrapelvic bleeding and periuterine adhesions

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When is the best time to examine a pt with suspected endometriosis?

During early menses

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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

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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

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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 ____

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?

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