Sept17 A3-Gynecological-Chronic-Pain

Question 1

most common cause of chronic pelvic pain (CPP)

Answer 1

endometriosis

Question 2

problem in chronic pain

Answer 2

• nociceptive signals form peripheral nerves to CNS
• signals are interpreted by the brain as danger
• BUT pain is not accurate indication of the danger

Question 3

factors that can modify pain experience

Answer 3

• mood, stress
• environment
• past experiences
• meaning of pain
• spine and brain have mechanisms to amplify or diminish pain*

Question 4

sensitization def

Answer 4

PNS and CNS are overxited and get huge amount of synapses firing in resp to one stimulation

• peripheral sensitization OR
• central sensitization

Question 5

crpss-sensitization def

Answer 5

somato-visceral or viscero-visceral convergence

Question 6

why some people remain functional with endometriosis and some don’t

Answer 6

in certain people, the brain can adapt to a certain level but in others, there is sensitization

Question 7

most common sx of endometriosis (BUT NOT CPP)

Answer 7

dysmenorrhea

Question 8

(IMP) 2most imp components of central sensitization

Answer 8

• hyperlagesia (uncomfortable stimulus becomes painful)

- allodynia (not uncomfortable stimulus becomes painful)

Question 9

how central sensitization occurs

Answer 9

normal descending inhibitory pathwys are gone

Question 10

pain is not a good indicator of:

Answer 10

• the problem
• where the problem is (bc of cross sensitization)
• how dangerous the problem is (degree of tissue damage)

Question 11

positive thing with chronic pain

Answer 11

neuroplasticity

• possibility to retrain brain to desensitize
• pain does not necessarily mean danger
• empower the patient

Question 12

CPP def

Answer 12

at least 3-6 months

• episodic or constant
• no cyclical pain like dysmenorrhea
• in anatomic pelvis (between umbilicus and inguinal lig)
• can cause functional disability
• unrelated to pregnancy
• requires tx

Question 13

common causes of CPP (that also often coexist)

Answer 13

• gyn (ENDOMETRIOSIS, adenomyosis, chronic pelvic infections, fibroids)
• urologic (interstitial cystitis or painful bladder syndrome)
• GI (IBS = irritable bowel syndrome)

Question 14

endometriosis def

Answer 14

presence of endo glands and stroma outside of normal location

Question 15

endometriosis most common location

Answer 15

on pelvic peritoneum

Question 16

pathophgy of endometriosis

Answer 16

• retrograde menstruation (most accepted theory) = endometrial cells pass through fallopian tubes and within peritoneal cavity
• coelomic metaplasia (PMD (Muellerian duct)) from highly pluripotential coelomic epith formed endometrium in ectopic places
• lymphatic or vascular spread

Question 17

why endometriosis happens to some women and not to others (nbr of women with retrograde menstruation >nbr with endometriosis)

Answer 17

• immune system dysfunction contributes to genesis of endometriosis
• NK cells, macrophages and lymphocytes usually get rid of endometrial tissue*

Question 18

hormone role in endometriosis

Answer 18

estrogen
-ectopic tissue is deficient in enzymes inactivating estrogens (progesterone responsive enzymes in normal endo)
-it expresses aromatase to make estrogen (normal endo doesn’t)
END RESULT: estrogen makes the endometriosis grow. (E = fertilizer. P = lawn mower)

Question 19

classic sx of endometriosis

Answer 19

• severe dysmenorrhea
• severe dyspareunia
• chronic pelvic pain
• dysuria
• dyschezia (painful bowel mvmts)

Question 20

endometriosis possible PE findings

Answer 20

• non mobile tender uterus
• adnexal mass (endometrioma)
• tender nodules in posterior cul de sac (Douglas)
• can be normal PE with no pain (good inhibition in brain). but still some infertility

Question 21

how imaging helps for endometriosis

Answer 21

can only detected ADVANCED stage endometriosis or LARGE nodules using

• pelvic US
• MRI

Question 22

gold std (best sensitivity) to dx endometriosis

Answer 22

laparoscopy and pathologic confirmation

Question 23

why does endometriosis cause CPP

Answer 23

mostly bc of inflammation (for ex bc of pressure caused by a nodule)

Question 24

medical endometriosis tx

Answer 24

• pain control with NSAID or tylenol)

- OCPs (stops from ovulating so no more E produced + OCP contains P), progestins, GnRH agonists

Question 25

surgical tx for endometriosis is done in who

Answer 25

- severe pain refractory to medical management | - infertility

Question 26

do IUDs work for endometriosis?

Answer 26

- copper IUD: no | - LNG-IUS: for endometriosis in rectouterine pouch or adenomyosis. BUT not for endometrioma

Question 27

stage 1 endometriosis on laparoscopy

Answer 27

few little spots

Question 28

stage 4 endometriosis on laparoscopy

Answer 28

major anatomical disfigurement, large ovarian lesions

Question 29

causes of dyspareunia

Answer 29

``` SUPERFICIAL: -vulvovaginal diseases such as candida, herpes, lichen sclerosus, post menopausal atrophy, lichen planus, any dermato thing causing inflammation DEEP: -endometriosis -painful bladder syndrome -fibroids -STIs -PIDs ```

Question 30

(imp?) most common cause of longstanding dyspareunia unrelated to deep pathologies like endometriosis

Answer 30

vulvodynia and vaginismus

Question 31

vulvodynia def

Answer 31

vulvar pain. subcategorized in - location - timing - onset - temporal pattern

Question 32

most common type of vulvodynia

Answer 32

localized provoked vulvodynia (feeling of small cuts or burning at the introitus (entrance of the vagina)

Question 33

cause of vulvodynia

Answer 33

- multifactorial - neurogenic inflammation - increased vascular permeablity and vasodilation mediated by substance P axons and serotonin - can occur post surgery for gyn indications or after delivery with perineal laceration or episiotomy (cut of perineum)

Question 34

most common location of localized prokoved vulvodynia (LPV)

Answer 34

5 to 7 oclock in introitus (vestibule)

Question 35

vulvodynia tx

Answer 35

- address identifiable and tx causes like lesions - minimize irritants - pelvic floor physio - meds (xylocaine get, hormones, oral or topical tricyclic antidepressant or anticonvulsants) - interventional (injection of local anesthesia + CS) - surgical vestibulectomy

Question 36

vaginismus def

Answer 36

- reflex or involuntary contraction of pelvic floor muscles at penetration which essentially closes the vaginal orifice to prevent penetration. at intercourse or while inserting anything like tampons - genito-pelvic pain and penetration disorder described in the DSM5 and with important physical and emotional components

Question 37

tx of vaginismus

Answer 37

- exclude other pathologies by palpating the pelvic floor muscles - multidisciplinary tx (education about normal female sexual response, pelvic floor physio, reverse kegels (kegels = contract pelvis. reverse to relax) - sex therapy, progressive relaxation - vaginal suppositories of benzo or muscle relaxants