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Flashcards in Pelvic and Ovarian Disorders Deck (62)
1

What is chronic pelvic pain?
5

1. Pain of at least 6 months' duration that occurs below the umbilicus
2. Significantly impacts a woman’s daily functioning and relationships
3. Episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
4. Continuous non-cyclic pain
5. Many times etiology not found or treatment of presumed etiology fails: pain becomes the illness

2

Six major sources need to be considered for pelvic pain?
6

1. Gynecological
2. Gastrointestinal
3. Urological
4. Psychological
5. Musculoskeletal
6. Neurological

3

Etiologies of Chronic Pelvic Pain
1. episodic? 3
2. Continuous? 5

1. Episodic
-dyspareunia
-midcycle pelvic pain (Mittelschmerz)
-dysmenorrhea

2. Continuous
-Endometriosis (mostly cyclic pain)
-adenomyosis
-chronic salpingitis (PID)
-adhesions
-loss of pelvic support

4

1. What is the most common gynecological cause of CPP?

2. What are other gynecological causes? 6

1. Endometriosis
2.
-PID: 30% of women w/ PID develop CPP
-Dysmenorrhea
-Adenomyosis
-Adhesions
-Ovarian cysts
-Ovarian cancer

5

Risk Factors for
Chronic Pelvic Pain
8

1. History of sexual abuse or trauma
2. Previous pelvic surgery
3. History of PID
4. Endometriosis
5. Personal or family history of depression
6. History of other chronic pain syndromes
7. History of alcohol and drug abuse
8. Sexual dysfunction

6

Chronic Pelvic Pain: History findings
9

1. Pain duration > 6 months

2. Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics

3. Significantly impaired functioning at home or work

4. Signs of depression such as early morning awakening, weight loss, and anorexia

5. Pain out of proportion to pathology

6. History of childhood abuse, rape or other sexual trauma

7. History of substance abuse

8. Current sexual dysfunction

9. Previous consultation with one or more health care providers and dissatisfaction with their management of her condition

7

Chronic Pelvic Pain: Physical Exam
7

1. Systematic PE of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain

2. Attempt to reproduce the pain

3. Note general appearance, demeanor, and gait… may suggest the severity of the pain and possible neuromuscular etiology.

4. inspect & note any well healed scars
5. palpate scars for incisional hernias
6. Palpate for femoral and inguinal hernias
7. Palpate for any unsuspected masses

8

Chronic Pelvic Pain: Physical Exam
-Abdominal symptoms of more acute process? 5

1. rebound tenderness (peritoneal irritation)
2. increased abdominal pain on palpation with tension of the rectus muscles
3. straight leg raise
-Decrease…. pelvic origin
-increase …. abdominal wall or myofascial origin
4. Fever?...acute process
5. Vomiting?...acute process.

9

Chronic Pelvic Pain: Physical Exam
1. Speculum exam: What would be the source of parametrial irritation?

2. Bimanual/rectal exam: What may be findings for this? 5

3. If you see these symptoms what should you think? 3

4. Palpate the ________, both internally and externally

1. Cervicitis

2.
-tender pelvic or
-adnexal mass,
-abnormal bleeding,
-tender uterine fundus,
-cervical motion tenderness

3. Think acute process such as
-PID,
-ectopic pregnancy, or
-ruptured ovarian cyst

4. coccyx

10

What would the following findingd on bimanual/rectal exam show:
1. Non-mobility of uterus?
2. Cul-de-sac nodularities?
3. Identify any areas that reproduce what?
4. Cerival motion tenderness also called?

1. presence of pelvic adhesions

2. endometriosis
3. deep dyspareunia

4. Chandelier sign

11

Diagnostic Tests for Chronic Pelvic Pain

8

1. Should be selected discriminately as indicated by the findings of the H & P
2. Avoid unnecessary and repetitive diagnostic testing
3. Serum HCG
4. UA
5. Wet prep/KOH
6. Cervical cultures/GC and chlamydia
7. CBC with diff
8. ESR
9. Stool guaiac…if + do GI w/u
10. Ultrasound to identify pelvic masses

12

CPP: Diagnostic laparascopy may identify?
8

1. acute or chronic salpingitis
2. ectopic pregnancy
3. hydrosalpinx
4. endometriosis
5. ovarian tumors and cysts
6. torsion
7. appendicitis
8. adhesions

13

Treatment of Chronic Pelvic Pain

3

May have a surgical interventions? 2

1. Treat underlying cause
2. Psychosocial interventions
3. Medications

1. diagnostic and therapeutic laparoscopy
2. hysterectomy

14

Medications for CPP? 3

Avoid what? 1

1. NSAIDs
2. antidepressants
3. oral contraceptives

1. Avoid long-term narcotic use

15

CPP: Alternative interventions
8

1. biofeedback
2. stress management techniques
3. self-hypnosis
4. relaxation therapy
5. transcutaneous nerve stimulation (TNS)
6. trigger-point injections
7. spinal anesthesia
8. nerve blocks

16

Pelvic Inflammatory Disease
1. What is it?

2. Comprises a spectrum of inflammatory disorders including any combination of what? 4

1. Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.

Comprises a spectrum of inflammatory disorders including any combination of:
1. endometritis,
2. salpingitis,
3. tubo-ovarian abscess, and
4. pelvic peritonitis.

17

PID Risk Factors
9

1. Young age at onset of sexual activity
2. New, multiple, or symptomatic partners
3. Unprotected sexual intercourse
4. History of PID
5. Gonorrhea or chlamydia, or a history of gonorrhea or chlamydia
6. Current vaginal douching
7. Insertion of IUD (within 1st 3 weeks)
8. Bacterial vaginosis
9. Sex during menses

18

PID Microbial Etiology
2


2. Overgrowth of microorganisms that comprise the vaginal flora such as? 6

1.
-N. gonorrhoeae: recovered from cervix in 30%-40% of women with PID
-C. trachomatis: recovered from cervix in 20%-40% of women with PID

2.
-streptococci,
-staphylococci,
-Enterobacteriaceae,
-anerobes,
-gardenella vaginalis,
-strep. agalactiae.

19

PID: Pathway of Ascendant infection?
4

1. Cervicitis
2. Endometritis
3. Salpingitis/ oophoritis/ tubo-ovarian abscess
4. Peritonitis

20

Complications of PID
5

Approximately 10-20% of women with a single episode of PID will experience sequelae, including:
1. ectopic pregnancy
2. Infertility
3. Tubo-ovarian abscess
chronic pelvic pain
4. Fitz-hugh-curtis syndrome (perihepatitis)
5. Tubal infertility occurs in 50% of women after three episodes of PID

21

Minimum Criteria in the Diagnosis of PID
2

1. Uterine/adnexal tenderness or
2. Cervical motion tenderness (positive Chandelier Sign)

22

Additional Criteria to Increase Specificity of Diagnosis
6


More Specific Criteria 4

1. Temperature >38.3°C (101°F)
2. Abnormal cervical or vaginal mucopurulent discharge
3. Presence of WBCs on saline wet prep
4. Elevated erythrocyte sedimentation rate (ESR)
5. Elevated C-reactive protein (CRP)
6. Gonorrhea or chlamydia test positive

1. Transvaginal ultrasound
2. Pelvic CT or MRI
3. Laparoscopy
4. Endometrial biopsy

23

General PID Considerations
1. Treatment should be instituted when?

2. Need to treat sexual partners if what?

3. Educate patient to avoid what?

1. as early as possible to prevent long term sequelae

2. +GC/Chlamydia

3. sexual activity until she and partner complete treatment.
-Need close f/u to ensure cure.

24

PID Treatment
1. Regimens must provide coverage of what? 5

2. Outpatient first line therapy?
(3 combinations) + (may add what?)

1.
-N. gonorrhoeae,
-C. trachomatis,
-anaerobes,
-Gram-negative bacteria, and
-streptococci

2.
-Ceftriaxone 250 mg IM in a single dose, AND azithromycin 1 g PO once weekly x 2 weeks

-Ceftriaxone 250 mg IM in a single dose AND doxycycline 100 mg orally 2 times a day for 14 days

-Cefoxitin 2 g IM in a single dose AND Probenecid 1 g orally in a single dose, AND Doxycycline 100 mg orally 2 times a day for 14 days

-WITH OR WITHOUT
Metronidazole 500 mg orally 2 times a day for 14 days

25

Follow-Up
1. Patients should demonstrate substantial improvement within __ hours.

2. Patients who do not improve usually require what? 3

3. Some experts recommend rescreening for what 4-6 weeks after completion of therapy in women with documented infection with these pathogens? 2

1. 72

2.
-hospitalization,
-additional diagnostic tests, and
-surgical intervention.

3.
-C. trachomatis and
-N. gonorrhoeae

26

PID Criteria for Hospitalization
6

1. Inability to exclude surgical emergencies
2. Pregnancy
3. Non-response to oral therapy
4. Inability to tolerate an outpatient oral regimen
5. Severe illness, looks septic, nausea and vomiting, high fever or tubo-ovarian abscess
6. HIV infection with low CD4 count

27

Parenteral Regimens: PID
CDC-recommended parenteral regimen A? 3

CDC-recommended parenteral regimen B? 2


Continue either of these regimens for at least 24 hours after substantial clinical improvement, then what? 2

CDC-recommended parenteral regimen A
1. Cefotetan 2 g IV every 12 hours, OR
2. Cefoxitin 2 g IV every 6 hours
3. PLUS doxycycline 100 mg orally or IV every 12 hours

CDC-recommended parenteral regimen B
1. Clindamycin 900 mg IV every 8 hours
2. PLUS gentamicin loading dose IV of IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be used.

Complete a total of 14 days therapy with
1. Doxycycline (100 mg orally twice a day) with regimen A or with
2. Doxycycline or Clindamycin (450 mg orally 4 times a day), if using regimen B

28

Screening
1. To reduce the incidence of PID, screen and treat for _______?

1. chlamydia.

29

PID: Annual chlamydia screening is recommended for:
1. Sexually active women = age?
2. Sexually active women >___ that are high risk?

3. Screen pregnant women in the ___ trimester.

1. 25 and under
2. 25


3. 1st

30

Report cases of PID to the local STI program (RSH) in states where reporting is mandated.
Which STIs are reportable in all states?
2

Gonorrhea and chlamydia

31

Patient Counseling and Education
5

1. Nature of the infection
2. Transmission
3. Assess patient's behavior-change potential
4. Discuss prevention strategies
5. Develop individualized risk-reduction plans

32

What is the most common cause of androgen excess and hirsutism in women?

Polycystic Ovarian Syndrome (PCOS)
-Most common hormonal disorder among women of reproductive age

33

PCOS: Typical symptoms include?
7

Highly associated with what?

1. oligomenorrhea or
2. amenorrhea,
3. anovulation,
4. obesity,
5. acne,
6. hirsutism, and
7. infertility.

Highly associated with insulin resistance (many patients have impaired glucose tolerance or frank DM2)

34

PCOS Dx?
3

Diagnosis: no single definitive test for PCOS because no exact cause of the condition has been established (remember, this is a syndrome)

Rotterdam Criteria (est. 2003): a diagnosis of PCOS can be made with
2 out of the following 3 features (***once related disorders have been excluded):
-Oligomenorrhea (light or infrequent flow)or anovulation
-Clinical and/or biochemical signs of hyperandrogenism (acne and hirsutism)
-Polycystic ovaries on US

35

PCOS possible PP and etiology? 4

1. Defect in hypothalmic-pituitary axis causing the release of excessive LH by the anterior pituitary which cause increased androgen production in the ovary making local concentrations of androgens elevated thus inhibiting ovulation

2. Defects of ovaries which cause androgen overproduction (testosterone, androstenedione, DHEAS, DHA, 17 hydroxyprogesterone and estrone)

3. Defect in insulin sensitivity, leads to insulin resistance and compensatory hyperinsulinemia; Increased insulin levels, can stimulate androgen production by the stromal cells of the ovary.

4. Genetic factors contribute

36

1. Acanthosis Nigricans can be present in these patients because of the what?

2. Fasting blood sugar to fasting insulin ratio should be greater than ___ in a normal patient… anything below that is considered insulin resistant

3. 70% of women with PCOS have what?

4. Results in what?

5. Insulin stimulates storage of glucose in the liver and muscle cells as _______?

6. Once the maximum amount of glycogen has been reached, insulin next converts excess glucose into ___?

7. As little as ___% weight reduction can be effective in restoring regular ovulation and menses

1. elevated insulin levels

2. 4.5

3. insulin resistance

4. elevated blood glucose level

5. glycogen

6. fat

7. 10

37

Ultrasound findings of PCOS

Multiple follicles around the periphery of the ovary (this is a finding not the cause-25% of normal women can have this finding, and not all PCOS patient’s will have cystic ovaries)

Ultrasound is not necessary to make the diagnosis

38

Lab tests for PCOS
10

1. Testosterone
2. Androstenedione
3. DHEAS (dehydroepiandrosterone)
4. 17 hydroxyprogesterone
5. Prolactin
6. TSH
7. HCG
8. Fasting Blood sugar
9. Fasting Insulin level
10. LH/FSH

39

Why treat PCOS?
4

1. Decrease risk of endometrial hyperplasia and cancer,
2. possibly decrease risk of breast CA,
3. decrease all sequella that occur with DM
4. Patient satisfaction

40

PCOS therapeutic options?
5

1. ***Diet and Exercise!!:

2. OCPs:

3. Spironolactone:

4. Metformin (Glucophage)

5. Clomiphene (Clomid)

41

1. How does Spironolactone work for PCOS?


2. Make sure to monitor what?

1. acts as an antiandrogen (will help with hirsutism in conjunction with OCPs) (Well, it happens to bind with androgen receptors and block the effects of dihydrotestosterone as well)

2. Pregnancy cat. D, monitor for hyperkalemia, may be tumorigenic.

42

How do OCPs work to help PCOS?
2

1. these suppress LH and therefore suppress circulating androgens.
2. Also regulates periods (but not so good if you want to have children, right?)

43

How does metformin help with PCOS?

this helps with insulin resistance as well as weight loss

44

1. Clomid helps with which PCOS pts?

2. How does this work to help PCOS?

1. for those trying to become pregnant and are still anovulatory after diet, exercise, and Metformin have been tried

2. binds to estrogen receptors in the hypothalamus to create a state of hypoestrogenicity, thereby causing an enhanced Gonadotropin-releasing hormone (GnRH) release followed by an increased secretion of gonadotropins which induces ovulation.

45

Ovarian Disease
1. Often the key to evaluating ovarian disease is with what?

2. The ovaries should NOT be palpable when? 2

3. When can it be palpable?

4. Ovaries are palpable less frequently in reproductive age women taking what?

5. The older the woman, the more likely a tumor is what?

1. excellent history and physical exam

2. The ovaries should NOT be palpable in the premenarchal group, nor should they be palpable in the postmenopausal group

3. Ovary is palpable about half the time in the reproductive age group

4. OCPs

5. malignant versus benign

46

1. How does an ovarian cyst arise?
2. What are they?
3. Ovarian cysts occur commonly in women of what ages?

4. How does it present? 2

1. An Ovarian cyst is NOT a neoplasm, but arises as a result of normal ovarian physiology.

2. Ovarian cysts are fluid-filled sacs that develop in or on the ovary.

3. all ages

4. Some women with ovarian cysts have pain or pelvic pressure, while others have no symptoms

47

1. What is a follicular cyst?
2. How may it present?
3. WHen do they become clinically significant?
4. What are the characteristics you may find on a clinical exam? 3

5. Prognosis?
6. Management? 3
7. Rupture may produce what?

1. If an ovarian follicle fails to rupture during maturation, ovulation does NOT occur, and a follicular cyst may develop.

2. May be symptomatic or asymptomatic

3. Clinically significant if large enough to cause pain or if it persists beyond one menstrual interval

4. Characteristics on physical exam:
-mobile,
-cystic,
-adnexal mass

5. Usually spontaneously resolves

6. Management:
-Reevaluation in six to eight weeks to ensure the cyst has resolved.
-May order transvaginal US as needed on a case by case basis
-OCP may be given to suppress gonadotroin stimulation of the cyst

7. Note: rupture of a follicular cyst may produce transient acute pelvic pain

48

1. What is a Corpus Luteum Cyst?

2. Presentation? 3

3. Rupture may cause what?


4. What do you think this is confused with most of the time?

5. What simple test can help to rule out the more dangerous pathology?

1. Enlarged corpus luteum, which often continues to produce progesterone for longer than the standard 12 days.

2. Often the presentation is of
-dull lower quadrant pain
-along with a missed menstrual period
-Physical exam findings usually the same as that of a follicular cyst

3. Cyst may rupture and hemorrhage with blood causing paiin

4. Pregnancy

5. US

49

Corpus Luteum Cyst
Management
3

1. May reevaluate this patient as well to make sure cyst has resolved.
2. Patients may benefit from cyclic OCP therapy.
3. May use transvaginal US on a case by case basis

50

Ovarian Cysts
Always make sure to F/U if what?

Always make sure to follow up if palpating a mass
Some cysts can be persistent for some time and may benefit from laparoscopy

51

Ovarian Tumors
Benign Neoplasms:
1. Tumors coming from where? 4
2. 80% occur in what ages?
3. Often produce tumors markers such as?
2

1.
-Benign Epithelial Cell Tumors
-Benign Germ Cell Tumors
(-Ever heard of a benign cystic teratoma …also called a dermoid cyst)
-Benign Stromal Cell Tumors

2. 80% of these occur during reproductive years
3. Often produce tumor markers such as HCG or AFP

52

Benign Neoplasms: The following information is important to understand with regards to Benign Ovarian Neoplasms?
4

1. More common than malignant tumors of the ovary in all age groups

2. Chance for malignancy transformation increases with age

3. Warrant surgical treatment because of their potential for transformation to malignancy

4. Surgical treatment may be conservative for benign tumors, especially if future pregnancy is desired

53

Ovarian tumors-
Malignant Neoplasms:
1. What dramatically increases the risk that an ovarian enlargement is malignant?

2.
How critical is it for an aging woman to have a yearly well-woman exam even if they don’t necessarily have to have a pap smear?

1. increasing age

2. Should still have physical and bimanual exam annually. Educate your patients about this.

54

Ovarian Cancer: Malignant Neoplasms:
1. Describe the early stages of this cancer?
2. Presents most commonly in what ages?
3. What gene is associated with this?
4. What tends to have a protective effect?

1. Rarely symptomatic in the early stages of disease

2. Presents most commonly in the fifth and sixth decade of life

3. BRCA1 gene has been found to be associated with ovarian cancers in approximately 5% of cases

4. Suppression of ovulation tends to have a protective effect
-use of OCPs for five years decreased lifetime risk of ovarian cancer in half

55

Risk Factors for Ovarian Cancer
5

1. aging (especially 45-60 year old women)
2. postmenopause
3. periods of prolonged ovulation without pregnancy
4. having a 1st degree relative with ovarian, colon, or breast cancer
5. BRCA1 and BRCA2 gene mutation

56

Ovarian Cancer Screening
no effective method of mass screening has yet been developed. Neither is recommended but what are your options? 2

What is reccomended by the ACOG?

routine ultrasound and CA-125


annual bimanual exam

57

90% of ovarian malignancies are of what?

epithelial cell type

58

What is ovarian Torsion?

Complete or partial rotation of the ovary on its ligamentous supports
-the ovary typically rotates around both the infundibulopelvic ligament and the utero-ovarian ligament

59

1. Ovarian Torsion often results in what?

2. What is adnexal torsion?

1. Often resulting in impedance of its blood supply.

2. The fallopian tube often twists along with the ovary; when this occurs, it is referred to as adnexal torsion.

60

Ovarian Torsion
1. Secondary to ___________ in approximately 50-60% of patients 2. Which side more often that the other?

1. ovarian mass

2. Right more often than left (3:2)
-possibly because the right utero-ovarian ligament is longer than the left and/or that the presence of the sigmoid colon in the left side of the colon may help to prevent torsion

61

Ovarian Torsion
Presentation?
5

1. Abrupt onset of acute, severe, unilateral, lower abdominal and pelvic pain often
2. associated with nausea and vomiting.
3. Often the severe pain will come on suddenly with a change of position.
4. A unilateral, extremely tender adnexal mass is found in more than 90% of patients
5. Many patients have noted intermittent previous episodes of similar pain for several days to several weeks

62

1. Ovarian Torsion Dx?


2. Rx? 2

1. Color flow Doppler US can help with diagnosis.

2.
-With early diagnosis, patients often managed with conservative surgery
-If necrosis developing, unilateral salpingo-oopherectomy is treatment of choice