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9/04
Chief Complaint: "I have such bad pain with my periods that I have to miss work." "I have pelvic pain all the time. It hurts to have sex and it interferes with my life."
Differential Diagnoses
Primary Dysmenorrhea
Endometriosis
Adenomyosis
Pelvic Inflammatory Disease
Fibroids
Cervical stenosis
IUD
Fibromyalgia
Malignancy: Ovary, Cervix, Uterus
Work up
Detailed menstrual history and pain history
Pelvic exam, check uterosacral ligaments and cul-de-sac
Pelvic ultrasound
Labs: HCG, Cervical cultures, CBC, Sed Rate, CBC,
Guiac of stool
Problem and Treatment
Primary dysmenorrhea (Prostaglandin mediated menstrual cramps. Review normal menstrual physiology)
Treatment
a. General approach
b. Pharmacologic treatments
(1) Prostaglandin synthesis inhibitors. Note: fenamate family most effective in many clinical trials
(2) Non-PGSI's
(3) Nonpharmacologic remedies (oral contraceptive pills).
Endometriosis (Sometimes referred to as Secondary Dysmenorrhea. Note. Many women do not seek diagnosis and treatment until they are unable to get pregnant.) If your patient desires pregnancy, refer to OB-GYN for care. They may require surgery and extensive and complicated treatment. Although women with endometriosis are usually in their late 20's, 30's and 40's, adolescents and women in their early 20's may, also, have endometriosis. Remember that women with few identifiable implants found on laboroscopy may have a great deal of pain and women with extensive disease may have few symptoms.
Treatment
a. Presumptive diagnosis. Oral contraceptive pills, NSAIDS
b. Definitive diagnosis requires laproscopic exam. Surgical removal of implants.
Adenomyosis
Chronic Pelvic Pain (Pelvalgia)
Definition:
Chronic pelvic pain is noncyclic and lasts longer than 6 months and is not relieved by nonnarcotic analgesics, affects daily functioning and relationships.
Anatomy:
Fallopian tube is extremely sensitive as is broad ligament.
Sources of pain and differential diagnoses:
Chronic pelvic pain:
Plan:
I. Vulva
A. Bartholin's Duct Cyst & Abscess
1. Pathophysiology: Obstruction of the main duct of Bartholin's gland results in retention of secretions and cystic dilatation. The gonococcus is an important cause of obstruction. Cysts of these glands are the most common vulvar cysts.
2. Clinical Findings: Acute symptoms are usually the result of infection which causes pain, tenderness, and dyspareunia. The surrounding tissues become edematous and inflamed and the mass is palpable. Small, non inflamed cysts are asymptomatic and of little consequence unless the vaginal introitus is compromised.
3. Treatment: Conservative treatment includes warm vaginal baths and soaks, antibiotic therapy. Drainage of infected cysts or abscesses. Marsupialization of the cysts is performed. It involves making an incision in the mucous membrane overlying the cyst, draining the cystic cavity, excising a portion of the cyst lining and forming a stoma which eventually shrinks. The edges of the cyst was are everted and sutured to the surrounding skin and mucous membranes. I&D are temporary measures.
A. Gartner's Duct Cyst
1. Pathophysiology: Cyst-like or tubular vestiges of mesonephric or wolffian duct which may persist to a variable degree parallel to the vagina and uterus.
2. Clinical findings: Cysts found along the sides of the vagina. May be multiple or single. Large cysts may cause dyspareunia.
3. Treatment: Rarely need treatment.
A. Myoma's
1. Pathophysiology: Occur in 20-25 % of reproductive-age women. One of the most common human neoplasms. They are the most common GYN pelvic neoplasm. Often called "fibroids". This is a misnomer. The tumors are composed primarily of smooth muscle rather than fibrous tissue. Should be termed "leiomyoma". For an unknown reason, they are 3-9 times more frequent in black than white women. They grow only during the reproductive years. Often increase in size with estrogen therapy and during pregnancy. They decrease in size or disappear following menopause. Can produce infertility to hemorrhage.
a. Classification:
Submucous: These lie just beneath the endometrium and tend to compress it as they grow. They may develop pedicles and protrude into the uterine cavity.
Intramural or interstitial myomas like within the uterine wall, giving it a variable consistency.
2. Clinical findings: Usually asymptomatic. Excessive bleeding from myomas is one of the most common indication for hysterectomy in the US.
a. Abnormal endometrial bleeding. This is the most important clinical manifestation and is present in about 30% of patients. Most commonly, the patient has prolonged, heavy menses (menorrhagia), but she may display any variant along the spectrum of abnormal bleeding. Premenstrual spotting is common, as is prolonged light staining following menses. Abnormal bleeding from leiomyomas commonly produces iron deficiency anemia.
b. Pain. Not usually present. Large tumors may produce a sensation of heaviness and "bearing-down" feeling. Backache is common, but general.
c. Pressure effects. Tumors may distort or obstruct other organs. Compression of surrounding structures may cause difficulty to urinary track or GI track.
d. Infertility.
e. Spontaneous abortion. Possibly 2-3 times tin incidence in normal pregnant women.
f. Myomas are easily discovered by routine bimanual palpation of the uterus. Uterus is irregular and/or enlarged, unusually firm, mobile, nontender.
g. Laboratory: anemia often present.
Pelvic sonography.
Do a pregnancy test.
3. Treatment: Depends on patient's age, parity, pregnancy status, desire for future pregnancies, general health, and symptoms and the size, location , and state of preservation of the leiomyomas.
a. D&C To verify diagnosis. May temporally decrease bleeding.
b. Myomectomy. For symptomatic patient who wishes to preserve fertility. Helps to control chronic bleeding.
c. Hysterectomy.
d. GnRH analogs. Induce pseudomenopause.
e. See pt twice, 3 months apart to check growth, then q 6 months.
B. Adenomyosis
1. Pathophysiology: Adenomyosis is present when endometrial glands and stroma are found to be present within the myometrium. The fundus is usually the site of adenomyosis. Has been called "endometriosis interna", but it is not. Frequently found in multiparas in the late reproductive years.
2. Clinical findings: Must differentiate from pregnancy, submucous leiomyomas, endometrial cancer, endometriosis.
a. May be asymptomatic. But, often, increasing dysmenorrhea.
b. Uterus may be diffusely enlarged and globular owing to hypertrophy of the smooth muscle elements adjacent to the ectopic glands, irregularly firm, and vascular.
c. Hypermenorrhea.
d. Dysmenorrhea
e. Tests. Contrast hysterography, MRI. CBC.
3. Treatment:
a. Hysterectomy
A. Follicular cysts. Most frequently encountered type of ovarian cyst.
1. Pathophysiology. Dominant follicle fails to ovulate and continues to grow or other follicles fail to undergo atresia.
2. Symptoms: Have some effect on menses e.g. irregular menses.
3. Management: Most disappear within 60 days. Oral contraceptives man help establish a normal rhythm. R/O pregnancy.
B. Lutein cysts.
1. Corpus luteum (Granulosa Lutein) cysts.
a. Pathophysiology> After ovulation, the granulosa cell becomes luteinized. Blood accumulated. Resorption of blood results in a corpus luteum cyst. It is excessive bleeding that forms the cyst.
b. Symptoms: Irregular menses. Local pain and tenderness.
c. Treatment: R/o ectopic. Symptomatic therapy.
2. Theca Lutein Cysts.
a. Pathophysiology. Cyst filled with straw colored fluid. Associated with PCO, mole, etc.
b. Symptoms: Minimal. Sense of pelvic weight or aching.
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