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Gynae > Chronic pelvic pain/endometriosis > Flashcards

Chronic pelvic pain/endometriosis Flashcards

1
Q

Define endometriosis:

A

The presence of tissue similar to endometrium, outside of the uterus.

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2
Q

Who does endometriosis typically affect?

A

30-45yo
Nulliparous
1-2% of women

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3
Q

When does endometriosis typically regress and why?

A

After menopause and in pregnancy.

It is oestrogen dependent

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4
Q

Give 2 common places for endometriosis to exist:

A

Uterosacral ligament

Behind the ovaries (pelvis side wall)

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5
Q

Give two pathologies associated with/due to endometriosis which could be picked up on USS:

A

Chocolate cysts (endometrioma)

‘Frozen pelvis’ - endometriosis driven inflammation -> progressive fibrosis + adhesions

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6
Q

What is the thought aetiology of endometriosis?

A

Retrograde menstruation

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7
Q

Give 5 features of endometriosis:

A
  • Chronic pelvic pain -> cyclical
  • Dysmenorrhoea before onset of menstruation
  • Deep dyspareunia
  • Sub-fertility
  • Dyschezia (pain on passing stool) during menses
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8
Q

Give 3 DD of endometriosis:

A
  • Adenomyosis (endometriosis interna)
  • CPID (chronic pelvic inflammatory disease
  • Chronic pelvic pain
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9
Q

Give 4 investigations which can be performed in the case of suspected endometriosis:

A

1) Physical examination:
- Vagina: tednerness and thickening behind uterus
- Uterus can be retroverted and immobile (adhesions)

2) Laparoscopy:
- Diagnosis only made after visualisation and biopsy
- active lesions appear as red dots, large raides red vesicles
- Less active - black powder-burn dots
- severe disease: ovarian endometriomas + ^^adhesions

3) Transvaginal USS:
- to exclude ovarian endometriomas
- adenomyosis detection (endometriosis inside myometrium) (MRI better however)

4) MRI +/- intravenous pyelogram (IVP):
- used to detect even peritoneal endometriosis, ureteric, bladder and bowel involvement.
- CA 125 sometimes elevated

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10
Q

Give 4 SE of progestogens:

A
  • Fluid retention
  • Weight Gain
  • Erratic bleeding
  • Premenstrual syndrome-like features
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11
Q

What is an intravenous pyelogram (IVP)?

A

X-ray examination of kidneys, ureters and bladder which used iodinated contrast media which is injected into the veins

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12
Q

What is the medical Rx of endometriosis?

A

Choose one of the following:

  • Analgesia
  • COCs
  • GnrRH-analogues (down regulates GnRH receptors) + add-back HRT (to maintain bone mineral density)
  • IUS - progesterone IUS helps with dysmenorrhoea
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13
Q

What is the issue with medical treatment of endometriosis?

A

That once medical treatment ends, endometriosis usually recurs.

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14
Q

What are the surgical Rx for endometriosis?

A
  • Laparoscopic laser ablation +/- adhesiolysis

- Hysterectomy +/- BSO -> +HRT if ovaries removed

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15
Q

How does endometriosis relate to fertility?

A

Severity correlated with sub-fertility.

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16
Q

When can Rx help to improve fertility in endometriosis?

A

If fallopian tubes affected.

Chocolate cysts can be stripped/drained (ovarian endometriomas)

17
Q

What is the definition of chronic pelvic pain (CPP)?

A

Intermittent or constant pain in the lower abdomen for >6 months, not exclusively with menstruation or intercourse.

18
Q

What Ix should be performed for CPP?

A
  • Transvaginal USS (TVUSS) or MRI
  • Full Hx (to r/o non-gynae causes)
  • Psychological evaluation
19
Q

List 5 causes of chronic pelvic pain:

A
  • Endometriosis and adenomyosis (pain varies with menstrual cycles)
  • Pelvic/ovarian adhesions
  • IBS
  • Psychological factors
  • Pelvic congestion syndrome (venous congestion in pelvis)
  • Myofascial syndrome
20
Q

If a patient presents with IBS-like CPP, what would you prescribe?

A
  • Antispasmodics (antimuscarinic: hyoscine)

- Analgesia

21
Q

If a patient presents with cyclical pelvic pain, what Rx would you give?

A
  • COC or GnRH-analgogue with add-back HRT for 3-6months

- If no improvement after 3-6 months, diagnostic laparoscopy

22
Q

If you suspect a patients CPP if due to psychological origins, what Rx would you provide?

A
  • Counselling and psychotherapy
  • Pain management programmes (relaxation techniques, diet, exercise, sex therapy)
  • Amitriptyline (tricyclic antidepressant) or gabapentin (inhibits calcium channel receptors which inhibits neurotransmitter release)
23
Q

When is gabapentin and pregablin typically used for?

A
  • Focal Epilepsy
  • Neuropathic pain
  • Generalised Anxiety disorders
  • Migraine Prophylaxis

Gynae (8 decks)

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