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Chronic Pelvic Pain/Menstrual Abnormalities Flashcards

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1
Q

Chronic pelvic pain definition

A

Noncyclic pain lasting for ***more than six months that localize to the anatomic pelvis, anterior abdominal wall, at or below the umbilicus, the lumbosacral back or buttocks
And is of sufficient **severity to cause, functional disability or lead to medical care

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2
Q

History in patient with chronic pelvic pain should include

A

Timing
Localization
Quality
Radiation
Intensity
Duration
Alleviating or aggravating factors
Patient perception

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3
Q

What do you want to know the relationship to in possible CPP

A

Relationship of pain to *Menstrual cycle
Bowel movements, intercourse, urination, physical activity

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4
Q

What physical exams do you want to perform for a patient with possible chronic pelvic pain

A

Abdominal exam to locate pain and determine radiation, peritoneal inflammation, etc.
Pelvic exam to localized pain and determine pathology
Back exam to determine skeletal or renal origin

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5
Q

What does every woman with abdominal pelvic pain must have

A

Pelvic and rectal exam

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6
Q

What further investigation steps do you want to do for a patient with possible CPP?

A

Labs- CBC, ESR, CMP to evaluate for infection, inflammation
Culture of vaginal discharge - rule out STI
HCG - rule out pregnancy, ectopic
Urine studies - rule out infection
Psychological evaluation - usually last resort if you can’t find a cause

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7
Q

What imaging studies can you perform for possible CPP?

A

Ultrasound- pelvic or transvaginal ultrasound can evaluate uterus, ovaries, and fallopian tubes
Plain film radiography (XR) - flat, an upright, abdominal radiographs to rule out intestinal obstruction or other G.I. disorders. Also want to look at pelvis to see if they’re passing a kidney stone
CT and MRI provide information on anatomic structures and differentiate abdominal from uterine mass
G.I. pathology may be evaluated with barium enema , colonoscopy, or proctoscopy

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8
Q

What imaging can you do to evaluate renal system?

A

Cystoscopy or pyelography
Need to have renal consultation

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9
Q

What is the ultimate method to diagnose etiologies of CPP?

A

Laparoscopy

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10
Q

What is the most common indication for laparoscopy?

A

CPP

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11
Q

Why are the three signs and symptoms(distinguishable) of endometriosis?

A

3 “Ds”
Dyspareunia, dysmenorrhea, dyschezia

Adhesions, scarring
Pain doesn’t let up after Cycle, severe pain

organic cause of CPP

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12
Q

What is the suspected cause of endometriosis?

A

Retrograde flow when women have menses and tissue can flow through fallopian tubes

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13
Q

18 to 35% of women status post what develop CPP

A

Chronic PID
Patients have adhesions and inflammation
Fitz Hugh curtis - adhesions between liver and diaphragm showing “violin string”

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14
Q

How can ovarian cysts cause chronic pelvic pain?

A

May result in pain from rapid distention of ovarian capsule or torsion of the ovary

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15
Q

What is adenomyosis?

A

Endometrial tissue within uterine musculature (myometrium)
Causes dysmenorrhea and dyspareunia

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16
Q

What are leiomyomas also known as

A

Fibroids

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17
Q

When do fibroids cause pain?

A

Leiomyomas do not cause pain unless degenerating, undergoing torsion, or pressing on nerves

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18
Q

What is pelvic congestion syndrome? What is the treatment?

A

Varicosities of pelvic veins and congested organs cause premenstrual pain, worse with fatigue, standing and intercourse
Veins are dilated and pressing on structures
Dx- Doppler US or laparoscopy
Tx- vasoconstrictors or hormones (progestins, GnRH agonists, embolotherapy, vein ligation, hysterectomy)

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19
Q

What are some genitourinary causes of chronic pelvic pain?

A

Urinary retention, cystitis, trigonitis

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20
Q

What are some symptoms of cystitis?

A

Frequency, urgency, dysuria, pelvic pain, blood in urine
This is chronic inflammation of the submucosal surface of the bladder
Can result from holding urine too long

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21
Q

Why can G.I. and GYN pain be difficult to distinguish?

A

Innervation of lower G.I. tract is the same as the uterus and fallopian tubes

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22
Q

What are some Gastro intestinal causes of CPP

A

Penetrating neoplasm of G.I. tract
Irritable bowel syndrome
Partial bowel obstruction
Diverticulitis
Hernia

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23
Q

How can neuromuscular pain cause CPP

A

Pain of neuromuscular origin presents as low back pain and increases with activity and stress
Can indicate radiating pain

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24
Q

Who is included in a multi disciplinary pain clinic for CPP

A

Gynecologist
Psychologist
Anesthesiologist
Acupuncturist

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25
Physical Therapy management of chronic pelvic pain
Hot cold applications Stretching Ultrasound therapy Transcutaneous electrical nerve stimulation(TENS)
26
Medical management of chronic pelvic pain
Trial of ovulation/ menstruation suppression with birth control pills, progestins, GnRH agonist can help if pain is related to menstrual cycle or ovarian pathology(cysts) NSAIDs are useful Antidepressants (increase norepinephrine, serotonin)
27
When do you manage CPP surgically?
Only if pathology is discovered
28
When is something considered an abnormality of menstruation?
When it occurs for more than three months
29
What is menorrhagia?
Prolonged or excessive uterine bleeding at regular intervals (>80 mL or longer than seven days) A.k.a. Hypermenorrhea
30
What is metrorrhagia?
Irregular menstrual bleeding or bleeding between periods
31
What is menometrorrhagia?
Frequent menstruation bleeding that is excessive and irregular in amount and duration
32
What is oligomenorrhea?
Menstrual flow at intervals of over 35 days in frequency
33
What is polymenorrhea
Menstrual flow at intervals of less than 21 days
34
What can cause abnormal uterine bleeding in newborns?
Withdrawal bleeding Newborn girls get withdrawal from hormones from mom - common within days after birth
35
Causes of abnormal uterine bleeding before menarche (before normal age range)
Malignancy Trauma or sexual abuse Foreign body Urinary tract problems or irritation Precocious puberty (early start of puberty before 9)
36
What age should the hypothalamic pituitary axis be matured?
18 to 21 years
37
When may periods be irregular?
For the first few months, may be up to a year
38
In childbearing years abnormal bleeding may be caused from this, so you have to rule it out first
Pregnancy and pregnancy related conditions (ectopic, abruptio placenta, spontaneous abortion)
39
Once pregnancy is ruled out what are other causes of abnormal bleeding in childbearing years
Medication’s- (anticoagulants, psych meds, corticosteroids, OC’s, Hormone Replacement Therapy (HRT) Medical problems - thyroid, hematologic disorders, hepatic disorders (liver impacts platelet production), adrenal, pituitary, hypothalamic problems IUD- usually when newly placed
40
GYN disorders that can cause abnormal bleeding in childbearing years
Anovulation PCOS Neoplasms , endometrial intraepithelial neoplasia, endometrial cancer Trauma Cervical polyps STI’s Leiomyomas (fibroids)
41
Palm-Coein Classification for Abnormal Uterine Bleeding
Abnormal uterine bleeding can be distinguish between structural and nonstructural causes
42
PALM CAUSES OF ABNORMAL UTERINE BLEEDING
Palm is structural Polyp Adenomyosis Leiomyoma Malignancy and hyperplasia
43
COEIN causes of abnormal uterine bleeding
Non-structural causes Coagulopathy Ovulatory dysfunction (hormonal) Endometrial Iatrogenic Not yet classified
44
Evaluation of abnormal uterine bleeding in childbearing years
History Specifics of bleeding, prior GYN problems, STI’s, abnormal paps, sexual history, contraceptives, medication’s PE Evaluate for coagulopathies, liver, thyroid disease Pelvic exam to verify source of bleeding Rectal exam Diagnostic test- HCG , CBC, platelet, bleeding time, thyroid, liver function, Pap smear(not in emergency setting), endometrial biopsy, ultrasound
45
What is the average age for menopause in women in the US?
51 years
46
abnormal bleeding in Perimenopause women
During perimenopause (up to five years before menopause) periods become irregular Rule out, endometrial cancer and pregnancy
47
What is postmenopausal bleeding considered unless proven otherwise
Cancer!
48
Benign causes of bleeding after menopause
Atrophic vaginitis(thin vaginal walls) Polyps Endometrial hyperplasia
49
Evaluation of abnormal bleeding after menopause
Transvaginal or abdominal ultrasound Dilation and curettage (can you remove an entire section of abnormal tissue or can biopsy) Endometrial biopsy
50
In patients with mild bleeding like in asymptomatic or no blood changes what can you do to treat?
Oral contraceptives, maybe used to suppress the endometrium and establish regular predictable withdrawal cycles
51
In severe endometrial hemorrhage what do you do first
Patient is hypotensive, anemic Address bleeding quickly stabilize the patient first
52
What can prolonged endometrial bleeding be caused by?
May be a result of denuded epithelial lining (very thin, can worsen bleeding
53
If the patient is having a severe endometrial hemorrhage what do you do first? if successful what do you do?
High dose estrogen to support endometrium and stop bleeding If successful, follow with low-dose estrogen +/- progestin- OC’s 3/day for a week
54
If medical treatment feels of severe, endometrial hemorrhage, what can you do?
D&C, endometrial ablation, or hysterectomy may be necessary to control bleeding Ablation or hysterectomy is usually used for patients who don’t want children
55
What is dysfunctional uterine, bleeding considered
Diagnosis of exclusion
56
DUB definition
Abnormal uterine bleeding in women between menarche and menopause that cannot be attributed to medications, blood disorders, systemic disease, trauma, uterine neoplasms, or pregnancy
57
What is anovulatory bleeding most commonly caused by in adolescents
Problem or immaturity of the hypothalamic pituitary system Check hormones
58
What can cause anovulatory bleeding in perimenopausal women?
May result from declining function of the ovary
59
Treatment of the DUB for younger, more mild cases
Maybe educated or treated with oral contraceptives for 21 days with 7 day withdrawal (28 day pack) If withdrawal is positive (bleed) indicates it could be hormone related This suppresses endometrial development and reestablishes normal patterns and decreases blood loss
60
Treatment of DUB in a stable patient with moderate bleeding
Cyclic estrogens with progesterone added for the last 10-15 days of the 25 day cycle expect withdraw bleeding for 5 to 7 days when you stop taking progesterone Repeat each month for 3 to 6 months - normal pattern may be established
61
Who should not receive oral contraceptives? why?
Should not be given to smokers >35 years (and increased BMI) OCs increase the risk of blood clots, can lead to PE
62
What can you do if Medical therapies fail to control DUB?
Endometrial biopsy, vaginal ultrasound, or saline infused sonohysterography for further Dx If all else fails Hysterectomy or endometrial ablation (allows new tissue (scar tissue) to grow back) * results in infertility**
63
What is primary amenorrhea?
No spontaneous uterine bleeding by the age of 15 with normal secondary characteristics (has all physical stages of development) OR 13 years with abnormal secondary sexual characteristics (no development of breast bud, no coarse/fine hair on mons pubis, etc.)
64
What is secondary amenorrhea?
Absence of menstrual periods for 3 to 6 months, or the duration of three typical menstrual cycles for the patient * has already established bleeding*
65
Amenorrhea may result from
Pregnancy (most common) Hypothalamic pituitary causes (not making hormones) Ovarian/ovulatory dysfunction (not responding to hormones) Uterine causes
66
Hypothalamic pituitary causes of amenorrhea
Congenital deficiency of GnRH Hypothalamic pituitary dysfunction Defect of GnRH transport Defects of GnRH pulse production Congenital absence of pituitary
67
What is congenital deficiency of GnRH? Primary or secondary
No GnRH secretion from the hypothalamus, so the anterior pituitary is not told to secrete FSH or LH Follicular recruitment an ovulation do not occur Sexual maturation may be delayed or completely absent * primary amenorrhea*
68
What is hypothalamic pituitary dysfunction? Primary or secondary
GnRH release occurs in pulsatile fashion normally. If disrupted, anterior pituitary is not stimulated to secrete FSH and LH Follicles do not develop. Ovulation does not occur. * primary amenorrhea*
69
What is can cause defect of GnRH transport?
Hypothalamic lesions (craniopharyngioma) Benign brain tumor near pituitary Prevents flow of GnRH from hypothalamus to pituitary Want to recommend imaging to rule out tumor , can have neurological side effects
70
What can cause defects of GnRH pulse production?
Anorexia nervosa (affects secretion of hormones) Extreme weight loss (thyroid hormones) Severe stress Vigorous athletic exertion LH , FSH not released, follicles do not develop no ovulation
71
Congenital absence of pituitary causes what
Rare- lethal
72
What is Sheehan’ syndrome?
Pituitary defect causing amenorrhea Pituitary ischemic necrosis resulting from postpartum hemorrhage and severe hypotension Not enough oxygen to pituitary almost like an ischemic stroke - permanent damage
73
What are some ovarian causes of amenorrhea?
PCOS Turner syndrome Premature ovarian failure
74
What is PCOS? Primary or secondary amenorrhea
Polycystic ovarian syndrome Secondary amenorrhea *This is not a problem with GnRH * Cystic ovaries inhibit the follicles from doing what they’re supposed to (hormone imbalance)
75
Signs and symptoms of PCOS
Insulin resistance (BGL high= eat more) and obesity Anovulation Hirsuitism (facial hair) Androgen excess ( deepened voice) Infertility Clitoromegaly
76
What is turner syndrome? Signs and symptoms?
Also called Gonadal dysgenesis Abnormal X chromosome 45x (one X is missing or partially missing ) Webbed neck, increased carrying angle, streak (nonfunctional) ovaries, infertility, short stature, shield chest Ovaries aren’t developed or are under developed so they don’t function Some cases may have a little ovarian function with hormones
77
What is premature ovarian failure?
Depletion of over before age of 40 (stop making estrogen or responding to GnRH) Cause unknown Signs and symptoms of menopause
78
Uterine causes of amenorrhea
Congenital absence or malformation of the uterus Unresponsive or a trophic endometrium Ashermans Syndrome Imperforate hymen
79
What is Asherman syndrome?
Scarring adhesions of the uterine cavity as a result of D&C or ablation May be treated with lysis of adhesions if mild estrogen after surgery to regenerate denuded areas of endometrium Scar tissue prevents endometrium from shedding For women who want to have kids- hormone therapy
80
Imperforate hymens can cause
False amenorrhea More common in peds maybe bleeding but has no outlet This is why physical exam is important
81
Lab tests for amenorrhea
TSH Estrogen FSH LH Testosterone Thyroid studies Pregnancy test MRI or CT of hypothalamus or pituitary Genetic evaluation Evaluate anatomy of uterus or service with ultrasound or MRI
82
What are girls with permanent hypogonadism (turner syndrome) treated with?
Estrogen replacement therapy May help secondary characteristics to develop, but still infertile
83
What can be used for treatment of pituitary tumors?
Bromocriptine which inhibits the high prolactin secretion, surgical excision, radiation therapy
84
Galactorrhea
Hyperprolactinemia Ask about discharge from nipple (milk)
85
What can estrogen deficiency reveal on physical exam?
Smooth vaginal, dry endocervix
86
What is the progesterone challenge?
Progesterone given and if there’s withdraw bleeding indicates presence of estrogen if no bleeding, low estrogen levels or problem with outflow tract
87
Who does primary dysmenorrhea affect most? When does it occur? Etiology?
Usually affects women in late teens to early 20s Occurs during ovulatory cycles Etiology- excess prostaglandin production Prostaglandins cause forceful uterine muscle contraction
88
Clinical features of primary dysmenorrhea
Cramping starting several hours after onset of bleeding, lasting hours or days Lower abdomen pain- may radiate to thighs, lower back Pane may be associated with altered bowel habits, nausea, vomiting, fatigue, dizziness, headache, but *not dyspareunia* PE/pelvic exam usually normal
89
Treatment for primary dysmenorrhea
NSAIDs- ibuprofen(Motrin), naproxen(Naprosyn) to decrease prostaglandin production Oral contraceptives, reduce menstrual flow and inhibit ovulation Topical heat Diet low in fat and meat decrease intensity of dysmenorrhea DepoProvera and Mirena IUD (may) benefit If no response considered secondary dysmenorrhea with further work up (ultrasound, laparoscopy) to exclude pelvic pathology
90
What is secondary dysmenorrhea? When does it develop and what is a usually associated with?
Painful menstruation due to some underlying cause, prostaglandins may be involved Develops in women in 30s and 40s May occur before during or after menses Usually associated with dyspareunia, infertility, or abnormal bleeding Little or no response to NSAIDs or oral contraceptives
91
Clinical findings in secondary dysmenorrhea
Pelvic pathology may be noted during pelvic exam Adnexal tenderness Pelvic masses or nodules
92
What are some causes of secondary dysmenorrhea?
Endometriosis Adenomyosis
93
What are some clinical features of endometriosis causing secondary dysmenorrhea
Pane may be premenstrual postmenstrual or continuous WITH dyspareunia Pre-menstrual spotting , on ultrasound you can see tender pelvic nodules Onset in 20s or 30s but may start in teens
94
Clinical features of secondary dysmenorrhea in fibroids and adenomyosis
Dysmenorrhea with dull pelvic dragging sensation Uterus enlarged and may be tender
95
Evaluation of secondary dysmenorrhea
Cervical c/x to rule out STI WBC to r/o infection HCG to rule out pregnancy Pelvic US to evaluate intrauterine or ectopic pregnancy, pelvic mass, ovarian cysts Hysterosalpingogram to r/o endometrial polyps, fibroids Laparoscopy to determine pathology
96
What is a hysterosalpingogram?
Die is injected, looking at patency of fallopian tubes
97
What is premenstrual syndrome (PMS)
Emotional and physical symptoms occurring in luteal phase of menstrual cycle, which interfere with some aspects of a patient’s life More severe dysmenorrhea
98
What is more significant than PMS
Premenstrual Dysphoric Disorder (PMDD) symptoms are severe, and significantly disrupt daily functioning and relationships
99
PMS causes
Exact is not known Abnormal serotonin response from normal hormonal fluctuations Altered levels of estrogen, progesterone, endorphins, catecholamines Vitamin and mineral deficiencies
100
Physical symptoms of PMS
Abdominal pain Breast tenderness and swelling Bloating Weight gain Edema headache
101
Diagnosing PMS
No specific lab test Symptom diary over 2 to 3 menstrual periods to evaluate timing and symptoms
102
Nonpharmacologic treatment of PMS
Reassurance Adequate rest Aerobic exercise Diet, high in fruits and vegetables **Low sodium sugar, caffeine chocolate, alcohol and fat
103
Over the counter therapies for PMS
Midol, premsyn contain mild diuretics, analgesics, prostaglandin inhibitors, anti-histamines
104
Pharmacologic treatment of PMS
Vitamin and mineral supplementation for electrolyte imbalance Mild diuretics (Spironolactone) SSRI antidepressants (fluoxetine- Prozac) in luteal phase GnRH agonists (Lupron) Physical behavioral symptoms NSAIDs for dysmenorrhea , breast pain, edema Anti-anxiety meds - BuSpar(buspirone) **Oral contraceptives may worsen symptoms of PMS/PMDD **

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