Pelvic Pain and Masses

Question 1

Common conditions that can cause acute abdominal pain

Answer 1

appendicitis, cholecystitis, choledocholithiasis, diverticulitis, pancreatitis, bowel, perforation, mesenteric ischemia, ischemic colitis, intestinal obstruction

Question 2

three categories of gynocologically cause abdominal pain

Answer 2

acute cases in nonpregnant
chronic problems in nonpregnant
acute cases in pregnant

Question 3

PID, adnexal torsion, ruptured ovarian cyst, horrhage corpus luteum cyst, ovarian torsion, endometriosis, tubovarian abscess all fall into what category of gynecologic cause of abdominal pain

Answer 3

acute causes in nonpregnant

Question 4

Dynmenorrhea, Mittelscherz, Endometriosis, obstruction mullerian duct abnormalities, leiomyomas, cancer, pelvic congestion syndrome all fall under the category of what gynecologic cause of abdominal pain

Answer 4

chronic causes in nonpregnant

Question 5

ectopic pregnancy, retained products of conception, septic abortion, and ovarian torsion all fall under what category of gynecologic cause of abdominal pain

Answer 5

acute causes in pregnancy

Question 6

what do you want to include in your history when assessing a patient with abdominal pain

Answer 6

LMP, menstrual history, sexual history, family history

Question 7

pain associated with menstural cycle

Answer 7

dysmenorrhea

Question 8

primary vs secondary dysmenorrhea

Answer 8

primary has no pathologic findings.

Secdonary as some associated findings/pathology.

Question 9

What is the etiology of dysmenorrhea?

Answer 9

increased production of endometrial prostaglandin → increases uterine tone and uterine contraction during menses

Question 10

Patient presents with low midline cramping pain during peak flow; occasionally associated with nausea, vomiting, diarrhea, headahce, flushing, fatigue

Answer 10

primary dysmenorrhea

Question 11

what symptoms would warrant further workup in primary dysmenorrhea?

Answer 11

dysmenorrhea before age 25
abnormal pelvic exam
infertility

Question 12

Treatment for primary dysmenorrhea

Answer 12

NSAID, Cox 2 inhibitor

oral contraceptive, depo, levonorgestrel IUD

Question 13

What fall under the category of secondary dysmenorrhea?

Answer 13

endometriosis, adenomyosis, uterine fibroids, ovarian cysts, ovarian torsion

Question 14

abnormal growth of endometrial tissue outside of the uterus → irritates surrounding tissue and may develop scar tissue or adhesions

Answer 14

endometriosis

Question 15

Endometriosis is the leading cause for what 2 things

Answer 15

chronic pelvic pain and infertility

Question 16

when will a patient with endometriosis have the most pain?

Answer 16

occurs around cycle

Question 17

What is believed to be the etiology of endometriosis?

Answer 17

retrograde menstruation

Question 18

what can pelvic exam reveal in patient with endometriosis?

Answer 18

tender nodules in cul-de-sac or rectovaginal septum, decreased uterine mobility, cervical motion tenderness, adnexal mass or tenderness

Question 19

How is endometriosis diagnosed?

Answer 19

histology of lesions removed at surgery

Question 20

What is the preferred medical management for endometriosis?

Answer 20

hormonal therapy → lowers hormone levels and prevents cyclic stimulation of endometrial implants → induces atrophy

Question 21

what is approved in treating endometriosis associated pain?

Answer 21

progestins → oral norethindrone acetate and subQ DMPA (Depo)
GnRH agonist

Question 22

What are some side effects seen in GnRH agonists?

Answer 22

vasomotor symptoms and bone demineralization

Question 23

What is the androgenic drug that may be used for endometriosis associated pain?

Answer 23

danazol

Question 24

What are side effects of Danazol?

Answer 24

decreased breast size, weight gain, acne, hirsutism

Question 25

If a patient with endometriosis desires fertility what is the preferred treatment management?

Answer 25

laparoscopic ablation of endometrial implants

Question 26

If a patient with endometriosis does not desire fertility and/or if the pain is too bad, what is the preferred treatment??

Answer 26

total abdominal hysterectomy and bilaterial salpingo-oophrectomy add HRT if premenopausal

Question 27

Symptoms of endometriosis

Answer 27

dysmenorrhea, dyspareunia, pain with BM/urination, excessive bleeding, infertility

Question 28

Term for endometrial tissues that grows into the muscular wall of the uterus

Answer 28

adenomyosis

Question 29

Symptoms of adenomyosis

Answer 29

heavy/prolonged menstrual bleeding, dysmenorrhea, menstrual cramps throughout period, dyspareunia, blood clots pass during period

Question 30

How will adenomyosis present on pelvic exam?

Answer 30

enlarged and tender uterus

Question 31

What is the treatment for adenomyosis?

Answer 31

NSAID and hormonal contraceptive → hysterectomy if all fails

Question 32

Most common benign neoplasm of female genital tract

Answer 32

uterine leiomyoma (fibroid)

Question 33

Most common location for uterine fibroid → within the uterine wall

Answer 33

intramural

Question 34

Uterine fibroid develops just under the lining of the uterine cavity

Answer 34

submucosal or pedunculated subucosal

Question 35

uterine fibroid located near the outside of the uterus and may prodrude into the abdominal cavity

Answer 35

subserous or pedunculated subserois

Question 36

Uterine fibroid found in the supporting structures

Answer 36

intra-ligamentois

Question 37

Uterine fibroid that develops in the cervis

Answer 37

cervical

Question 38

What is believed to be the cause of uterine fibroids?

Answer 38

muscle cells that transform and is stimulated to grow into benign tumor

Question 39

When will uterine fibroids quit growing?

Answer 39

during menopause → usually hormonally responsive to estrogen and progesterone

Question 40

What race has greater lifetime risk for fibroids?

Answer 40

AA > Caucasians

Question 41

What are risk factors for fibroids?

Answer 41

AA, smoking, early menarche, nulliparity, EtOH use, HTN

Question 42

Two most common symptoms of uterine fibroids and are what makes women seek treatment (otherwise asymptomatic)

Answer 42

abnormal uterine bleeding (heavier and longer) | pelvic pain/pressure

Question 43

If a fibroid degenerates, how will the patient feel?

Answer 43

intense pain

Question 44

How can uterine fibroids complicate pregnancy?

Answer 44

increase risk of miscarriage if they distort uterine cavity, possible preterm labor and delivery

Question 45

What lab finding may you find in patient with uterine fibroid?

Answer 45

IDA

Question 46

what imaging technique can you used to confirm and monitor the growth of uterine fibroid?

Answer 46

US

Question 47

What imaging technique would you use to differentiate intramural and submucous myomas?

Answer 47

MRI

Question 48

What imaging technique is used to confirm cervical or submucous myomas?

Answer 48

hysterography or hysteroscopy

Question 49

What is the treatment for acute torsion of pedunculated myoma?

Answer 49

emergency surgery

Question 50

If you are performing emergency surgery for uterine fibroid and the patient is severely anemic, what do you give them pre-operatively?

Answer 50

DMPA or GnRH agonist

Question 51

What is the only emergency indication for myomectomy during pregnancy?

Answer 51

torsion

Question 52

What would be indication for surgical removal of uterine fibroid?

Answer 52

patient symptoms and desire for fertility

Question 53

What uterine fibroids require removal?

Answer 53

cervical myomas > 3-4 cm | pedunculated myoma that protrude through the cervix

Question 54

How can you preoperatively reduce the size of myoma?

Answer 54

GnRH analogs

Question 55

What is the curative treatment for uterine fibroid?

Answer 55

surgery

Question 56

What treatment can a woman get for uterine fibroid if she desires fertility in the future? What are some risk factors?

Answer 56

myomectomy → recurrence is common and post OP pelvic adhesions

Question 57

Three types of functional ovarian cysts

Answer 57

follicular, corpus luteum, theca luteum

Question 58

This cyst is common in reproductive age women → forms when follicle fails to rupture and release the egg → often spontaneously resolves

Answer 58

follicular cyst

Question 59

This cyst is common in reproductive age women → forms when corpus luteum fails to regress → may produce progesterone and may be hemorrhagic

Answer 59

corpus luteum cyst

Question 60

when does follicular cyst become clinically significant?

Answer 60

large enough to cause pain or persists beyond one menstural cycle

Question 61

Symptoms that patient with follicular cyst present with

Answer 61

lower abdominal/pelvic pain, irregular bleeding

Question 62

What occurs when corpus luteum cyst develops?

Answer 62

when the follicle ruptures and releases the egg and if fluid accumulates when it is sealing off → cyst forms

Question 63

What cyst is considered postovulatory?

Answer 63

corpus luteum cyst

Question 64

What fertility drug increases risk for for cyst formation?

Answer 64

clomiphene (Clomid)

Question 65

What are symptoms of corpus luteum cyst?

Answer 65

pain and missed period (produce progesterone longer than usual and delay menstruation)

Question 66

The least common cyst and often associated with pregnancy (high HCG)

Answer 66

theca lutein cyst

Question 67

Cyst containing tissue (such as hair, skin, teeth) since they are derived from germ cells (oocytes)

Answer 67

dermoid cyst

Question 68

cyst that develops from ovarian tissue and may be filled with watery liquid or mucous → mostly benign

Answer 68

cystademonas

Question 69

cyst that develops as a result of endometriosis tissue within the ovary → "Chocolate Cyst"

Answer 69

endometriomas

Question 70

If ovarian cyst gets too large what is the patient at risk for?

Answer 70

torsion of ovary

Question 71

What would occur that would require prompt intervention with a cyst?

Answer 71

rupture or bleed

Question 72

What labs would you order for patient with ovarian cyst?

Answer 72

pregnancy test, CA 125

Question 73

What is the only way to diagnosi ovarian cyst?

Answer 73

pelvic US

Question 74

How do you diagnose and treat ovarian cyst?

Answer 74

laparoscopic surgery

Question 75

How do you treat cysts and prevent others from forming?

Answer 75

watchful waiting | hormone therapy may prevent new cysts

Question 76

ovary twists around supporting structures → occlusion of vascular supply to ovary →ischemia → pain

Answer 76

ovarian torsion

Question 77

Two etiologies of ovarian torsion

Answer 77

complication of ovarian cyst and pregnancy is risk factor

Question 78

signs and symptoms of ovarian torsion

Answer 78

sudden, acute abdominal/pelvic pain (constant or intermittent), pelvic tenderness

Question 79

How do you diagnose ovarian torsion?

Answer 79

US with Doppler

Question 80

How do you definitely diagnose and treat ovarian torsion ?

Answer 80

laparoscopy

Question 81

How do you treat recurrent ovarian cysts that cause torsion?

Answer 81

salpingo-oophrectomy