Obgyn Gyn Problems Ii

OBSTETRIC & GYNECOLOGY OBSTETRIC & GYNECOLOGY

COMMON GYNECOLOGICAL COMMON GYNECOLOGICAL

PROBLEMSPROBLEMS

Part IIPart II

Pascale Gehy-Andre PA-CPascale Gehy-Andre PA-C

Common Gynecological Common Gynecological ProblemsProblems

LEIOMYOMALEIOMYOMA

ADENOMYOSISADENOMYOSIS

ENDOMETRIAL POLYPSENDOMETRIAL POLYPS

ENDOMETRIOSISENDOMETRIOSIS

GYNECOLOGICAL ABDOMINAL PAINGYNECOLOGICAL ABDOMINAL PAIN

LeiomyomasLeiomyomas

LeiomyomasLeiomyomas

UTERINE LEIOMYOMA INCIDENCEUTERINE LEIOMYOMA INCIDENCE

- AKA: Myoma, fibroid fibromyoma & benignAKA: Myoma, fibroid fibromyoma & benign- Myomata UteriMyomata Uteri - Common benign tumors in female of - Common benign tumors in female of

reproductive agereproductive age- - 20 to 40% of women by age 40- 20 to 40% of women by age 40- 3 to 9 X more common in black women 3 to 9 X more common in black women - Varying size from 15 cm to > 100 lbsVarying size from 15 cm to > 100 lbs- Usually more common multipleUsually more common multiple

LEIOMYOMA ETIOLOGYLEIOMYOMA ETIOLOGY

- Smooth muscle and some connective tissueSmooth muscle and some connective tissue-Originate from the myometriumOriginate from the myometrium-Etiology is unknownEtiology is unknown-Estrogen sensitiveEstrogen sensitive

Increase in pregnancy Increase in pregnancy

Decrease with menopauseDecrease with menopause

LOCATION OF LEIOMYOMASLOCATION OF LEIOMYOMAS

Classification is by anatomic location:Classification is by anatomic location:Uterine 95% Cervical 5%Uterine 95% Cervical 5%

SUBMUCOSALSUBMUCOSAL (Immediately beneath (Immediately beneath the endometrium)the endometrium)

INTRAMURAL OR INTERSTITIALINTRAMURAL OR INTERSTITIAL (within the uterine wall)(within the uterine wall)

SUBSEROSALSUBSEROSAL ( beneath the serosa) ( beneath the serosa) PEDUNCULATED (may become parasitic)PEDUNCULATED (may become parasitic)

Leiomyoma of the Leiomyoma of the UterusUterus

LEIOMYOMA HistoryLEIOMYOMA History-Most are asymptomatic-Most are asymptomatic

Symptoms depends on size, location, pregnancy, Symptoms depends on size, location, pregnancy, sarcomatous degeneration (0.1 to 0.5%)sarcomatous degeneration (0.1 to 0.5%)

Abnormal uterine bleeding; most commonAbnormal uterine bleeding; most common

-Menorrhagia, metrorrhagia-Menorrhagia, metrorrhagia

Dysmenorrhea is not a typical featureDysmenorrhea is not a typical feature

Pain: Vascular compromise, torsion, infectionPain: Vascular compromise, torsion, infection

Large fibroids can put pressure on the rectum Large fibroids can put pressure on the rectum causing constipation.causing constipation.

Fever, spontaneous abortion, infertilityFever, spontaneous abortion, infertility

LEIOMYOMALEIOMYOMA

Physical Exam and laboratory Physical Exam and laboratory findingsfindings

Most discovered by routine P/EMost discovered by routine P/ECBC; + anemiaCBC; + anemiaPelvic UltrasoundPelvic Ultrasound

particularly helpful in obese Patientsparticularly helpful in obese PatientsPelvic/ low abdominal XraysPelvic/ low abdominal XraysMRI gives accurate definition of size, MRI gives accurate definition of size,

location, and numberlocation, and numberEndometrial biopsyEndometrial biopsyFractional D&CFractional D&CHysteroscopy/laparoscopyHysteroscopy/laparoscopy

LEIOMYOMALEIOMYOMATREATMENTTREATMENT

Corrective measures for AnemiaCorrective measures for Anemia

Asymptomatic requires no treatment Asymptomatic requires no treatment

GnRH agonists (Lupron) may be considered in poor GnRH agonists (Lupron) may be considered in poor surgical candidatessurgical candidates-Hysterectomy Hysterectomy

--Myomectomy because pregnancy is possible Myomectomy because pregnancy is possible Requires q 6 month F/U. 33% will need hysterectomyRequires q 6 month F/U. 33% will need hysterectomy

LEIOMYOMALEIOMYOMA COMPLICATIONSCOMPLICATIONS

-Myomectomy has a 2 to 3% yearly recurrence -Myomectomy has a 2 to 3% yearly recurrence

- Infertility & recurrent spontaneous abortions- Infertility & recurrent spontaneous abortions

- Pregnancy: Increased preterm labor & PROM, - Pregnancy: Increased preterm labor & PROM, dysfunctional labor and dystocia.dysfunctional labor and dystocia.-.01 to 0.5% risk of leiomyosarcoma. .01 to 0.5% risk of leiomyosarcoma.

ADENOMYOSISADENOMYOSIS

INTERNAL INTERNAL ENDOMETRIOSISENDOMETRIOSIS

ADENOMYOSISADENOMYOSIS

EtiologyEtiology-Local invasion of eLocal invasion of endometrial tissue in the myometrium ndometrial tissue in the myometrium more than 3 mm beneath the endometrium & associated more than 3 mm beneath the endometrium & associated with muscular hypertrophywith muscular hypertrophy-Invasion mostly diffuse from the endometrial surface Invasion mostly diffuse from the endometrial surface -Rarely may produce a localized endometrial mass Rarely may produce a localized endometrial mass -Etiology is not known Etiology is not known -Growth occurs only during reproductive years Growth occurs only during reproductive years -Usually occurs in parous woman, increase with age and Usually occurs in parous woman, increase with age and usually regress with menopauseusually regress with menopause

ADENOMYSISADENOMYSIS

- CLINICAL FINDINGSCLINICAL FINDINGS- Parous middle-aged woman with hx of:Parous middle-aged woman with hx of:- Dysmenorrhea, menorrhagiaDysmenorrhea, menorrhagia- Uterine tenderness on palpation (Halban’s Sign)Uterine tenderness on palpation (Halban’s Sign)- Varying degree of chronic pelvic pain Varying degree of chronic pelvic pain - US useful in diagnosingUS useful in diagnosing- Chronic severe anemia may be presentChronic severe anemia may be present

ADENOMYOSISADENOMYOSIS

ADENOMYOSISADENOMYOSIS

ADENOMYOSISADENOMYOSIS

TREATMENTTREATMENT HysterectomyHysterectomy

Confirmatory of diagnosisConfirmatory of diagnosis Definite treatment of choiceDefinite treatment of choice

Hormonal TherapyHormonal Therapy GnRH agonists may provide temporary GnRH agonists may provide temporary

relief of symptoms but not very effectiverelief of symptoms but not very effective OC may exacerbate symptomsOC may exacerbate symptoms

ENDOMETRIAL ENDOMETRIAL

POLYPSPOLYPS

POLYPSPOLYPS

ETIOLOGYETIOLOGY Hystogenesis is not clearHystogenesis is not clear May be pedunculated or sessile May be pedunculated or sessile Considered estrogen sensitiveConsidered estrogen sensitive Risk FactorsRisk Factors Obesity, hypertension, Tamoxifen therapyObesity, hypertension, Tamoxifen therapy More common near menopauseMore common near menopause May undergo malignant changes May undergo malignant changes

Carcinomas and SarcomasCarcinomas and Sarcomas

POLYPSPOLYPS Clinical FindingsClinical Findings Menorrhagia Menorrhagia Pre or post menstrual spottingPre or post menstrual spotting In postmenopausal woman sudden In postmenopausal woman sudden

occurrence of bleeding accompanied by occurrence of bleeding accompanied by uterine pain (Infarct)uterine pain (Infarct)

Exam may reveal ulceration of the distal Exam may reveal ulceration of the distal tip of the polyptip of the polyp

Trans-vaginal US helpful in diagnosis Trans-vaginal US helpful in diagnosis HysteroscopyHysteroscopy

Treatment of Uterine Treatment of Uterine PolypsPolyps

Hysteroscopic resectionHysteroscopic resection D&C of attachment siteD&C of attachment site

Progestin may cause regressionProgestin may cause regression Hysterectomy for malignant Hysterectomy for malignant

changeschanges

ENDOMETRIOSISENDOMETRIOSIS-DefinitionDefinition-Aberrant growth of endometrial tissue outside the Aberrant growth of endometrial tissue outside the uterusuterus-Most common site is the ovary Most common site is the ovary -Other areas of the pelvis and the abdomen may be Other areas of the pelvis and the abdomen may be involvedinvolved-3-15% premenopausal women rare postmenopause3-15% premenopausal women rare postmenopause-Accounts for 25% gyn laps & 50% of infertilityAccounts for 25% gyn laps & 50% of infertility

ENDOMETRIOSISENDOMETRIOSIS-EtiologyEtiology-Common health problem Common health problem in women in women etiology unknownetiology unknown-Classic theory of John Sampson Classic theory of John Sampson

-Retrograde menstruation subsequent bleeding from the Retrograde menstruation subsequent bleeding from the fallopian tubes into the abdomen. Desquamated fallopian tubes into the abdomen. Desquamated endometrium implants on the pelvic visceraendometrium implants on the pelvic viscera

-Estrogen dependentEstrogen dependent- Genetic influences possibleGenetic influences possible-Socioeconomic factors ?Socioeconomic factors ?

ENDOMETRIOSISENDOMETRIOSIS-Menstrual implantation- tubal regurgitation Menstrual implantation- tubal regurgitation especially dominant tubeespecially dominant tube- Intra-operative implantation occurs within scarsIntra-operative implantation occurs within scars-Lymphatic hematogenous route lymphatic Lymphatic hematogenous route lymphatic dissemination similar to that of the malignant dissemination similar to that of the malignant metastasismetastasis-Embryonic implantation re-differentiation or Embryonic implantation re-differentiation or persistence of various embryonic tissuepersistence of various embryonic tissue

ENDOMETRIOSIS ENDOMETRIOSIS Clinical FindingsClinical Findings

- - History very helpful. Not uncommon to have History very helpful. Not uncommon to have symptoms early often 1-2 year after onset of mensessymptoms early often 1-2 year after onset of menses-Severity classified from I-IV based on the extent, Severity classified from I-IV based on the extent, locations, stage and degree of symptoms locations, stage and degree of symptoms -Dysmenorrhea, dyspareunia, infertility are the main Dysmenorrhea, dyspareunia, infertility are the main presenting complaints.presenting complaints.-Dyspareunia is a key symptom in differentiating Dyspareunia is a key symptom in differentiating endometriosis from dysmenorrheaendometriosis from dysmenorrhea

ENDOMETRIOSIS ENDOMETRIOSIS Clinical FindingsClinical Findings

- Change in bowel habits, cramping, rectal Change in bowel habits, cramping, rectal and pelvic pain, nausea vomitingand pelvic pain, nausea vomiting

- Dysuria, spotting, frank hematuria irregular Dysuria, spotting, frank hematuria irregular menses, Infertility , backache, premenstrual menses, Infertility , backache, premenstrual - Less common plural pain if pulmonary & - Less common plural pain if pulmonary & seizure from CNS lesionsseizure from CNS lesions

ENDOMETRIOSISENDOMETRIOSIS

DIAGNOSISDIAGNOSIS

-- Physical ExamPhysical Exam: Pelvic tenderness with uterine/ : Pelvic tenderness with uterine/ pelvic nodularity, ovarian enlargement & pelvic nodularity, ovarian enlargement & tenderness, pain upon uterine motion uterine may be tenderness, pain upon uterine motion uterine may be fixed, retroverted due to adhesions. fixed, retroverted due to adhesions.

- Can have cutaneous or extraperitoneal disease- Can have cutaneous or extraperitoneal disease-Lab: CA 125 often elevated with extensive disease, Lab: CA 125 often elevated with extensive disease,

- Cytology is always negative - Cytology is always negative

ENDOMETRIOSISENDOMETRIOSISDIAGNOSISDIAGNOSIS

- - Imagining Pelvic U/S have high false positives/ Imagining Pelvic U/S have high false positives/ negatives. MRI/CT limited valuenegatives. MRI/CT limited value-Laproscopy only definitive way & always with Laproscopy only definitive way & always with biopsy secondary to wide variation of lesion biopsy secondary to wide variation of lesion appearance. Most common powered burn lesions. appearance. Most common powered burn lesions. Superficial red-brownish or black-blue lesions. Superficial red-brownish or black-blue lesions. Later fibrosed or chocolate cystic changes. Can be Later fibrosed or chocolate cystic changes. Can be non-pigmented & hemorrhagicnon-pigmented & hemorrhagic- Chocolate cyst presentChocolate cyst present

- If many adhesions may need a laparotomy- If many adhesions may need a laparotomy

ENDOMETRIOSISENDOMETRIOSISTREATMENTTREATMENT

- Based on severity of symptoms, age, desire - Based on severity of symptoms, age, desire for childbearing.for childbearing. -Observation - Minimal symptomsObservation - Minimal symptoms-Hormonal therapy – interruption of the cycles using Hormonal therapy – interruption of the cycles using Depo Provera 150mg/mth*6mths Depo Provera 150mg/mth*6mths -BCP double usual dose after 1 mth then increase BCP double usual dose after 1 mth then increase -PregnancyPregnancy

- Danazol (Danocrine) 200 to 800 mg bid for 6 mths - Danazol (Danocrine) 200 to 800 mg bid for 6 mths 80 to 95% effective pain relief and other symptoms 80 to 95% effective pain relief and other symptoms

--

TREATMENT OF TREATMENT OF ENDOMITRIOSISENDOMITRIOSIS

GnRH Agonists lupron IM 3.75mg/mth*6mthGnRH Agonists lupron IM 3.75mg/mth*6mth Intranasal Nafarelin 200mg bid*6mth Intranasal Nafarelin 200mg bid*6mth Surgical indicated in severe disease, patients over Surgical indicated in severe disease, patients over

40 y/o and severe adhesion 40 y/o and severe adhesion Laparoscopic lysis of adhesions, laser ablation. Laparoscopic lysis of adhesions, laser ablation. Total abdominal hysterectomy in severe and Total abdominal hysterectomy in severe and

patients with no desire of childbearing. Bilateral patients with no desire of childbearing. Bilateral salpingo-oophorectomy followed by HRTsalpingo-oophorectomy followed by HRT

Still AliveStill Alive

GYNECOLICAL REASONS FOR GYNECOLICAL REASONS FOR ABDOMINAL MASS OR CHRONIC PELVIC ABDOMINAL MASS OR CHRONIC PELVIC

PAINPAIN

Pelvic Pain Pelvic Pain SourcesSources Referred pain- Visceral or splanchnic pain over the Referred pain- Visceral or splanchnic pain over the

somatic fibers of the parasympathetic ANS is poorly somatic fibers of the parasympathetic ANS is poorly localized does not respond to thermal or tactile it is localized does not respond to thermal or tactile it is stretch/tension & inflammation in naturestretch/tension & inflammation in nature

Hypogastric plexus Vaginal upper 1/3, cervix, lower Hypogastric plexus Vaginal upper 1/3, cervix, lower segment, bladder trigone, uterosacral ligaments, lower segment, bladder trigone, uterosacral ligaments, lower ureters, posterior urethra, recto-sigmoid & dorsal external ureters, posterior urethra, recto-sigmoid & dorsal external genitalgenital

Thoraco-lumbar plexus (T Thoraco-lumbar plexus (T 1111- L- L11) Fundus, Proximal 1/3 ) Fundus, Proximal 1/3 tube, Broad ligaments, upper bladder, appendix, cecum tube, Broad ligaments, upper bladder, appendix, cecum terminal large bowelterminal large bowel

Superior Mesenteric plexus (T Superior Mesenteric plexus (T 5 5 - T- T1111) Ovaries, lateral 2/3 ) Ovaries, lateral 2/3 fallopian tube & upper ureters fallopian tube & upper ureters

Pelvic Pain Pelvic Pain SourcesSources Can be either sudden or gradual onsetCan be either sudden or gradual onset May be associated with various type of abdominal painMay be associated with various type of abdominal pain Epigastric Pain - Stomach, duodenum, pancreas, liver and Epigastric Pain - Stomach, duodenum, pancreas, liver and

gallbladder gallbladder Periumbilical Pain – Small intestines, appendix, upper Periumbilical Pain – Small intestines, appendix, upper

ureters and ovariesureters and ovaries Hypogastric/suprapubic Pain – Colon, bladder lower Hypogastric/suprapubic Pain – Colon, bladder lower

ureters and uterusureters and uterus Pelvic Pain – Cervix, ovaries and fallopian tubes Pelvic Pain – Cervix, ovaries and fallopian tubes Shoulder Pain- Diaphragm or diaphragmatic irritation Shoulder Pain- Diaphragm or diaphragmatic irritation

Pelvic Pain Quality Pelvic Pain Quality Cramping or colicky pain - muscular contraction or Cramping or colicky pain - muscular contraction or

intraluminal pressure of a hollow viscusintraluminal pressure of a hollow viscus Constant pain – Inflammatory process, distention of a Constant pain – Inflammatory process, distention of a

solid organ, ischemiasolid organ, ischemia Intermittent pain – adnexal mass with partial torsionIntermittent pain – adnexal mass with partial torsion Positional pain – mobile pelvic massPositional pain – mobile pelvic mass Sharp pain – obstruction or acute peritoneal processSharp pain – obstruction or acute peritoneal process Dull pain – inflammatory processDull pain – inflammatory process

Pelvic Pain DurationPelvic Pain Duration Acute < 48 hours initial episode or chronic >48 hours or Acute < 48 hours initial episode or chronic >48 hours or

recurrentrecurrent

Pelvic Pain SeverityPelvic Pain Severity Minor vs. major. Evaluate appearance and look for any Minor vs. major. Evaluate appearance and look for any

associated pallor or toxicityassociated pallor or toxicity

Associated symptomsAssociated symptoms Vaginal bleeding, discharge, fever, chills, nausea, Vaginal bleeding, discharge, fever, chills, nausea,

vomiting, anorexia, syncope, hypovolemia, dysuria, flank vomiting, anorexia, syncope, hypovolemia, dysuria, flank pain, dyspareunia or shoulder pain pain, dyspareunia or shoulder pain

Physical ExamPhysical Exam General appearance, orthostatic, activity level, anxiety, toxicity, General appearance, orthostatic, activity level, anxiety, toxicity,

LOC, postureLOC, posture Chest Chest look for abnormalities that often cause referred pain look for abnormalities that often cause referred pain Abdominal Abdominal Pelvic Pelvic

Inspection external genitalia vagina and cervix for trauma, Inspection external genitalia vagina and cervix for trauma, infection, discharge, hemorrhage, asymmetry or massesinfection, discharge, hemorrhage, asymmetry or masses

Palpate vaginal wall and cervix for location of any tenderness, Palpate vaginal wall and cervix for location of any tenderness, cervical motion tenderness first without than with abdominal cervical motion tenderness first without than with abdominal pressure pressure

Palpate the adnexa for masses or tendernessPalpate the adnexa for masses or tenderness Presence of CVA tendernessPresence of CVA tenderness

Laboratory TestLaboratory Test CBC|with diffCBC|with diff UA with macro/microUA with macro/micro Urine cultureUrine culture Qualitive Qualitive ββHCG may need serial quantitive levelsHCG may need serial quantitive levels Cervical culturesCervical cultures Possible CuldocentesisPossible Culdocentesis Radiographs flat & upright right lateral decubitus for Radiographs flat & upright right lateral decubitus for

obstructions, free air, free fluid, fluid levels, calcifications obstructions, free air, free fluid, fluid levels, calcifications or massesor masses

Ultrasound abdominal/pelvic for IUP, fluid, masses & Ultrasound abdominal/pelvic for IUP, fluid, masses & shifts shifts

Laproscopy/Open laparotomy - Visualization Laproscopy/Open laparotomy - Visualization

ETIOLOGY CHRONIC PELVIC PAINETIOLOGY CHRONIC PELVIC PAIN

FistulasFistulas

SalpingitisSalpingitis