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Women’s Health - OB/gyn week 3

Women’s Health - OB/gyn week 3. Pelvic Pain, Pelvic Masses Amy Love, ND. TOPICS . Questions about previous material? Pelvic pain Pelvic masses. PELVIC PAIN. Acute Intense, sudden onset, sharp rise, short course Cyclic occurs in association with menstrual cycle Chronic

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Women’s Health - OB/gyn week 3

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  1. Women’s Health - OB/gynweek 3 Pelvic Pain, Pelvic Masses Amy Love, ND

  2. TOPICS • Questions about previous material? • Pelvic pain • Pelvic masses

  3. PELVIC PAIN • Acute • Intense, sudden onset, sharp rise, short course • Cyclic • occurs in association with menstrual cycle • Chronic • greater than 6 months duration

  4. ACUTE PELVIC PAIN • Rapid onset • Associated with perforation or ischemia • Colic or cramping • Associated with muscular contraction or obstruction • Generalized • Associated with generalized reaction to an irritating fluid within the peritoneal cavity • Eg. Ovarian cyst rupture

  5. DDX ACUTE PELVIC PAIN • Complication of pregnancy • Acute infections • Adnexal disorders • Ruptured ovarian cyst • Torsion of adnexa • Rare, twisting of ovary and sometimes also fallopian tube, usually due to ovarian swelling - cyst, tumor, fertility drugs • GI, GU, musculoskeletal, CV causes *

  6. Review of Anatomy:What else could cause pain in pelvis or lower abdomen?

  7. ECTOPIC PREGNANCY • Implantation of fetus in site other than uterine cavity • Sx’s • Amenorrhea, spotting, pelvic pain • Dizziness, syncope if rupture with blood loss • Left shoulder pain in 25% of ruptured ectopics (from blood into L hemidiaphragm) • Signs • Pulse may be up, BP down • Abdomen tender, esp affected side • Palpable adnexal mass • Pos hCG or b-hCG • Mass confirmed by US

  8. Ectopic Pregnancy • Diagnosis • Clinical signs and symptoms • Positive Urine hCG • Pelvic ultrasound • Beta-hcg if US equivocal • Serial beta-hCG to determine doubling times if necessary • Repeat US if necessary

  9. MANAGEMENT OF ECTOPIC PREGNANCY • Medical emergency • Tx – surgical removal of mass and possibly fallopian tube OR methotrexate • CAM Tx – adjunct support post op

  10. LEAKING OR RUPTURED OVARIAN CYST • Sx’s • Sudden onset pelvic pain • If blood loss, dizziness and syncope can occur • Signs • Rebound abdominal tenderness • Pelvic mass if cyst is leaking, not ruptured • Hypovolemia if blood loss • Dx • hCG, CBC, US, possibly culdocentesis

  11. MANAGEMENT OF RUPTURED CYST • If significant bleeding, surgical removal of cyst/ovary • If little bleeding, observation • CAM Tx – follow-up to prevent new cysts from forming • Ovarian cysts grow in response to estrogen activity • Reduce estrogen activity

  12. PID - pelvic inflammatory dz • Polymicrobial infection of upper genital tract • Usually associated with GC or CT infection • Up to 50% also associated w polymicrobial infection of aerobes and anaerobes that make up normal vaginal flora

  13. PID • Sx’s • Rapid onset pelvic pain • Fever • Purulent vaginal discharge • Nausea/vomiting on occasion • Signs • Direct and rebound abdominal tenderness • Cervical motion tenderness • Bilateral adnexal tenderness • Fever • Leucocytosis • Positive for WBC’s and bacteria on culdocentesis

  14. PID • Dx • Made initially on clinical grounds • Confirm with gram stain and positive tests for GC/CT • Laparoscopy is definitive diagnosis, not usually necessary • Tx • Outpatient broad spectrum antibiotics • Hospitalization if dx uncertain, abscess suspected, pregnant, or no response within 48 hours to antibx • CAM Tx • Supportive after care • Pro-biotics

  15. CYCLIC PELVIC PAIN • Common causes • Primary dysmenorrhea • Secondary dysmenorrhea • Endometriosis • Adenomyosis • Chronic functional cyst formation

  16. PRIMARY DYSMENORRHEA • Very common - ~75% • Usually in women < 25 • Cause is hypoxia and ischemia from increased endometrial PG production --> high amplitude uterine contractions resulting in decreased uterine blood flow • Onset a few hours before or just after onset of menses • Typically lasts 48-72 hours • Sx’s • Suprapubic cramping and/or lumbosacral pain and/or radiation down anterior thigh • Can have nausea/vomiting/diarrhea

  17. PRIMARY DYSMENORRHEA • Dx • Based on clinical history and a normal pelvic exam • May want to R/O infection • Tx • Conventional • NSAIDS or • OCP’s • Initiate work-up for secondary dysmenorrhea if OCP’s fail • Codeine/hydrocodone if these fail • Uterine nerve ablation or presacral neurectomy if all else fails

  18. PRIMARY DYSMENORRHEA • CAM Tx • Strategies • Reduce prostaglandin production • Improve blood flow to uterus • Whole foods, low fat, vegetarian diet minimizing arachidonic acid intake and emphasizing omega-3 EFA’s • Exercise

  19. PRIMARY DYSMENORRHEA • CAM Tx continued • Niacin 100 mg BID all month, q 2-3 hours during pain episodes • Vitamin C and rutin increase effect of niacin – 300 mg/60mg qD • Magnesium – 400 mg/ Day • Thiamin HCl – 100 mg QD X 90 days • Vitamin E – 400-500 iu/d 2 days before menses through 3 days of menses • EPA/DHA/EPO (fish oil) – 2-3 grams qD • Botanicals • Valerian, viburnum o. and p., zingiber, cimicifuga, piscidia • Progesterone cream – ¼ tsp BID 3-12 days before menses • TENS

  20. SECONDARY DYSMENORRHEA • Usually occurs years after onset menses • Onset 1-2 weeks before menses • Lasts a few days beyond cessation of menses • Less likely to respond to PG inhibitors or OCP’s • Most common cause is endometriosis, followed by adenomyosis, pelvic adhesions, pelvic infections, pelvic congestion

  21. Endometriosis • Common medical condition characterized by the presence and growth endometrial tissue outside of the uterus • Affects 10-15% of menstruating women between ages 24-40 in the U.S. • Found in approx. 33% women with chronic pelvic pain • Found in 30-45% women with infertility

  22. Endometriosis • Risk factors: • Increased estrogen levels • Lack of exercise from an early age • Women with menstrual cycles closer together and longer in length (e.g. bleeds 7 days every 25 days) • Heredity (main risk factor): • Likelihood for mother to also have endometriosis is 8.1% • Sister 5.8%

  23. Endometriosis (con’t) • Typical patient: • mid-30’s • Nulliparous • Involuntarily infertile • Dysmenorrhea • Pelvic pain • Dysparunea • May be found in post-menopausal women (5% incidence) • Usually due to exogenous hormones/ HRT • May occur prior to puberty

  24. Endometriosis etiology • Theories of causation include • Ectopic transplantation of endometrial tissue by retrograde menstruation • Endometrial cells shed during menses may implant on other pelvic tissues; grow as grafts under hormonal influence • Frequently found in women with outflow obstruction of genital tract • Supported by studies where cervix of monkeys sutured shut • Most frequently found in areas immediately adjacent to openings of Fallopian tube

  25. Etiology continued • Induction theory – some undefined biochemical factor induces undifferentiated peritoneal cells to develop into endometrial cells – documented in rabbits, not humans • Metaplasia= reversible replacement of one differentiated cell type with another mature differentiated cell type • During embyronic development, cells that have the potential to become endometriosis are laid down in tracts, usually in the posterior pelvis. • Tracts act as “seeds” that lie dormant until estrogen stimulation or other triggers (inflammation, immune mediators) • Supporting examples: presence of endometriosis in pre-pubertal girls, women with congenital absence of uterus, and rarely in men

  26. Etiology (con’t) • Lymphatic and vascular metastasis • Explains endometriosis found in remote areas such as spinal column, nose • 30% of women with endometriosis have affected pelvic lymph nodes • Immunologic changes • Abnormalities in both cell-mediated and humoral components of immune system • Hyperactive macrophages secrete multiple growth factors and cytokines • Iatrogenic dissemination • After C-section, endometriosis discovered in anterior abdominal wall, incision scars

  27. Endometriosis etiology (con’t) • Environmental • Endocrine disruptors: • PCBs (polychlorinated biphenyls) e.g. bisphenol-A • Dioxins (found in tampons, among many other places) • Pesticides/ Herbicies • Detergents • Household cleaners

  28. Diagnosis of Endometriosis • Sx’s • Progressive dysmenorrhea that began years after menarche • Occurs before menses, lasts beyond end of menses • Subfertility • Can occur outside of pelvis • Can be asymptomatic • Dysparunea: • seems to be due to immobility of pelvic organs or direct pressure on tissue with endometriosis • Other possible symptoms: • intermittent constipation, diarrhea, dyschezia, urinary frequency, dysuria, hematuria • Abnormal bleeding in 15-20% women • Premenstrual spotting • menorrhagia

  29. DX OF ENDOMETRIOSIS • PE • May be normal • May find nodularity in uterosacral ligaments or cul-de-sac • In advanced dz, may find fixed uterus, ovaries, tubes • Dx confirmed with laparoscopy (gold standard) and biopsy of suspect tissue

  30. Endometriosis • Diagnosis may be incidental: • Laparoscopy for different condition • Infertility evaluation • Pelvic pain not proportional to extent or amount of endometriosis • Some patients may have large amounts and no pain (and may never be diagnosed!) • Size and location of endometrial tissue and adhesions in pelvis is used to classify dz • Stage I is minimal, stage IV is severe • Dz is progressive in 30-60% of patients

  31. Endometriosis (con’t) • Great individual variability • Does not follow a typical course • Is benign, yet has characteristics of malignancy: locally infiltrative, invasive, and widely disseminating • Cyclic hormones usually cause growth while continuous hormones reverse growth pattern

  32. Endometriosis • Pathology: • Endometrial implants are most commonly found on ovaries • Involvement usually bilateral • Other common sites: pelvic cul-de-sac, peritoneum over uterus, uterosacral, round, and broad ligaments • May penetrate deeply into other tissues (>5mm); these represent a more progressive form of the disease

  33. Endometriosis • Pathology • Histological features: ectopic endometrial glands, ectopic endometrial stroma, and hemorrhage into adjacent tissue • Implants may bleed at same time as menstrual cycle or have cycles of their own! • Disease may spontaneously regress • Pathophysiology of progression from subtle to severe disease is unknown

  34. Endometriosis • Gross pathological changes: • Vary in color, size, shape; depends on location, blood supply, amount of hemorrhage and fibrosis, degree of edema • New lesions small (<1cm diameter) and raised above surrounding tissues • Older lesions become larger and assume light/dark brown color; may be described as “chocolate cysts” or “powder burn” • Most active lesions are red and blood-filled

  35. Treatment of Endometriosis • Prevention • Aerobic activity from an early age may reduce incidence • Conventional Tx • NSAID’s or narcotic analgesics • OCP’s • Progestin injections • Danazol • GnRH agonists - Lupron • Surgical excision or coagulation • Recurrence rate for all tx’s 5-20% per year, and 40% after 5 years

  36. Tx of Endometriosis • CAM Tx • Strategies • Reduce stimulation of ectopic endometrial tissue by estrogen • Optimize immune system function • Reduce inflammation • Provide pain relief

  37. ND TX ENDOMETRIOSIS • Whole foods diet to reduce exogenous estrogens, optimize excretion of estrogen, and reduce arachidonic acid • Avoid caffeine – associated with endometriosis • Aerobic exercise 30 minutes 5 X/wk • EFA’s to reduce inflammation • Support liver function to optimize metabolism of estrogen • Optimize gut flora • Treat constipation

  38. ND TREATMENT ENDOMETRIOSIS • Vitamin E - 1200 iu/d and Vitamin C 1000mg/d X 2 months – RCT • Resulted in reduced pain • Beta-carotene – 50,000-150,000 iu/d • Decreases IL-6 an inflammatory mediator recently implicated in endometriosis • Botanicals for pain relief • Valerian, piscidia, viburnum, cimicifuga • Traditional tincture – equal parts – ½ tsp TID • Vitex for estrogen balance • Dandelion root for supporting liver function • Prickly Ash to simulate blood flow through pelvis • Motherwort as antispasmodic

  39. ND TX ENDOMETRIOSIS • Progesterone cream – 1/4-1/2 tsp BID days 8-28, or days 15-26, or week before menses • Contrast pelvic hydrotherapy • Pelvic sitz bath • Hot 3 minutes • Cold 1 minute • Repeat 3X • Pine Bark Extract (pycnogenol) • N=58, RCT, PBE vs Gn-RHa • 30 mg caps BID X 48 weeks • 33% reduction in sx’s within 4 weeks • Kohama T, J Reprod Med. 2007;52:000-000.

  40. ADENOMYOSIS • Endometrial tissue within the myometrium • Sx’s • Dysmenorrhea and heavy or prolonged menstrual bleeding • Can be asymptomatic • Occurs up to a week before menses, resolves after cessation of menses

  41. ADENOMYOSIS • Signs • Uterus may be enlarged, soft and tender during menses • Dx • R/O pregnancy • Based on clinical findings • US, MRI, or HSG may be helpful • Tx • NSAID’s, narcotic analgesics,OCP’s, progestins • Hysterectomy if meds fail • ND Tx • See endometriosis tx

  42. CHRONIC PELVIC PAIN • Broad category that includes many causes from GU, GI, musculoskeletal, urologic, psychologic • Important to complete thorough Hx and ROS to sort through above DDX possibilities • Most common gyn causes of chronic pelvic pain • Endometriosis • Pelvic adhesions • visceral manipulation, oral enzymes • Pelvic congestion • contrast hydrotherapy, acupuncture, herbs…

  43. KEY CONCEPTS of PELVIC PAIN • Acute pelvic pain is often an emergency • R/O ectopic, ruptured cyst with bleeding, infection • Cyclic pelvic pain - usually primary or secondary dysmenorrhea • Chronic pelvic pain associated with many DDX’s from many different systems • Gyn causes of chronic pelvic pain most commonly endometriosis, pelvic adhesion, pelvic congestion

  44. PELVIC MASS • Most pelvic masses occur on ovary or in uterus • Ectopic pregnancy, abscess, endometriosis, bowel masses are exceptions • Ovarian masses • Functional cysts • Abscess • Benign or malignant tumor • Endometrioma • Uterine masses • Pregnancy • Leiomyoma (fibroid)

  45. OVARIAN MASSES • While ovarian mass is rare in prepuberty, if it occurs, 80% are malignant • Functional ovarian cysts are common in adolescents • Functional ovarian cysts and endometriomas are common in reproductive age women • Malignant ovarian masses are most common in post-menopausal women

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