• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/198

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

198 Cards in this Set

  • Front
  • Back
What are the physical findings in pt w/ androgen insensitivity syndrome? (pt is XY)
Neither wolffian duct nor mullerian system develops, so no uterus, little to no axillary or pubic hair
Usually have large breasts w/ immature nipples
If incomplete, there could be some pubic and axillary hair plus phallic development

Note: serum testosterone levels are in normal MALE range
What is another name for androgen insensitivity syndrome?
Testicular feminization
Treatment for androgen insensitivity syndrome?
Allow to finish sexual maturity then remove gonads (to prevent dev't of gonadoblastoma or dysgerminoma
What are the physical findings in pt w/ mullerian agenesis?
Sexual hair + mature nipples
No uterus

Note: serum testosterone levels are in FEMALE range
What other physical abnormality is associated with mullerian agenesis?
Renal anomalies
Perform renal US or intrravenous pyelography on these pts
15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does HIGH LH/FSH indicate?
What is next test to do?
What additional studies?
Gonadal failure.
Get karyotype
Do CXR, IV pyelogram, thyroid fxn tests
15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does LOW LH/FSH indicate?
What is next test to do?
What additional studies?
Unstimulated gonads
Head MRI/CT to r/o pituitary tumors
thyroid fxn tests, GH, cortisol, PRL
Consider pituitary stimulation tests
15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does NORMAL LH/FSH plus negative progesterone challenge indicate?
Pituitary-CNS failure – glycoprotein hormones are immunologically but not biologically active
W/u is similar to low LH/FSH w/u
What are pituitary causes of amenorrhea? (4)
1) Cells are damaged 2/2 anorexia, thrombosis, hemorrhage (Sheehan's or Simmons)
2) Neoplasms: often PRL secretors
3) Acromegaly
4) Cushing's
What are hypothalamic causes of amenorrhea? (5)
1) Congenital: Kallman's (anosmia + midline facial defects) or isolated Gn deficiency
2) CNS neoplasms
3) Infiltrating disease: TB or sarcoid
4) Stress
5) Eating disorder: anorexia or bulimia
Secondary amenorrhea plus high FSH in pt <40?
What are some causes of this?
Premature ovarian failure
Autoimmune disease like Hashimoto's, Addison's, DM, or Hypoparathyroidism
What are symptoms of premature ovarian failure?
Hypoestrogenism
High FSH
Ovarian biopsy: Generalized sclerosis or only primordial follicles (no progression past antrum stage)
When to check karyotype in pt with premature ovarian failure? (4)

What else to check in these pts?
1) Pt < 30y/o (46XX/XY mosaic → remove gonads to prevent malignancy)
2) Pt <63 inches tall (Turner's)
3) Gonadal failure = uterus, no breasts, high FSH
4) Androgen insensitivity = breast, no uterus, male testosterone levels

Antithyroid antibodies, antinuclear antibodies, 24-hr cortisol
What are other, less common or rare causes of premature ovarian failure? (5)
1) Chemo or rads
2) Lung cancer
3) Single gonadotropin deficiency
4) Resistant or insensitive ovaries (bad or absent receptors)
5) Galactosemia (rare AR galactose metabolism dz)
What is MC cause, overall, of amenorrhea?
Pregnancy!
Always get UPT first
Which drugs can cause amenorrhea?
Antipsychotics (phenothiazines, haloperidol, droperidol)
TCAs
Antihypertensive (reserpine, methyldopa)
Anti-anxiolytics (benzos)
Metoclopramide
Opiates
Barbiturates
Estrogens
Any drug that stimulate PRL excretion
Initial eval of amenorrhea should include which tests?
TSH
PRL
Progesterone challenge
What is the mechanism behind athletic amenorrhea?
High stress levels
Energy deficit
Eating disorder
The 1st 2 cause increase in catechol estrogens and beta endorphins → mess w/GnRH release and hence LH & FSH
Treatment for athletic amenorrhea?
Encourage pt to improve diet, decrease stress, decrease strenuous exercise
Replace estrogen and progesterone if the other changes don't help
Which enzyme defect can cause cause amenorrhea?
17-α-OHlase deficiency → effects both ovarian and adrenal gland production → no sex hormones or breast development
Pts do have uterus
Also have xs mineralocorticoids → HyperNa, HypoK, HTN
Decreased cortisol

Tx: replace cortisol and sex hormones
What is major cause of anovulatory amenorrhea?
PCOS
What percentage of reproductive age women have PCOS?
5%
What are 2 other names for PCOS?
Stein-Leventhal syndrome
Chronic ovarian hyperandrogenism
What systemic fxns are affected in PCOS?
Ovulation
Glycemic control
XOL metabolism
What are possible criteria for diagnosing PCOS?
Menstrual dysfunction (anovulation or oligo-ovulation)
PCOS on US
Hyperandrogenism (clinical or biochemical)
Absence of other androgen disorders or hyperPRL
What other syndromes can present like PCOS?

What are tests to differentiate?
Hyperprolactinemia
Late-onset adrenal hyperplasia
Ovarian and adrenal hyperplasia
Cushing's syndrome

Tests to differentiate:
Serum PRL
17-OH progesterone
Serum testosterone
DHEAS
1mg o/n dexamethasone suppression test & 24hr urine free cortisol
MC presenting symptoms of PCOS?
Infertility (64%)
Hirsutism (69%)
Amenorrhea (51%)
Obesity (41%)
Dysfunctional uterine bleeding (29%)
Which labs may be abnormally HIGH in PCOS pts?
Testosterone and androstenedione
E1
DHEA and DHEAS
LH (often 3:1 to FSH)
Hyperinsulinemia(more frequent in obese PCOS pts)
Which labs may be abnormally LOW in PCOS pts?
FSH (can be normal)
Sex hormone binding globulin
E2
Decreased fasting glucose:insulin (<4.5:1)
What are clinical findings in PCOS?
Hirsutism
Acanthosis nigricans (often associated w/ hyperinsulinemia = HAIR-AN)
Anovulation
Cardiovascular disease
Abnormal glucose metabolism
What is the inheritance pattern of inherited PCOS?
XLD or AR (other chapter says AD!)
Theoretical 50% inheritance but is more like 40% because of genetic and environmental factors
How to treat PCOS if desire fertility?(4)
Clomiphene (80% ovulaton rate, 50-60% pregnancy rate)
Human menopausal gonadotropin is 2nd-line therapy (hMG)
Wedge resection/ovarian drilling
Metformin
Wt loss
IVF
Treat PCOS obesity? (3)
Diet/exercise
Anti-obesity drugs
Metformin
Treat PCOS dysfunctional uterine bleeding? (3)
OCPs
Progestins
Dilation and curretage
Treat PCOS hirsutism?
OCPs
Vaniqa (eflornithine)
Progestins
Spironolactone (anti-androgen)
Fluatmide (anti androgen)
Finasteride (5α-reductase inhibitor)
GnRH analog
Metformin
Cimetidine
Electrolysis
Laser vaporization
Traditional acne treatments
Treat PCOS recurrent miscarriage?
hCG
progesterone supplementation
Best treatment for PCOS?
Likely insulin-lowering drugs
Who gave PMS its name?
What year?
Dalton
1953
What is the definition of PMS?
Constellation of symptoms that occurs in a cyclic pattern, always in the same phase of the menstrual cycle, interfering with work or lifestyle and followed by a period entirely free of symptoms
What year was 1st published description of PMS symptoms?
1931
What symptoms are associated with PMS?
1) Physical:
Wt gain, breast swelling and tenderness, pelvic pain
Skin changes like acne
Hot flashes
Diarrhea or constipation
H/a
craving sweets
2) Emotional:
Irritability
Insomnia
Depression
Confusion or forgetfulness
Anxiety
Fatigue
Feeling of being “out of control”
What are theories of PMS's cause?
All related to hormonal alterations:
1) Ovarian hormones (estrogen and progesterone)
2) Fluids and electrolytes (PRL, Aldosterone, RAAS, Vasopressin)
3) Neurotransmitters (monoamines, acetylcholine)
4) Others: endorphins, androgens, glucocorticoids, melatonin, insulin
5) Serotonin (since SSRIs help!)
Does decrease in progesterone levels trigger depression and other emotional symptoms in PMS?
Supplementing progesterone seems to INCREASE these symptoms, so likely not. Does seem to help a small number of pts, but this might be due to placebo effect.
Note: The theory was used by Dalton in England as defense in a murder trial.
What is the relationship between progesterone and monoamine oxidase in PMS?
During which phase?
Progesterone increases MAO levels in plasma
Luteal phase
What is role of aldosterone antagonist in PMS?
May be related to physical symptoms of fluid retention (wt gain and breast tenderness)
Some of the emotional symptoms may be related to renin/angiotensin and aldosterone increases
So spironolactone is good treatment (has antiandrogenic fx) that offers relief to many people.
What is thought to be the mechanism behind carb and chocolate cravings in PMS?
Falling serotonin levels
The body ingests carbs trying to raise serotonin and l-tryptophan levels). Normally, when serotonin levels are high enough, the body craves protein which lowers serotonin to begin a new cycle.
In PMS, the pt only craves carbs and chocolate, and serotonin levels never get high enough to trigger protein cravings
What is best diet for reducing PMS symptoms?
Low fat, salt, and sugar
Higher in proteins and complex carbs
Maybe vitamins and minerals (no definitive results)
Do prostaglandins help PMS symptoms?
PGE1 may be low in some women w/ PMS (who have symptoms related to altered carb metabolism)
This can also contribute to dysmenorrhea as well
Both can benefit from NSAIDs, ibuprofen, others
Does sterilization reduce PMS?
Nope (if tubal or ligasure)
In extreme circumstances, TAH and BSO can help with debilitating disease
What is role of psychogenic meds in treatment of PMS?
Double-blind, placebo controlled studies have shown significant PMS symptom reduction with SSRI fluoxetine 20mg PO qday thruout cycle
Sertraline or alprazolam may also help
How to treat PMS?
Assure pt that her symptoms are real
Pt should chart her symptoms for several cycles (really premenstrual?)
Stress healthy diet, exercise, sleep
Consider SSRIs, spironolactone, prostaglandin inhibitors
Consider progesterone therapy for non-responders
OCPs
How to treat breast tenderness associated with PMS?
Bromocriptine 5mg qday during luteal phase
What is dysmenorrhea?
Pelvic pain associated with periods
Cramping
Can also be backache, headache, extemity
Lightheadedness, insomnia, GI symptoms
Nausea, vomiting, diarrhea
What difference between primary and secondary dysmenorrhea?
Primary: aka intrinsic; not associated with identifiable pathology
Secondary: caused by gynecological condition – uterine myomas, adenomyosis, endometriosis, pelvic infection
What is incidence of dysmenorrhea?
As high as 72% of women experience some discomfort
A smaller percentage experience it to a point that it interferes with activities, work, or school
Is less common and less severe in women who have given birth
How to evaluate dysmenorrhea?
H&P – r/o other gynecological or non-gyn causes (U or GI)
Get timing of onset and exacerbation – should be tied to menstrual bleeding
What is mechanism that causes pain in primary dysmenorrhea?
Seems to be PGF2α
Causes cramping, nausea, diarrhea, headache
How to treat dysmenorrhea?
Manage both primary and secondary via:
NSAIDs (decrease PGs)
OCPs (atrophies endometrium – less and shorter bleeding)

COX-2s help
Secondary: treat underlying pathology (try medical before surgery)
Non-medical options to treat dysmenorrhea?
Massage
Exercise
Heating pad
Acupuncture
Hypnosis
What to do if dysmenorrhea response to medical therapy is inadequate?
Primary: do more extensive w/u to look for underlying cause – pelvic US, sonohysterography, laparoscopy, MRI
Short-term PO narcotics for a few days of severe sx
Secondary: treat underlying pathology (usually via surgery)
How much blood is typically lost during menses?
How much is considered abnormal?
How long does bleeding typically last?
35mL
80mL
4d (range: 1-8d)
What is abnormal uterine bleeding?
Bleeding at irregular time intervals
-OR-
Bleeding that is excessive but at normal time
Define:
1) Menorrhagia
2) Metrorrhagia
3) Menometrohagia
1) XS bleeding at regular intervals
2) Menstrual bleeding at irregular intervals
3) XS, prolonged bleeding at irregular intervals
Define:
1) Intermenstrual bleeding
2) Polymenorrhea
3) Oligomenorrhea
4) Postmenopausal bleeding
1) Bleeding btw normal cycles
2) Frequent, regular bleeding that occurs in <21d cycles
3) Infrequent, irregular bleeding that occurs in >45d intervals
4) Bleeding that occurs >1yr after menopause, or at irregular intervals while on HRT
What are the pregnancy related causes of abnormal uterine bleeding? (3)
Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
What are the infectious causes of abnormal uterine bleeding? (2)
Cervicitis
Endometriosis
What are the neoplastic causes of abnormal uterine bleeding? (4)
Cervical dysplasia/carcnioma
Endometrial hyperplasia/polyps/carcinoma
Submucous leiomyomas
Estrogen-producing ovarian tumors
What are the systemic causes of abnormal uterine bleeding? (4)
Thyroid disease
Liver disease
Coagulation disorders
Sepsis
What are the iatrogenic causes of abnormal uterine bleeding? (5)
Menstrual history: # days of flow, #pads/tampons used per day, impact on daily living
Hx of unusual bleeding from gums; easy bruising, prolonged bleeding after minor cuts
Symptoms of wt gain, constipation, hair loss, fatigue, edema
Galactorrhea
Sexual hx & use of contraception
What should you ask in H&P of pt w/ abnormal uterine bleeding?
Tanner stage of breast & pubic hair development
Ht & wt
xs hair growth
What tests to order to eval abnormal uterine bleeding?
Beta-hCG
CBC
Coags
TSH
PRL
FSH, LH, Testosterone, DHEA-S (if wondering about PCOS)
What is dysfunctional uterine bleeding (DUB)?
Diagnosis of exclusion after r/o pregnancy-related, infectious, neoplastic, systemic, iatrogenic causes
Is result of anovulation or oligo-ovulation → ovary makes estrogen but no corpus luteum forms & no progesterone is secreted
What are major physiologic causes of anovulation? (4)
Adolescence
Perimenopause
Lactation
Pregnancy
What are major pathologic causes of anovulation (4)
Hyperandrogenic states
HyperPRL
HypoTH
Premature Ovarian failure
What is connection btw age and anovulation?
Perimenarchal: teens have immature HPG axis; can't respond to E or LH surge
Perimenopausal: women have declining ovarian fxn
When to do endometrial biopsy when evaluating abnormal uterine bleeding?
When suspect hyperplasia or endometrial cancer: all women over age 35 and any obese woman under 35
What is incidence of endometrial cancer?
Age 35: 6.1/100k
Age 40-49: 36.2/100k
When to do US in evaluating abnormal uterine bleeding?
When you've ruled out organic causes of AUB and suspect a structural abnormality (e.g., fibroids or polyps)
How to medically manage abnormal uterine bleeding in teens?
Treat any underlying cause (like hypothyroidism)
Anovulation: Can tx w/ Provera or OCPs; Fe for anemia
Acute menorrhagia: IV conjugated estrogen 25mg q4H or OCPs 35-50mcg TIDx3d → BIDx2d → QD to finish pack (2mo)
How to medically manage abnormal uterine bleeding in reproductive age women?
Consider OCPs
Mirena
Can induce ovulation w/ clomiphene citrate or gonadotropins
How to medically manage abnormal uterine bleeding in perimenopausal patient?
Low dose OCPs if nonsmoker
Can get HRT once menopausal
What is non-hormonal medical therapy of abnormal uterine bleeding?
Can use NSAIDs to reduce these women's abnormally high levels of PGI2 & PGE2:PGF2α, and EN-1
How to treat abnormal uterine bleeding caused by fibroids?
GnRH agonist like Lupron (leuprolide acetate) → fibroids re-grow when tx is stopped
Vaginal hysterectomy
Myomectomy
What are surgical treatments for abnormal uterine bleeding?
Endometrial ablation (destroys basalis layer) via:
Thermal ablation w/ rollerball or resectoscope
Thermal ablation balloon (5% dextrose @87F x 8min)
Hydrothermal ablation (NS 80-90C thru insulated sheath
Microwave endometrial ablation (thru 8mm applicator)
What is success rate of endometrial ablation?
70-97%
>85% of pts only need 1 treatment
If pt fails medical therapy and endometrial ablation, what is option?
Hysterectomy
Definition of hirsutism?
XS body hair growth in anatomic sites in “male” pattern
What are 3 types of body hair?
Lanugo: light, thin, found in neonates
Vellous: fine, non-pigmented, found in most adult body regions
Terminal: pigmented, coarse, found in scalp, axilla, pubic area of adult men and women, and on face and chest of men.
What are 3 phases of growth cycle of hair follicle?
Anagen: growth
Catagen: involution → hair stops growth and moves up in follicle
Telogen: resting phase that precedes hair loss
What are causes of hirsutism?
Increased exposure to androgens 2/2:
Exogenous
Increased adrenal androgen production
Increased ovarian androgen production
Alterations in binding globulins

Increased end-organ sensitivity 2/2 increased 5α-reductase activity in skin
What are androgens made by body?
Where produced?
Ovary: testosterone + androstenedione
Adrenals: DHEA, DHEAS
Periphery: testosterone + DHT
What modulates androgen action? (2)
1) Sex-hormone binding globulin (grabs and holds circulating androgens, decreasing their free concentration & hence action)
2) 5α-reductase (converts androgens to DHT; can only affect follicle if is DHT)
What is Ferriman & Gallwey Scoring System?
Score hirsutism depending on body site
normal <8
severe >15
What is DDX of hirsutism in women? (7)
PCOS
Nonclassical adrenal hyperplasia
Cushing syndrome\
Androgenic tumors (ovary, adrenals)
HyperPRL
Exogenous androgens
Idiopathic
What meds have androgenic activity? (3)
Anabolic steroids
Danazol
Testosterone
What is significance of abrupt onset of hirsutism?
More likely to be associated w/ tumor or exogenous hormone use
What tests to use w/ pt w/ hirsutism?
Total testosterone (>200ng/dL = tumor)
DHEAS (>700ug/dL = tumor)
17OH-progesterone (drawn in early morning)
PRL
24 urine cortisol or o/n dexamethasone suppression test
What are medical treatments for hirsutism?
OCPs (FDA approved)
Cyproterone acetate (strong progestin + estrogen)
Spironolactone (blocks androgen-R)
Flutamide (blocks androgen-R)
Finasteride (5α-reductase blocker)
GnRH analogs (suppress HPG axis)
Glucocorticoids (blocks adrenal androgen production)
Insulin-sensitizers (for PCOS)
What are adjuvant therapies for hirsutism?
Wt loss
Bleaching/waxing/depilatories/plucking/shaving
Electrolysis/laser
Eflornithine Hcl cream (Vaniqa) (FDA approved)
How long does it take to see improvement in hirsutism after treatment has begun?
3-6mo
What is best treatment approach for hirsutism?
Androgen suppression plus hair removal
What are common findings in PCOS?
Elevated LH:FSH (>2:1)
Perimenrchal onset of symptoms
polycystic ovaries on US
Obesity
Insulin resistance in lean or obese pts
How do sex steroid levels affect SHGB concentrations?
Decrease if testosterone is high
Increase in response to estrogens
How does PCOS present in teenager?
Premature adrenarche
Persistent oligomenorrhea
Hirsutism
Acne
Wt gain
What are health consequences of PCOS?
Hyperlipidemia
Adult-onset DM
Endometrial hyperplasia
Infertility
Obesity
What is acanthosis nigricans a marker of?
Insulin resistance
What percent of PCOS women are obese?
50-75%
What are the cysts in PCOS?
Atretic follicles, usually 3-5mm in diameter
What percentage of PCOS pts have impaired glucose tolerance?
DM?
1) 35%
2) 10%
What are surgical treatments for PCOS?
Wedge resection of ovary
Laparoscopic drilling
Laparoscopic needle cautery
How to prevent endometrial hyperplasia in PCOS?
Combined OCPs
Cyclic progestin therapy
What is a leiomyoma?
Aka fibroid, fibromyoma, myoma
Growth of uterine muscular wall, +/- fibrous tissue
Benign >99% of the time
Most common pelvic tumor?
Leiomyoma
Incidence of leiomyoma?
25% caucasians
50% black women
Note: 77% of post-hysto uteruses are found to have incidental myomas
Account for 25-30% of hysterectomies
What is etiology of leiomyomas?
Thought to be somatic mutation of monoclonal myometrial cell line
Often occur in clusters & recur, so likely is genetic predisposition
Have not been documented to occur more frequently in 1st degree relatives of probands, though.
What conditions cause leiomyomas to grow?
Under what conditions do leiomyomas stay the same size?
Under what conditions do leiomyomas abate?
1) During menstrual life
2) Pregnancy, OCPs, HRT
3) After menopause (if grow at this time, consider malignancy!)
What percent of leiomyomas are malignant?
0.3-0.7%
What are most common locations of leiomyomas? (3)
1) Subserosal (on external surface)
2) Intramural (on uterine wall)
3) Submucosal (protrude into endometrial lining)
What symptoms are commonly associated w/ leiomyomas? (4)
Dysmenorrhea
Abnormal uterine bleeding
Pressure
Pain (w/ menses or w/ myoma degeneration)
What specific symptoms are commonly associated w/ LARGE leiomyomas? (2)
Urinary frequency
Pelvic pressure
What specific symptoms are commonly associated w/ SUBMUCOSAL leiomyomas?
DUB – usually menorrhagia
What specific symptoms are commonly associated w/ INTRAMURAL leiomyomas?
Abnormal uterine bleeding
What is mechanism behind which myomas lead to DUB (dysfxnal uterine bleeding)? (5)
1) increased endometrial surface area
2) endometrium ulcerates over myoma
3) endometrial hyperplasia at myomal-endometrial jxn
4) uterine wall can't contract & close spiral arteries during menses
5) abnormal microvascular pattern w/ stasis & change in venous drainage
When to remove leiomyomas?
1) If rapid growth or growing after menopause
2) Persistent abnormal bleeding not responsive to medical tx
3) excessive pain or pressure
4) Consider if >8cm in women who still desires childbearing
What are potential treatments for leiomyomas?
1) Surgery: hysto or myomectomy (laparotomy or -oscopy or w/ hystoscope)
2) Medical: GnRH agonist
3) IR: uterine artery embolization
How long does GnRH agonist take to effectively treat leiomyoma?
What is its max reduction in fibroid size?
What are major drawbacks of GnRH treatment?
1) 3-6 mo
2) 30-64%
3) Fibroid will grow back when d/c drug. Drug simulates menopausal state (but can give add-back low-dose HRT to younger pts)
What types of degeneration do myomas undergo?
1) Hyaline (65%)
2) Myxomatous (15%)
3) Calcific (10%)
4) Carneous – the most acute; 5-10% pregnancies have this complication
5) Cystic degeneration
6) Fatty degeneration
Relationship btw leiomyomas and infertility?
Not thought to be a major cause
If do have impact, is likely through uterine cavity distortion or mechanical obstruction @ cervix or tubial ostia
If in posterior uterine wall might inhibit implantation
If no other cause for infertility is found and leiomyomas are removed, what is resultant pregnancy rate?
70%
What is endometriosis?
Hormonally responsive tissue is found outside the uterus
Can see endometrial glands and stroma; macrophages w/ hemofusin and hemosiderin; & fibrosis on histology
Is progressive
Can have big impact on pt's quality of life via pelvic pain, dyspareunia + infertility
What is adenomyosis?
Endometrial tissue is found w/in uterine myometrium
Can cause severe menorrhagia & disabling dysmenorrhea
What is endometriosis prevalence?
Controversial
~5-15% of pre-menopausal women
20-50% in infertile women
>50% in chronic pelvic pain pts
Note: increased incidence amongst 1st degree relatives
Affects teens.
No racial preponderance
What is adenomyosis prevalence?
15-20%, usually in peri-menopausal women
May be association btw tamoxifen administration and adenomyosis
What are endometriosis anatomical sites?
Posterior cul-de-sac
Uterosacral ligament surface peritoneum
Bilateral ovarian fossa + ovarian surfaces
Broad ligament
Fallopian tubes
Anterior cul-de-sac
May see peritoneal defects (usu lateral to uterosacral ligs)
Has been reported in lung, nasal mucosa, bladder, kidney, incisional sites
What is metastatic theory of endometriosis?
Implantation after retrograde menstruation into peritoneal cavity, lymphatic dissemination, or hematogenous spread of endometrial tissue
Or, iatrogenic dissemination via procedures
What factors support the metastatic theory of endometriosis?
Endometriosis location in dependent parts of body
Endometrial cells can implant
Increased incidence of endometriosis in pts w/ outflow obstruction
IDing endometriosis in sites distant to abdominal cavity
What is embryonic cell rest and coelomic metaplasia theory of endometriosis?
Is de novo development of endometrial tissue outside uterus
What factors support the embryonic cell rest and coelomic metaplasia theory of endometriosis?
NONE
What is thought to be the true mechanism behind endometriosis?
Altered macrophage capacity to induce cytolysis of ectopic endometrial cells
Plus increased ability of this tissue to survive, proliferate, invade, and induce angiogenesis
Plus impaired endometrial cell apoptosis
Are more MPs in endometriosis, along w/ peritoneal MPs making increased synthesis of growth factors, cytokines, angiogenic factors
These MPs have impaired cytotoxic ability
No one knows why this happens, though.
What is clinical presentation of endometriosis? (5)
1) Pelvic pain
2) Infertility
3) Dypareunia
4) Rectal discomfort and tenesmus
5) Abnormal uterine bleeding
What is clinical presentation of adenomyosis?
Abnormal uterine bleeding (usually prolonged)
Severe dysmenorrhea
What are characteristics of pelvic pain associated w/ endometriosis?
Usually cyclic, occurring prior to or w/ menses
Unilateral or bilateral in lower quadrants
Progression: increased pain week before menses
What is thought to be the etiology behind the pelvic pain of endometriosis?
Tissue edema
Blood extravasation
These stimulate A-delta and C primary afferent fiber mechanoreceptors
What is the relationship between pelvic pain and extent of endometriosis spread?
NONE!
What is the mechanism behind infertility caused by endometriosis?
Scarring and adhesions distort pelvic architecture and affect oocyte transportation from ovary to tube
Peritoneal environment affects oocytes and sperm
Peritoneal fluid inhibits sperm function
What percent of women w/ endometriosis are affected by infertility?
30-40%
What is the mechanism behind dyspareunia in endometriosis?
An immobile, fixed uterus, usually present w/ severe disease
Note: there's an association btw endometriosis and pain in specific coital positions
What is the mechanism behind rectal discomfort and tenesmus in endometriosis?
Posterior cul-de-sac scarring & immobility
What are physical findings in endometriosis? (6)
VARIABLE! Can have:
1) Diffuse lower abdominal tenderness in various locations
2) Nodularity and tenderness along uterosacral ligaments
3) Immobility of pelvic viscera → pain w/ manipulation
4) Fixed, retroverted uterus
5) Narrowing of posterior vaginal fornix
6) Adnexal tenderness and immobility
What are physical findings in adenomyosis? (2)
Mobile uterus, often top-normal size or enlarged
No evidence of leiomyomas
How to diagnose endometriosis?
What are you looking for?
Laparoscopy or laparotomy

Macroscopic black&blue lesions
+ red, red/pink, yellow/brown, white, & clear vesicular lesions
+ peritoneal defects, fibrosis, & scarring
+/- microscopic implants (do histological exam of biopsies of normal-appearing tissue)
What are endometriomas?
What causes them?
How to diagnose?
1) Ovarian chocolate cysts
2) Endometriosis w/in ovary
3) US, MRI, CT
What possible future studies can be used to diagnose endometriosis?
What studies should to avoid?
1) Possibilities include peritoneal fluid markers like cytokines, growth factors, angiogenic factors
2) For surface endometriosis, avoid imaging (useless). Also, avoid CA-125, anti-endometrial antibodies (not specific or reproducible)
Which part of uterus is adenomyosis usually more extensive?
What does the myometrium look like?
Posterior wall
Trabeculated
What system is used to stage endometriosis?
Revised American Society for Reproductive Medicine Classification of Endometriosis
Done post-op, documenting extent & location of implants & adhesions
What are medical management options for endometriosis? (6)
What is rational behind treatment?
Which of the treatments are used as adjuncts?
1) OCPs, Danazol, Progestins, GnRH agonists, anti-inflammatories, antidepressants
2) Suppress ovarian E2 production → decrease stimulus for endometrial growth and proliferation
3) anti-inflammatories, antidepressants
What are surgical mgmt options for endometriosis?
(3 initial, 1 rare, 1 definitive)
1) Excision or destruction w/ laser vaprorization
2) Electrocoagulation or thermocoagulation
3) Lysis of adhesions
4) Rare: Presacral neurectomy or uterosacral ablation to manage pain
5) Definitive: TAH + BSO + Lyse adhesions + Excise all peritoneal surface lesions & endometriomas
What is Danazol?
What is its effect on endometriosis?
1) Synthetic 17-α-ethinyl-testosterone derivative
2) It inhibits multiple enzymes in steriodogenesis and cytosolic hormone receptors
Causes high androgen, low estrogen environment → reduces endometrial tissue activity
What type of bone loss is associated with long term (>6mo) GnRH agonist treatment for endometriosis?
Trabecular
Note: Avoid this with add-back estrogen/progestin therapy!!
Which is the best treatment for endometriosis symptoms:
Medical, surgical, or combined?
Combined!
What is treatment for adenomyosis? (2)
1) OCPs + NSAIDs or GnRH agonist
2) Definitive: TAH if pt fails medical treatment
Define chronic pelvic pain in women
Nonspecific pelvic pain >6mo
May or may not be relieved by analgesics
Pain is associated w/ laparoscopically evident pathology, occult somatic pathology, and nonsomatic disorders.
How common is chronic pelvic pain in women?
Up to 10% of outpt gyn consults
Responsible for 10-35% of laparoscopies & 12% of hysterectomies in U.S.A.
What is innervation of major pelvic organs? (overall)
From ANS – both PSNS and SANS
Afferent pain: thru SANS w/ cell bodies in thoracolumbar distribution
PSNS is involved to a lesser extent & transmit painful stimuli
What are spinal cord levels of the mullerian-derived organs?
(i.e., uterus, tubes, upper vagina)
Transmit via PSNS or SANS?
1) T10, T11, T12, L1
2) SANS
What is innervation FROM the uterus?
Uterus → uterosacral ligaments → uterine inferior plexus → hypogastric plexus @ level of rectum & vagina
What are spinal cord levels of the lower vagina, cervix, and lower uterine segment?
Transmit via PSNS or SANS?
1) S2-S4
2) PSNS
What are spinal cord levels of ovaries and distal fallopian tubes?
T9 + T10
Have own nerve supply
What are spinal levels of bladder, rectum, perineum, and anus?
Transmit via PSNS or SANS?
S2-S4
SANS and PSNS
Fibers from the perineum and anus combine to form branches of which pelvic nerve?
Pudendal
What mechanisms can cause visceral pain? (6)
1) Distention of hollow viscera
2) Sudden stretching of solid organ's capsule
3) Hypoxia or necrosis of viscera
4) Prostanoid production
5) Chemical irritation of visceral nerve endings
6) Inflammation
What is difference btw splanchnic pelvic pain and referred pelvic pain?
1) Splanchnic: irritable stimulus is appreciated in specific organ 2/2 tension (stretching, distention, pulling) or peritoneal irritation/inflammation
2) Referred: autonomic impulses from diseased visceral organ → irritable response w/in spinal cord. Pain is sensed in dermatomes corresponding to cells getting the impulses.
What is DDx of gyn causes of chronic pelvic pain? (7)
1) PID
2) Endometriosis
3) Pelvic adhesions
4) Pelvic relaxation
5) Ovarian cysts
6) Mittelschmerz
7) Adenomyosis
What is DDx of ortho/MSK causes of chronic pelvic pain? (3)
1) Psoas muscle pain
2) Stress fracture of pelvis
3) Abdominal wall pain
What is DDx of urinary tract causes of chronic pelvic pain? (5)
1) Interstitial cystitis & urethral syndrome (UTI symptoms w/o bacteruria)
2) UTI/pyelo/cystitis
3) Bladder spasms
4) Ureteral obstruction (stone)
5) Perinephric abscess (usually caused by staph)
What is DDx of GI causes of chronic pelvic pain or lower abdominal pain? (5)
1) IBS, IBD
2) Constipation/bowel obstruction
3) Appy, diverticulitis
4) Strangulated hernia
5) Cholecystitis, cholangitis, GD ulcers, pancreatitis
What are the 11 most common causes of acute pain related to reproductive organs?
1) mittelschmerz
2) Fxnal ovarian cysts
3) Intrauterine pregnancy
4) Ectopic pregnancy
5) Pelvic infections
6) Uterine tumors
7) Adnexal neoplasia
8) Ovarian torsion
9) Endometriosis
10) Adenomyosis
11) Dysmenorrhea
What is mittelschmerz?
Dull pressure or aching during mid-cycle in RLQ or LLQ 2/2 ovulation, ovarian capsule distention, or mild bleeding associated w/ ovulation
What are fxnal ovarian cysts (2)?
What do each result from?
What are findings in each?
What are symptoms or complications in each?
1) Follicular or corpus luteum
2) Follicular: 2/2 failure of egg release from mature follicle during ovulation → aching in RLQ or LLQ
Corpus luteum: cyst persisting in center of corpus luteum; may be fxnal or non, so may delay menses. Rare except in pregnancy
3) F: Enlarged cystic ovary on exam
CL: Cyst in center of CL.
4) F: Torsion w/ pain, rupture w/ pain, rupture w/ hemorrhage, or nothing (spontaneous resolution)
CL: Torsion, rupture, hemorrhage; treat w/ OCPs or laparoscopy
How can an intrauterine pregnancy cause pelvic pain?
Stretching the visceral peritoneum via the enlarging uterus, early uterine contractions, ovarian capsule stretching from the corpus luteum cyst, corpus luteum rupture, and threatened abortion
How can ectopic pregnancy cause pelvic pain?
Before and after rupture 2/2 stretching of the fallopian tube hollow viscus or peritoneal irritation from a hemoperitoneum
Where might an ectopic pregnancy be located? (5)
Tubes
Cervix
Ovary
Intramural
Abdominal
How can uterine tumors (like leiomyomas or leiomyosarcomas) cause pelvic pain?
Via torsion, necrosis, visceral peritoneum stretching, or pressure against surrounding intra-abdominal structures.
How can adnexal neoplasia cause pelvic pain? (4)
Hemorrhage, necrosis, torsion, or rupture
What is the pathogenesis of pelvic pain in ovarian torsion?
Twists → venous blood flow ceases → ovary enlarges → arterial blood flow ceases → necrosis
Pain is usually acute, severe, and constant or intermittent. May also include n/v & diaphoresis
What is pathogenesis of pelvic adhesions?
What is MCC of these?
1) Adhesions happen 2/2 trauma to visceral or parietal peritoneum (2/2 operation, endometriosis, or infxn)
Can also happen w/ ischemic damage to peritoneum occurs → no fibrin lysis → fibrous adhesions occur
Foreign body granulomas can occur 2/2 talc or gauze/suture material → adhesions
2) Surgical intervention (~70%)
How do pelvic adhesions cause pelvic pain?
Theories include pain via mechanical stimulation (i.e., stretching) of visceral nociceptors
How to treat pelvic adhesions?
What percent of pts see improvement of pelvic pain from this?
1) Laparoscopic lysis
2) 65-85%. 75% of pts see continued improvement 6-12 mos after surgery
What are causes of deep vaginal pain?
What makes it worse?
How to treat?
1) Tender trigger points in the paracervical region or margins of the vaginal cuff after hysterectomy; pain is diffuse
2) Coitus, menses, examination
3) Inject w/ 1% procaine or 0.25% bupivacaine w/ min 3-5mm penetration of vaginal mucosa – may need to repeat 3x per week. Use diagnostic laparoscopy to r/o adhesions & endometriosis. Laser therapy for fulgurate endometriosis, lyse adhesions, transect uterosacral ligaments.
Myofascial trigger point vs abdominal wall trigger point?
MFTP: hyperirritable spot, usually w/in taut band of SKM or muscle fascia
AWTP: in fat or fascial planes above the aponeurosis on needle localization
How to detect myofascial trigger points?
Points are painful on compression (=jump sign)
May give rise to characteristic referred pain to arm, leg, or back
Tenderness
Autonomic phenomena: tearing, coryza, visual disturbances, tinnitus
How to treat myofascial trigger points?
Hyperstimulation
Analgesics: stretch, cold spray
Needle w/ local injection
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture
What diagnostic method can be used to distinguish visceral pathologic conditions from chronic abdominal pain of neurologic origin?
Careful neuro assessment w/ palpating small areas of tissue:
Place needle into tissue either abdominally or vaginally
Inject saline into local tissue & reproduce same pain w/ needle tip
T or F: Sexual abuse is associated w/ chronic pelvic pain
TRUE
Best approach to pt w/ chronic pelvic pain?
1) Complete medical, social, sexual history and PEx.
2) ID trigger points & use analgesia to improve accuracy
3) Differentiate btw somatic and visceral foci of pain
4) Consider US, CT, MRI, AbdXR & Renal rads to help diagnose
5) Use minimal am't of meds
6) Limit surgery to severe, refractory cases
7) Avoid removing normal tissue
8) Offer psych consultation – multidisciplinary therapy is key!
Which meds to use w/ chronic pelvic pain, & what are benefits or side effects?
1) Analgesics; may be addicting
2) Antidepressants; may potentiate analgesics
3) Anxiolytics: may potentiate analgesics but may be addicting
4) GnRH agonists for endometriosis; bone loss (add back tx)
What are the success rates for laparoscopic conservative surgery in endometriosis associated pelvic pain?
For hysterectomy for chronic pelvic pain?
For presacral neurectomy for difficult, non-responsive cases?
1) Relief up to 6mos in 40-70% of women
2) Up to 78% (even w/o uterine pathology)
3) 50-75%, but recurrence rate is >50%
What is laparoscopy's role in treatment for chronic pelvic pain?
40% of laparoscopy is done to treat chronic pelvic pain
40% have diagnosable abnormalities
50% may be helped with this procedure, though