Transcript GYNECOLOGY Winter, 2004

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
– greater than 6 months duration
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
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
*
Review of Anatomy:
What else could cause pain in pelvis or
lower abdomen?
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
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Pulse may be up, BP down
Abdomen tender, esp affected side
Palpable adnexal mass
Pos hCG or b-hCG
Mass confirmed by US
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
MANAGEMENT OF
ECTOPIC PREGNANCY
• Medical emergency
• Tx – surgical removal of mass and
possibly fallopian tube OR methotrexate
• CAM Tx – adjunct support post op
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
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
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
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
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
CYCLIC PELVIC PAIN
• Common causes
– Primary dysmenorrhea
– Secondary dysmenorrhea
• Endometriosis
• Adenomyosis
– Chronic functional cyst formation
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
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
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
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
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
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
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%
Endometriosis (con’t)
• Typical patient:
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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
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
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 prepubertal girls, women with congenital absence of uterus,
and rarely in men
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
Endometriosis etiology
(con’t)
– Environmental
• Endocrine disruptors:
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PCBs (polychlorinated biphenyls) e.g. bisphenol-A
Dioxins (found in tampons, among many other places)
Pesticides/ Herbicies
Detergents
Household cleaners
Diagnosis of Endometriosis
• Sx’s
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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
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
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
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
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
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
Common sites
Rare sites
Ovaries
Umbilicus
Pelvic peritoneum
Episiotomy scar
Ligaments of the uterus
Bladder
Sigmoid colon
Kidney
Appendix
Lungs
Pelvic lymph nodes
Arms
Cervix
Legs
Vagina
Nasal mucosa
Fallopian tubes
Spinal column
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
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
Tx of Endometriosis
• CAM Tx
– Strategies
• Reduce stimulation of ectopic endometrial
tissue by estrogen
• Optimize immune system function
• Reduce inflammation
• Provide pain relief
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
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
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Vitex for estrogen balance
Dandelion root for supporting liver function
Prickly Ash to simulate blood flow through pelvis
Motherwort as antispasmodic
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
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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.
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
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
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…
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
PELVIC MASS
• Most pelvic masses occur on ovary or in uterus
– Ectopic pregnancy, abscess, endometriosis, bowel masses
are exceptions
• Ovarian masses
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Functional cysts
Abscess
Benign or malignant tumor
Endometrioma
• Uterine masses
– Pregnancy
– Leiomyoma (fibroid)
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
UTERINE MASSES
• Uterine masses are rare in prepubertal and
adolescent girls
• In adolescent girls, R/O pregnancy and
PID/abscess
• Leiomyomas are the most common cause of
uterine masses in reproductive age women
• Persistent leiomyomas may be found in postmenopausal women, but new ones are
unlikely to appear
EVALUATION OF PELVIC
MASSES
• Complete history
• Pelvic and abdominal examination
• Labs – pregnancy test if applicable, CA-125,
CBC as indicated
• Imaging – abdominal or vaginal US – CT
and/or MRI if US inconclusive
• If bleeding is occurring in patient with a pelvic
mass, endometrial sampling is essential
Dx of Uterine mass
PE – enlarged uterus
R/O pregnancy if this is a possibility with urine hCG
Imaging – Pelvic or Trans-vaginal ultrasound
This will confirm leiomyoma
Leiomyomas
(uterine fibriods)
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Aka fibroid or myoma
Benign tumors of muscle cell origin
Most frequent pelvic tumors
Highest prevalence in women in 50’s
Majority found in body of uterus
Symptomatic uterine leiomyomas account for
30% of all hysterectomies
• Vary in size from microscopic to filling entire
abdomen
• May be single but more often multiple
Uterine fibroids
• Etiology unkown
• Higher concentrations of estrogen and
progesterone receptors in myoma than in
surrounding tissue
• Growth stimulated by estrogen
– Rare prior to menarche
– Usually diminish after menopause
– Smoking decreases estrogen and smokers are
found to have less fibroids
Uterine Fibroids
• Location varies:
– Subserosal– outer uterus wall
• May protrude through cervix into vagina
• May be pedunculated on long stalk and mistaken for
ovarian mass
– Intramural– within uterine wall
– Submucosal- just under endometrium
• Only account for 5-10% of myomas, but are the most
symptomatic (abnormal bleeding, fertility issues,
abortion)
Leiomyoma Symptoms
• Most are asymptomatic (50-80%)
• Symptoms may include:
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Discomfort / Pressure / Congestion of pelvis / abdomen
Bloating
Heaviness
Dysparunea
Urinary frequency
Backache
Abnormal bleeding in 30% of fibroids
– Menorrhagia– usually due to intramural fibroids which
enlarge the endometrial cavity and increase its surface
area
– Metrorrhagia– may be due to submucosal fibroid that
ulcerates through endometrial lining
Fibroid growth
– Fibroids generally have a poor blood supply
– With continued growth, will outgrow blood supply
– Eventually degenerate, rapidity with which this
occurs determines the extent of degeneration
• Different types of degeneration from histological
perspective (hyaline, myxomatous, calcific, cystic, fatty,
red, necrosis)
• Red: acute infarction causing severe pain
– Less than 1% are malignant
– Rapidly growing fibroids require special attention
– Initial management of fibroids is regular
ultrasounds every 6-12 months
Uterine Fibroid DDX
– Malignant ovarian tumor
– Pelvic abcsess
– Colon diverticulum
– Endometriosis
– Pelvic adhesions
– Congenital abormalities
– Rare: pelvic kidney, retroperitoneal tumor
Complications of fibroids
• Infertility in 2-10% of cases
– May interfere with implantation of fetus
– May decrease motility of sperm/ eggs
– May compress Fallopian tube
• In approx. 5% of cases, may compress
ureter, which leads to enlarged kidney
and may compromise kidney function
Fibroids and Pregnancy
• During pregnancy (high levels of estrogen
and progesterone)
– In some cases, blood flow diverted to fetus
– In other cases (esp. if large), fibroid may interfere
with pregnancy:
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•
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Interfere with fetal growth
Cause premature rupture of membranes
Retained placenta
Postpartum hemorrhage
Abnormal labor
MANAGEMENT OF FIBROID
TUMORS
•
Conventional tx
• Observation
• OCP’s – can reduce pain
• GnRH agonists or RU-486 short term
– Pre-op
– Close to menopause
– After cessation of therapy, fibroids usually return to original
size
• Surgery - indications
– Bleeding, anemia, chronic pain, urinary symptoms,
infertility
• Rapid enlargement of uterus may indicate uterine
sarcoma developing in leiomyoma
MANAGEMENT OF FIBROID
TUMORS
• Surgical techniques
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Hysterectomy
Laparoscopic myomectomy
Vaginal myomectomy
Hysteroscopic resection of small submucous fibroids
Uterine artery embolization
• Focused ultrasound - “sonication”
– Non-invasive, MRI guided, Thermoablative
• Recurrence rate up to 50% after myomectomy
MANAGEMENT OF FIBROID
TUMORS
• ND Tx
– Strategies
• Reduce estrogen activity
• Optimize circulation in pelvis
• Reduce sx’s of pain and bleeding
– Sample Tx
• Low estrogen diet
• Phytoestrogenic herbs
• Contrast pelvic sitz baths
• Maintain ideal weight
• Support liver and bowel function, flora
• Styptics – trillium, capsella, geranium, cinnamon
• Analgesics – viburnum, piscidia, cimicifuga
Natural Mgmt of Fibroids
– Difficult, varies with each individual
– Balance estrogen/ progesterone
– Liver support to help metabolize estrogen
– Good nutrition important
• Junk food, alcohol, caffeine, saturated fats and
sugar interfere with estrogen metabolism
• Low saturated fat and high fiber diet improves
circulating estrogen levels
Dx ovarian mass
• PE – enlarged ovary (ies)
• Pelvic or trans-vaginal ultrasound
• If ambiguous or suspicious for
malignancy - laparotomy
Ovarian Cysts
• Majority are asymptomatic
• Majority disappear or resorb
spontaneously
• If they rupture, patient feels transient
tenderness
– Patients respond differently to pain
• If persist over 2 months, need to rule
out ovarian neoplasm
Ovarian Cyst types
• Follicular cysts
– Most common type of ovarian cyst
– Frequently multiple
– Average 2.5-3 cm diameter
– Filled with straw-colored fluid
– Dominant follicle doesn’t undergo atresia
after ovulation, OR: incompletely
developed follicle doesn’t resorb
Ovarian Cyst types (con’t)
• Corpus luteum cysts
– May be associated with prolonged progesterone
secretion
– Average size 4 cm; usually unilateral
– May be asymptomatic
– May cause massive intraperitoneal bleeding upon
rupture; bleeding may be slight or require
transfusion
– When rupture, need to rule out ectopic pregnancy
– If grow and don’t rupture, need to follow with
ultrasound
– May resolve spontaneously or require surgery
Ovarian Cyst types (con’t)
• Theca lutein cysts
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Least common type of cysts
Usually bilateral
Moderate to massive enlargement of ovaries
1-10 cm diameter average
Majority are asymptomatic
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May cause increased abdominal girth
Felt upon palpation
May be diagnosed with ultrasound
Gradually regress
– Grow due to prolonged/excess ovarian stimulation
• Increased ovarian sensitivity
• Exogenous gonatotrophin stimulation, usually due to
drugs used to induce ovulation
MANAGEMENT OF
OVARIAN MASS
• Ovarian masses suspicious for malignancy –
solid or complex
– Exploratory laparotomy
• Biopsy will confirm or R/O malignancy, ovaries taken out
if malignant
• Functional ovarian cysts
– Conventional Tx
• OCP’s - reduce recurrence
– ND Tx – reduce estrogen activity
OVARIAN CANCER
• 2/3 of patients diagnosed with ovarian cancer will
have metastatic dz
• Peak incidence is 56-60 yrs
• Risk factors
– Infertility
– Low parity
– Early menarche, late menopause
– Talc use
– Galactose consumption
– Tubal ligation
– BRCA 1 and 2 (Ashkenazi, Icelandic women)
– Family hx of HNPCC
OVARIAN CANCER
• Reduces risk
– Having at least one child
– OCP’s
– Alpha and beta-carotenes
– Lycopene
– Green, black or oolong tea
– Selenium
– Low saturated fat diet
• Screening
– Currently no recommended screening tests
– Annual pelvic exam?
DX OVARIAN CANCER
• Sx’s - Usually asymptomatic
– May be vague and non-specific
• Abdominal discomfort, dyspareunia, bloating,
constipation, increased abdominal size
• Signs – usually only in advanced dz
– Firm, irregular, fixed pelvic mass
– Possible ascities
• Labs
– CA-125
• Confirm with exploratory laporotomy
MANAGEMENT OF
OVARIAN CANCER
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Cancer must be staged
5 yr survival rate for early stage dz is 70-90%
5 yr survival rate for late stage dz is 20-30%
Conventional Tx
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Surgery – remove tumor and other affected tissues
Chemotherapy – many protocols
Hormonal tx – tamoxifen
Immunotherapy
MANAGEMENT OF
OVARIAN CANCER
• ND Tx
– Strategies
• Optimize immune function
• Reduce side effects of chemotherapy
• Provide anti-tumor agents
– Sample TX
• Whole foods diet – smoothies
• Anti-oxidants, antiinflammatories
• CoQ10
• PSK - extract of mushroom trametes versicolor
• Green tea
KEY CONCEPTS
PELVIC MASSES
• Masses typically on ovary or in uterus
• Hx, PE, US are cornerstones of Dx
• Must R/O pregnancy in any
reproductive age woman
• Bleeding along with mass requires
endometrial sampling
• Ovarian cancer most common
malignant pelvic mass