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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