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Obgyn Gyn Problems Ii
 

Obgyn Gyn Problems Ii

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    Obgyn Gyn Problems Ii Obgyn Gyn Problems Ii Presentation Transcript

    • OBSTETRIC & GYNECOLOGY COMMON GYNECOLOGICAL PROBLEMS Part II Pascale Gehy-Andre PA-C
    • Common Gynecological Problems LEIOMYOMA ADENOMYOSIS ENDOMETRIAL POLYPS ENDOMETRIOSIS GYNECOLOGICAL ABDOMINAL PAIN
    • Leiomyomas
    • Leiomyomas
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    • UTERINE LEIOMYOMA INCIDENCE
      • AKA: Myoma, fibroid fibromyoma & benign
      • Myomata Uteri
      • - Common benign tumors in female of reproductive age
      • - 20 to 40% of women by age 40
      • 3 to 9 X more common in black women
      • Varying size from 15 cm to > 100 lbs
      • Usually more common multiple
    • LEIOMYOMA ETIOLOGY
      • Smooth muscle and some connective tissue
      • Originate from the myometrium
      • Etiology is unknown
      • Estrogen sensitive
      • Increase in pregnancy
      • Decrease with menopause
    • LOCATION OF LEIOMYOMAS
      • Classification is by anatomic location:
      • Uterine 95% Cervical 5%
      • SUBMUCOSAL (Immediately beneath the endometrium)
      • INTRAMURAL OR INTERSTITIAL (within the uterine wall)
      • SUBSEROSAL ( beneath the serosa)
        • PEDUNCULATED (may become parasitic)
    • Leiomyoma of the Uterus
    • LEIOMYOMA History -Most are asymptomatic Symptoms depends on size, location, pregnancy, sarcomatous degeneration (0.1 to 0.5%) Abnormal uterine bleeding; most common -Menorrhagia, metrorrhagia Dysmenorrhea is not a typical feature Pain: Vascular compromise, torsion, infection Large fibroids can put pressure on the rectum causing constipation. Fever, spontaneous abortion, infertility
    • LEIOMYOMA
      • Physical Exam and laboratory findings
      • Most discovered by routine P/E
      • CBC; + anemia
      • Pelvic Ultrasound
      • particularly helpful in obese Patients
      • Pelvic/ low abdominal Xrays
      • MRI gives accurate definition of size, location, and number
      • Endometrial biopsy
      • Fractional D&C
      • Hysteroscopy/laparoscopy
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    • LEIOMYOMA
      • TREATMENT
      • Corrective measures for Anemia
      • Asymptomatic requires no treatment
      • GnRH agonists (Lupron) may be considered in poor surgical candidates
      • Hysterectomy
      • - Myomectomy because pregnancy is possible Requires q 6 month F/U. 33% will need hysterectomy
    • LEIOMYOMA
      • COMPLICATIONS
      • -Myomectomy has a 2 to 3% yearly recurrence
      • - Infertility & recurrent spontaneous abortions
      • - Pregnancy: Increased preterm labor & PROM, dysfunctional labor and dystocia.
      • .01 to 0.5% risk of leiomyosarcoma.
    • ADENOMYOSIS INTERNAL ENDOMETRIOSIS
      • ADENOMYOSIS
      • Etiology
      • Local invasion of e ndometrial tissue in the myometrium more than 3 mm beneath the endometrium & associated with muscular hypertrophy
      • Invasion mostly diffuse from the endometrial surface
      • Rarely may produce a localized endometrial mass
      • Etiology is not known
      • Growth occurs only during reproductive years
      • Usually occurs in parous woman, increase with age and usually regress with menopause
    • ADENOMYSIS
      • CLINICAL FINDINGS
      • Parous middle-aged woman with hx of:
      • Dysmenorrhea, menorrhagia
      • Uterine tenderness on palpation (Halban’s Sign)
      • Varying degree of chronic pelvic pain
      • US useful in diagnosing
      • Chronic severe anemia may be present
    • ADENOMYOSIS
    • ADENOMYOSIS
    • ADENOMYOSIS
      • TREATMENT
        • Hysterectomy
          • Confirmatory of diagnosis
          • Definite treatment of choice
        • Hormonal Therapy
          • GnRH agonists may provide temporary relief of symptoms but not very effective
        • OC may exacerbate symptoms
    • ENDOMETRIAL POLYPS
    • POLYPS
      • ETIOLOGY
      • Hystogenesis is not clear
      • May be pedunculated or sessile
      • Considered estrogen sensitive
      • Risk Factors
      • Obesity, hypertension, Tamoxifen therapy
      • More common near menopause
      • May undergo malignant changes
        • Carcinomas and Sarcomas
    • POLYPS
      • Clinical Findings
      • Menorrhagia
      • Pre or post menstrual spotting
      • In postmenopausal woman sudden occurrence of bleeding accompanied by uterine pain (Infarct)
      • Exam may reveal ulceration of the distal tip of the polyp
      • Trans-vaginal US helpful in diagnosis
      • Hysteroscopy
    • Treatment of Uterine Polyps
      • Hysteroscopic resection
        • D&C of attachment site
      • Progestin may cause regression
      • Hysterectomy for malignant changes
    • ENDOMETRIOSIS
      • Definition
      • Aberrant growth of endometrial tissue outside the uterus
      • Most common site is the ovary
      • Other areas of the pelvis and the abdomen may be involved
      • 3-15% premenopausal women rare postmenopause
      • Accounts for 25% gyn laps & 50% of infertility
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    • ENDOMETRIOSIS
      • Etiology
      • Common health problem in women etiology unknown
      • Classic theory of John Sampson
        • Retrograde menstruation subsequent bleeding from the fallopian tubes into the abdomen. Desquamated endometrium implants on the pelvic viscera
      • Estrogen dependent
      • Genetic influences possible
      • Socioeconomic factors ?
    • ENDOMETRIOSIS
      • Menstrual implantation- tubal regurgitation especially dominant tube
      • Intra-operative implantation occurs within scars
      • Lymphatic hematogenous route lymphatic dissemination similar to that of the malignant metastasis
      • Embryonic implantation re-differentiation or persistence of various embryonic tissue
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    • ENDOMETRIOSIS Clinical Findings
      • - History very helpful. Not uncommon to have symptoms early often 1-2 year after onset of menses
      • Severity classified from I-IV based on the extent, locations, stage and degree of symptoms
      • Dysmenorrhea, dyspareunia, infertility are the main presenting complaints.
      • Dyspareunia is a key symptom in differentiating endometriosis from dysmenorrhea
    • ENDOMETRIOSIS Clinical Findings
      • Change in bowel habits, cramping, rectal and pelvic pain, nausea vomiting
      • Dysuria, spotting, frank hematuria irregular menses, Infertility , backache, premenstrual - Less common plural pain if pulmonary & seizure from CNS lesions
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    • ENDOMETRIOSIS
      • DIAGNOSIS
      • - Physical Exam : Pelvic tenderness with uterine/ pelvic nodularity, ovarian enlargement & tenderness, pain upon uterine motion uterine may be fixed, retroverted due to adhesions.
      • - Can have cutaneous or extraperitoneal disease
      • Lab: CA 125 often elevated with extensive disease,
      • - Cytology is always negative
    • ENDOMETRIOSIS
      • DIAGNOSIS
      • - Imagining Pelvic U/S have high false positives/ negatives. MRI/CT limited value
      • Laproscopy only definitive way & always with biopsy secondary to wide variation of lesion appearance. Most common powered burn lesions. Superficial red-brownish or black-blue lesions. Later fibrosed or chocolate cystic changes. Can be non-pigmented & hemorrhagic
      • Chocolate cyst present
      • - If many adhesions may need a laparotomy
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    • ENDOMETRIOSIS
      • TREATMENT
      • - Based on severity of symptoms, age, desire for childbearing.
      • Observation - Minimal symptoms
      • Hormonal therapy – interruption of the cycles using Depo Provera 150mg/mth*6mths
      • BCP double usual dose after 1 mth then increase
      • Pregnancy
      • - Danazol (Danocrine) 200 to 800 mg bid for 6 mths 80 to 95% effective pain relief and other symptoms
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    • TREATMENT OF ENDOMITRIOSIS
      • GnRH Agonists lupron IM 3.75mg/mth*6mth
      • Intranasal Nafarelin 200mg bid*6mth
      • Surgical indicated in severe disease, patients over 40 y/o and severe adhesion
      • Laparoscopic lysis of adhesions, laser ablation.
      • Total abdominal hysterectomy in severe and patients with no desire of childbearing. Bilateral salpingo-oophorectomy followed by HRT
    • Still Alive
      • GYNECOLICAL REASONS FOR ABDOMINAL MASS OR CHRONIC PELVIC PAIN
      • Pelvic Pain Sources
      • Referred pain- Visceral or splanchnic pain over the somatic fibers of the parasympathetic ANS is poorly localized does not respond to thermal or tactile it is stretch/tension & inflammation in nature
      • Hypogastric plexus Vaginal upper 1/3, cervix, lower segment, bladder trigone, uterosacral ligaments, lower ureters, posterior urethra, recto-sigmoid & dorsal external genital
      • Thoraco-lumbar plexus (T 11 - L 1 ) Fundus, Proximal 1/3 tube, Broad ligaments, upper bladder, appendix, cecum terminal large bowel
      • Superior Mesenteric plexus (T 5 - T 11 ) Ovaries, lateral 2/3 fallopian tube & upper ureters
      • Pelvic Pain Sources
      • Can be either sudden or gradual onset
      • May be associated with various type of abdominal pain
      • Epigastric Pain - Stomach, duodenum, pancreas, liver and gallbladder
      • Periumbilical Pain – Small intestines, appendix, upper ureters and ovaries
      • Hypogastric/suprapubic Pain – Colon, bladder lower ureters and uterus
      • Pelvic Pain – Cervix, ovaries and fallopian tubes
      • Shoulder Pain- Diaphragm or diaphragmatic irritation
      • Pelvic Pain Quality
      • Cramping or colicky pain - muscular contraction or intraluminal pressure of a hollow viscus
      • Constant pain – Inflammatory process, distention of a solid organ, ischemia
      • Intermittent pain – adnexal mass with partial torsion
      • Positional pain – mobile pelvic mass
      • Sharp pain – obstruction or acute peritoneal process
      • Dull pain – inflammatory process
      • Pelvic Pain Duration
      • Acute < 48 hours initial episode or chronic >48 hours or recurrent
      • Pelvic Pain Severity
      • Minor vs. major. Evaluate appearance and look for any associated pallor or toxicity
      • Associated symptoms
      • Vaginal bleeding, discharge, fever, chills, nausea, vomiting, anorexia, syncope, hypovolemia, dysuria, flank pain, dyspareunia or shoulder pain
      • Physical Exam
      • General appearance, orthostatic, activity level, anxiety, toxicity, LOC, posture
      • Chest look for abnormalities that often cause referred pain
      • Abdominal
      • Pelvic
        • Inspection external genitalia vagina and cervix for trauma, infection, discharge, hemorrhage, asymmetry or masses
        • Palpate vaginal wall and cervix for location of any tenderness, cervical motion tenderness first without than with abdominal pressure
        • Palpate the adnexa for masses or tenderness
        • Presence of CVA tenderness
      • Laboratory Test
      • CBC|with diff
      • UA with macro/micro
      • Urine culture
      • Qualitive β HCG may need serial quantitive levels
      • Cervical cultures
      • Possible Culdocentesis
      • Radiographs flat & upright right lateral decubitus for obstructions, free air, free fluid, fluid levels, calcifications or masses
      • Ultrasound abdominal/pelvic for IUP, fluid, masses & shifts
      • Laproscopy/Open laparotomy - Visualization
    • ETIOLOGY CHRONIC PELVIC PAIN
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    • Fistulas
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    • Salpingitis
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