Obgyn Gyn Problems


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Obgyn Gyn Problems

  3. 3. Frequent Terms Hypermenorrhea- Heavy or prolonged bleeding & regular Menorrhagia- Heavy bleeding Metrorrhagia- Bleeding in between periods Polymenorrhea- Menses < 21 days, frequent period Menometrorrhagia- Prolonged flow with intermenstrual bleeding Oligomenorrhea- infrequent periods Amenorrhea- Absent periods Dyspareunia- Pain during intercourse Dysmenorrhea- Painful menstruation Mittelschmerz- Mid-cycle lower abdominal pains associated with ovulation
  4. 4. Case Study  A 17 year-old nulliparous woman complains of pelvic pain that occurs within 48 hours of each menses, continuing for three days, and is accompanied by nausea, vomiting, headache, back pain, and fatigue. Her physical exam is normal. What is your diagnosis?
  5. 5. DYSMENORRHEA  Painful menses occurring within 24-48 hours of the onset of menses  Most common medical problem of young woman  Variable disability for 50% of woman during their reproductive years 10% of patient with incapacitating pain for 1-3 days month  Either primary or secondary in nature Dysmenorrhea is a condition not a disease the Underlying cause must be diagnosed
  6. 6. PRIMARY DYSMENORRHEA  Uncommon prior to menarche  Most common in late teens Incidence increase until early adulthood then declines with age Parity often decreases severity with each successive gestation No identifiable cause present Excessive PGE F2α mediated uterine smooth muscle stimulation  Cervical stenosis, uterine ischemia  PGE E2 Vasodilator/platelet inhibitor increasing menstrual flow
  7. 7. PRIMARY DYSMENORRHEA H&P  Initial onset usually within 2 years of menarche Sharp, diffuse colicky suprapubic abdominal pain radiates to the back and last for 1-3 days  Often described as labor pain  Nausea, vomiting, diarrhea and headache secondary to systemic effects of prostaglandins  60% low back pain, 45% dizziness, nervousness  Does not occur between cycle or with anovulatory conditions  Dyspareunia uncommon and is suggestive of secondary dysmenorrhea  No anatomic or physiological causes present
  8. 8. PRIMARY DYSMENORRHEA Treatment  PGE inhibitors- NSAID  Combination OBCP (estrogen followed by progestin required for PGE secretion from endometrium so combination reduces natural cycle thus preventing ovulation and reducing PGE production) Therapy with Danazol (low dose testosterone helpful at times Progestin OBCP pills to reduce endometrial layer  Severity lessen with parity secondary to previous cervical dilation
  9. 9. SECONDARY DYSMENORRHEA  Uncommon in early adulthood. Increases with age  Occurrence & severity not effected by parity.  Pain is from inflammation, ischemia, stretch receptor, hemorrhage or perforation which increase peritoneal irritation  May occur between menstrual cycles but increases with or becomes more apparent during menses. When occurs between cycles becomes chronic pelvic pain
  10. 10. SECONDARY DYSMENORRHEA CAUSES Extrauterine Endometriosis, Inflammation, Adhesions, Tumors (benign & malignant), Non gynecologic systemic cause Intramural Adenomyosis, Leiomyomata Intrauterine Leiomyomata, Polyps, IUD, Infections cervical stenosis, endocervical adhesions, congenital uterine abnormalities
  11. 11. H&P  History often suggest etiology Usually initially mild and more general in nature  Often associated with heavy flow suggesting intramural/intrauterine etiologies  Increase abdominal pain suggest extrauterine causes Abdominal symptoms, contour changes or pelvic fullness suggest large leiomyomata or neoplasms  Fever, chills, malaise, vaginal discharge, suggest inflammatory Coexisting infertility suggest endometriosis or chronic pelvic inflammatory diseases
  12. 12. SECONDARY DYSMENORRHEA Diagnosis  H & P with pelvic exam  CBC  Cultures  Urine studies  Pelvic & abdominal U/S  CT scan  Hysteroscopy  Laparoscopy  Possible open laparotomy
  13. 13. AMENORRHEA - Defined as failure of menarche by age 16 regardless of development or the absence of menstruation for 3-6 months after menarche. - Typically menstruation start by age 12 with about 98% by age 16 & last from 24-38 days - Mean development by age 14 getting earlier recently ? etiology - Two different types primary & secondary
  15. 15. AMENORRHEA PRIMARY - Failure of development by 14 years of age - Failure of menses by 16 years of age regardless of development - Secondary to chromosomal (Turners 45,XO) genital agenesis/congenital abnormalities (absent vagina or imperforated Hymen) , failure of pituitary-ovarian axis
  16. 16. AMENORRHEA SECONDARY ****REMEMBER R/O PREGNANCY**** - Failure to menstruate for 3-6 months or 3 cycles after menarche -Ovarian failure most common i.e.: menopause but can be premature. -Outflow tract obstruction
  17. 17. AMENORRHEA ETIOLOGY Reproductive Outflow Disorders * Mullerian agenesis- absence of either vagina or uterus * Imperforated Hymen * Androgen Insensitive * Cervical stenosis * Intra uterine adhesions(Asherman’s syndrome naturally or surgical etiology)
  18. 18. AMENORRHEA ETIOLOGY Ovarian Disorders * Chronic anovulation * Resistant ovary * Gonadal dysgenesis * Premature ovarian failure
  19. 19. AMENORRHEA ETIOLOGY Pituitary Disorders * Hyperprolactinemia * Various tumors * Pituitary insufficiency
  20. 20. AMENORRHEA ETIOLOGY Hypothalamic Disorders * Functional- Exercise, stress anorexia S/P * OBC pill, obesity * Drugs TCA, tranquilizers * Neoplastic lesions * Nonfunctional- Space occupying lesions * Kallman’s Syndrome is LHRH hypogonadism
  21. 21. AMENORRHEA DIAGNOSTIC APPROACH - History: is extremely important in these cases detailing the physical sexual developmental, nutritional, medical, and psychological history. - Details of possible endocrine symptoms i.e.: (virilization, hypothyroid and diabetes) - Exercise & weight loss (Body fat index) - History anorexic or bulimia (menstruational anomalies are often the presenting symptom in adolescent females) - Emotional stress extremely important
  22. 22. AMENORRHEA -Exam: Neuro for possible intracranial lesions, Pelvic (limited external in adolescent) , Secondary sex characteristics -Any evidence of endocrine abnormalities. DIAGNOSTIC APPROACH - Laboratory: hCG, Prolactin, TFT (T3/T4/TSH) LH/FSH, estrogen/progesterone and possible testosterone/DHEA-S. May need CT/MRI. - Chromosome karyotyping
  23. 23. AMENORRHEA DIAGNOSTIC APPROACH - Progestin challenge test- MPA induced: -If bleeding occurs the cause is chronic anovulatory or oligo-ovulatory -If no withdrawal bleeding the cause is either a low estrogen state of anatomic
  24. 24. AMENORRHEA TREATMENT Depends on the basic cause Goal to induce menstrual flow 3-4 /year -Surgical-For any lesion/tumors or defects - 80 – 90% CNS or pituitary tumors will need resection - Absent genital: cosmetic surgery but will never be functional
  25. 25. TREATMENT -Pharmacological- Wide range usually long term * Hypothalamic disorder- Behavior or lifestyle changes Treat any hypothyroid and hyperprolactinimia with surgery &/or Parlodel * Ovulation can be induce by gonadotropins * Cycles managed by either 10 day progestin withdrawal 3-4/year or OBCP continuously * If associated with DUB after R/O organic causes May need estrogen supplementation or high dose estrogen/progestin OBCP combination. Treat anemia
  26. 26. Case Study  A 21 year-old woman complains of menstrual irregularity since menarche at age 17. The exam reveals excessive hair growth on face and chin as well as acne. She is 5.5” and weighs 135 pounds. The pelvic exam is unremarkable. What is your diagnosis?
  27. 27. 21 year-old woman  Which diagnostic tests would be most helpful in securing a diagnosis?  Pelvic Ultrasound  If this woman becomes pregnant, which obstetrical complications is she at highest risk for?  Gestational Diabetes
  28. 28. - AKA Stein-Leventhal Syndrome - Is most common cause of chronic anovulation - Can cause either amenorrhea or irregularity due to estrogen breakthrough - Triad: obesity-hirsutism-amenorrhea - Also may include anovulation and infertility - Thought to be X-linked - HX of insulin resistance may be present
  29. 29. Polycystic ovarian syndrome PCOS - Etiology: Increased adrenal androgens with obesity related increased extra-ovarian estrogens. - This leads to inappropriate follicular development with thecal layer over-activity producing increased levels of androgens. - Both leading to elevated LH and decreased FSH - Thus failure of conversion of progesterone to estrogen by depressed granulosa cells. - This leads to premature but slow regression of the follicle leading to multiple cystic formation.
  30. 30. Polycystic ovarian syndrome PCOS Diagnosis - Elevated LH and decreased FSH - Elevated near normal estrogens, progesterone low - Elevate LH/FSH ratio - U/S evidence ovarian enlargement with midsized cystic follicles.
  31. 31. Polycystic ovarian syndrome PCOS Treatment - Intermittent progesterone interruption with OBCP - Weight reduction ideal & often only issue needed - If pregnancy is a non issue periodic MPA withdrawal is indicated 3-4x/year - For Pregnancy use Clomiphene or gonadotropins - Hirsutism with spironolactone
  32. 32. MENOPAUSE - Cessation of menses may be perimenopausal - Median age 50 - Not related to age of menarche - smoking and family history - Chronic estrogen deficiency - Ovarian atresia with follicular failure
  33. 33. MENOPAUSE SYMPTOMS - Vasomotor disturbances 75% with hot flashes - Urogenital atrophy - Osteoporosis 1-3% bone loss/year increase Fx. - Cardiovascular change with increase LDL to male levels with slight decrease in HDL - Neuro/Psychiatric: increase depression, mood changes, decrease sexual desire & other subtle metal status changes. Estrogen reversible
  34. 34. MENOPAUSE DIAGNOSIS - Low estrogen/ progesterone with increased FSH/ LH. Vasomotor disturbances 75% with hot flashes. R/O pregnancy -Treatment controversial HRT -Absolute Contraindications- History breast CA, thrombophlebitis/thrombotic disorders, certain ovarian, endometrial cancers and undiagnosed vaginal bleeding
  35. 35. SIGNS & SYPMTOMS of ESTROGEN DEFICIENCY Symptoms: Hot flashes, Mood changes, sleep disturbances, Vaginal dryness, Dyspareunia Signs: Vaginal atrophy, thinning of skin & hair, Hot flashes
  36. 36. Atrophic Vaginitis  AKA Senile Vaginitis Senile urethritis  Epithelial mucosal atrophy of the vagina, urethra, cervix, endocervix, endometrium and myometrium  Estrogen deficiency both natural and surgical  Mucosa becomes thin, pale friable, with decreased secretions  Increased susceptibility to trauma and infections  IS A NATURAL PROCESS  Leading cause of sexual dysfunction  Treat as part of menopausal treatment
  37. 37. ABNORMAL UTERINE BLEEDING - Defined as alteration of normal flow - Dysfunctional uterine bleeding DUB is most common cause of abnormal uterine bleeding prior to menopause - Heavy, prolonged or inter-menstrual - Normal is for 3-7 day & 60-80 ml blood loss - DUB increase to 7-18 day & 100-200 ml - May have chronic Fe loss & anemia - About 15% have regular ovulation but lack adequate corpus function
  40. 40. ABNORMAL UTERINE BLEEDING ETIOLOGY - Organic: Coagulopathies, liver/renal disease, drugs (steroids, chemo & Coumadin) Obesity and endocrine abnormalities (thyroid, diabetes & adrenal). - Uterine: included Leiomyomas, polyps, endometrial hyperplasia, PID, IUD, pregnancy, cancers & endocrine active tumors. - Non organic: Persistent ovulatory failure, the most common cause is the continuous acyclic estrogen production leading to anovulation and endometrial proliferation. DUB is the most common cause of bleeding in adolescent & young adults.
  41. 41. ANATOMIC CAUSES OF IRREGULAR BLEEDING Uterine lesion: Myomas, Polyps, endometrial carcinoma Cervical lesion: Neoplasia, polyps, cervical inversion, cervicitis, cervical condylomas Vaginal lesions: Carcinoma, sarcoma, adenosis, laceration, trauma, infections, foreign bodies Other: Urethral carbuncle, urethral diverticulum, GI bleeding, and various labial lesions
  43. 43. ABNORMAL UTERINE BLEEDING DIAGNOSIS - History: Previous customary cycles, episode of irregular bleeding, heavy bleeding, sexual contact, STD, previous surgery - Exam: Pelvic for possible sites of internal bleeding (vaginal/rectal), uterine or adnexal enlargement - Lab: hCG, CBC, consider Prolactin Coag studies, TFT,LH, FSH, estrogen and Progestin levels. U/S trans vaginal U/S possible CT/MRI - May need biopsy, D&C, and hysteroscopy - Treatment depends of etiology
  44. 44. Polypoid mucosa Hyper-stimulated Mucosa
  45. 45. Fibroids Polyps
  46. 46. Adenocarcinoma
  47. 47. Dysfunctional Uterine bleeding  Pathology is excluded  Most patient anovulatory  May be related to hypothalamic-pituitary axis resulting in continued estrogenic stimulation of the endometrium. The endometrium outgrows its blood supply partially breaks down bleeding occurs in irregular manner  Organic causes ( Thyroid, adrenal must be excluded)
  48. 48. Dysfunctional Uterine Bleeding  Epidemiology: Most common in extremes of reproductive age (20% adolescents, 40% patients over 40)  Hx: to exclude all other pathology  Diagnosis is based on history, absence of ovulatory temperature changes, low serum progesterone, and result of endometrial sampling in the older woman.
  49. 49. TREATMENT - DUB is most common cause of abnormal bleeding - Unremarkable & negative workup - Acute stable :MPA or OBCP 3 to 4 X usual dose - Unstable: IV estrogen 25 mg q4 X6 if uncontrollable need D&C with cytology - Chronic: GnRH inhibitors, ergots, NSAID, various Progestin/EST/PROGEST/OBCP combinations - Surgical D&C, eletrocautery or laser endometrial ablation. Hysterectomy is final option for significant refractory bleeding without pathology
  50. 50. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING Always abnormal and is cancer until proven otherwise
  52. 52. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING DIAGNOSIS - History: Previous customary cycles, episode of irregular bleeding, heavy bleeding - Exam: Pelvic for possible sites of internal bleeding (vaginal/rectal), uterine or adnexal enlargement - Endometrial biopsy may be required - Possible D&C and hysteroscopy may be helpful.
  53. 53. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING DIAGNOSIS - HRT if bleeding acyclic or last greater than 10 days. If cyclic & before the 10 day & unresponsive to progesterone increase requires biopsy -HRT if bleeding acyclic for more than 6 months -If heavy and persistent initially requires biopsy - When in doubt refer for biopsy
  54. 54. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING TREATMENT - Depends on the final diagnosis refer for cancer or adenomatous hyperplasia - If cystic hyperplasia, proliferative endometrium increase Progestin and repeat 4-6 months - Secretory, non-proliferative or atrophic endometrium : normal provide reassurance but repeat 8-10 months if continues or for any changes - Never except insufficient sample or non definitive
  55. 55. PREMENSTRUAL SYNDROME -Psychoneuroendocrine -- PMS is a clinical syndrome with physical & emotional symptoms that increase just prior to the flow and rapidly dissipates - Nearly 100% with some degree of symptoms 50% present to MD & 5% with severe symptoms - Peak age is 30-45 with a + family history - Often is associated with early perimenopause
  56. 56. PREMENSTRUAL SYNDROME - Increases with use OBCP - 40% + history of sexual abuse (double general) - 15% childhood sexual abuse (triple general) - Increase with pregnancy complicated abortion, preeclampsia, or postpartum depression - Often linked with mid-life crises. - Symptoms rate mild, mod. severe
  57. 57. PREMENSTRUAL SYNDROME ETIOLOGY - Neurotransmitter dysfunction - Steroid imbalance (Estrogen:progesterone) - Prostaglandin imbalance - Fluid retention - Vitamin deficiency (A, B6, B complex) - Mineral deficiency ( Mg, Zn & Ca) - Psychosomatic illness
  58. 58. PREMENSTRUAL SYNDROME PRESENTATION -Abdominal bloating -Anxiety - Breast tenderness -Emotional liability - Depression -Fatigue -Irritability -Weight/water gain
  59. 59. PREMENSTRUAL SYNDROME DIAGNOSIS - Clinical diagnosis - Symptoms are cyclic & 2nd half of cycle - Symptoms increase as cycle progress - Symptoms are relief by menses onset - Symptoms complete absence 2-3 days of menses onset - Symptom free during rest of the cycle - Symptoms present during 3 consecutive cycles * - ?Interfere with daily function?
  60. 60. TREATMENT - Clinical diagnosis - R/O organic disease & treat if present - Luteal-phase progesterone &/or estrogen - Psychological support/reassurance/stress relief - Nutritional supplementation Vitamin B6/exercise - Mild diuretic spironolactone - Limit caffeine/smoking - Trial of OBCP or Danazol/Leupron - Trial of antidepressant/mild tranquilizer caution - NSAID drug (flavor of the month- Naprosyn) - Exercise