Obgyn Gyn Problems Ii

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Obgyn Gyn Problems Ii

  1. 1. OBSTETRIC & GYNECOLOGY COMMON GYNECOLOGICAL PROBLEMS Part II Pascale Gehy-Andre PA-C
  2. 2. Common Gynecological Problems LEIOMYOMA ADENOMYOSIS ENDOMETRIAL POLYPS ENDOMETRIOSIS GYNECOLOGICAL ABDOMINAL PAIN
  3. 3. Leiomyomas
  4. 4. Leiomyomas
  5. 9. UTERINE LEIOMYOMA INCIDENCE <ul><li>AKA: Myoma, fibroid fibromyoma & benign </li></ul><ul><li>Myomata Uteri </li></ul><ul><li>- Common benign tumors in female of reproductive age </li></ul><ul><li>- 20 to 40% of women by age 40 </li></ul><ul><li>3 to 9 X more common in black women </li></ul><ul><li>Varying size from 15 cm to > 100 lbs </li></ul><ul><li>Usually more common multiple </li></ul>
  6. 10. LEIOMYOMA ETIOLOGY <ul><li>Smooth muscle and some connective tissue </li></ul><ul><li>Originate from the myometrium </li></ul><ul><li>Etiology is unknown </li></ul><ul><li>Estrogen sensitive </li></ul><ul><li>Increase in pregnancy </li></ul><ul><li>Decrease with menopause </li></ul>
  7. 11. LOCATION OF LEIOMYOMAS <ul><li>Classification is by anatomic location: </li></ul><ul><li>Uterine 95% Cervical 5% </li></ul><ul><li>SUBMUCOSAL (Immediately beneath the endometrium) </li></ul><ul><li>INTRAMURAL OR INTERSTITIAL (within the uterine wall) </li></ul><ul><li>SUBSEROSAL ( beneath the serosa) </li></ul><ul><ul><li>PEDUNCULATED (may become parasitic) </li></ul></ul>
  8. 12. Leiomyoma of the Uterus
  9. 13. 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
  10. 14. LEIOMYOMA <ul><li>Physical Exam and laboratory findings </li></ul><ul><li>Most discovered by routine P/E </li></ul><ul><li>CBC; + anemia </li></ul><ul><li>Pelvic Ultrasound </li></ul><ul><li>particularly helpful in obese Patients </li></ul><ul><li>Pelvic/ low abdominal Xrays </li></ul><ul><li>MRI gives accurate definition of size, location, and number </li></ul><ul><li>Endometrial biopsy </li></ul><ul><li>Fractional D&C </li></ul><ul><li>Hysteroscopy/laparoscopy </li></ul>
  11. 16. LEIOMYOMA <ul><li>TREATMENT </li></ul><ul><li>Corrective measures for Anemia </li></ul><ul><li>Asymptomatic requires no treatment </li></ul><ul><li>GnRH agonists (Lupron) may be considered in poor surgical candidates </li></ul><ul><li>Hysterectomy </li></ul><ul><li>- Myomectomy because pregnancy is possible Requires q 6 month F/U. 33% will need hysterectomy </li></ul>
  12. 17. LEIOMYOMA <ul><li>COMPLICATIONS </li></ul><ul><li>-Myomectomy has a 2 to 3% yearly recurrence </li></ul><ul><li>- Infertility & recurrent spontaneous abortions </li></ul><ul><li>- Pregnancy: Increased preterm labor & PROM, dysfunctional labor and dystocia. </li></ul><ul><li>.01 to 0.5% risk of leiomyosarcoma. </li></ul>
  13. 18. ADENOMYOSIS INTERNAL ENDOMETRIOSIS
  14. 19. <ul><li>ADENOMYOSIS </li></ul><ul><li>Etiology </li></ul><ul><li>Local invasion of e ndometrial tissue in the myometrium more than 3 mm beneath the endometrium & associated with muscular hypertrophy </li></ul><ul><li>Invasion mostly diffuse from the endometrial surface </li></ul><ul><li>Rarely may produce a localized endometrial mass </li></ul><ul><li>Etiology is not known </li></ul><ul><li>Growth occurs only during reproductive years </li></ul><ul><li>Usually occurs in parous woman, increase with age and usually regress with menopause </li></ul>
  15. 20. ADENOMYSIS <ul><li>CLINICAL FINDINGS </li></ul><ul><li>Parous middle-aged woman with hx of: </li></ul><ul><li>Dysmenorrhea, menorrhagia </li></ul><ul><li>Uterine tenderness on palpation (Halban’s Sign) </li></ul><ul><li>Varying degree of chronic pelvic pain </li></ul><ul><li>US useful in diagnosing </li></ul><ul><li>Chronic severe anemia may be present </li></ul>
  16. 21. ADENOMYOSIS
  17. 22. ADENOMYOSIS
  18. 23. ADENOMYOSIS <ul><li>TREATMENT </li></ul><ul><ul><li>Hysterectomy </li></ul></ul><ul><ul><ul><li>Confirmatory of diagnosis </li></ul></ul></ul><ul><ul><ul><li>Definite treatment of choice </li></ul></ul></ul><ul><ul><li>Hormonal Therapy </li></ul></ul><ul><ul><ul><li>GnRH agonists may provide temporary relief of symptoms but not very effective </li></ul></ul></ul><ul><ul><li>OC may exacerbate symptoms </li></ul></ul>
  19. 24. ENDOMETRIAL POLYPS
  20. 25. POLYPS <ul><li>ETIOLOGY </li></ul><ul><li>Hystogenesis is not clear </li></ul><ul><li>May be pedunculated or sessile </li></ul><ul><li>Considered estrogen sensitive </li></ul><ul><li>Risk Factors </li></ul><ul><li>Obesity, hypertension, Tamoxifen therapy </li></ul><ul><li>More common near menopause </li></ul><ul><li>May undergo malignant changes </li></ul><ul><ul><li>Carcinomas and Sarcomas </li></ul></ul>
  21. 26. POLYPS <ul><li>Clinical Findings </li></ul><ul><li>Menorrhagia </li></ul><ul><li>Pre or post menstrual spotting </li></ul><ul><li>In postmenopausal woman sudden occurrence of bleeding accompanied by uterine pain (Infarct) </li></ul><ul><li>Exam may reveal ulceration of the distal tip of the polyp </li></ul><ul><li>Trans-vaginal US helpful in diagnosis </li></ul><ul><li>Hysteroscopy </li></ul>
  22. 27. Treatment of Uterine Polyps <ul><li>Hysteroscopic resection </li></ul><ul><ul><li>D&C of attachment site </li></ul></ul><ul><li>Progestin may cause regression </li></ul><ul><li>Hysterectomy for malignant changes </li></ul>
  23. 28. ENDOMETRIOSIS <ul><li>Definition </li></ul><ul><li>Aberrant growth of endometrial tissue outside the uterus </li></ul><ul><li>Most common site is the ovary </li></ul><ul><li>Other areas of the pelvis and the abdomen may be involved </li></ul><ul><li>3-15% premenopausal women rare postmenopause </li></ul><ul><li>Accounts for 25% gyn laps & 50% of infertility </li></ul>
  24. 30. ENDOMETRIOSIS <ul><li>Etiology </li></ul><ul><li>Common health problem in women etiology unknown </li></ul><ul><li>Classic theory of John Sampson </li></ul><ul><ul><li>Retrograde menstruation subsequent bleeding from the fallopian tubes into the abdomen. Desquamated endometrium implants on the pelvic viscera </li></ul></ul><ul><li>Estrogen dependent </li></ul><ul><li>Genetic influences possible </li></ul><ul><li>Socioeconomic factors ? </li></ul>
  25. 31. ENDOMETRIOSIS <ul><li>Menstrual implantation- tubal regurgitation especially dominant tube </li></ul><ul><li>Intra-operative implantation occurs within scars </li></ul><ul><li>Lymphatic hematogenous route lymphatic dissemination similar to that of the malignant metastasis </li></ul><ul><li>Embryonic implantation re-differentiation or persistence of various embryonic tissue </li></ul>
  26. 36. ENDOMETRIOSIS Clinical Findings <ul><li>- History very helpful. Not uncommon to have symptoms early often 1-2 year after onset of menses </li></ul><ul><li>Severity classified from I-IV based on the extent, locations, stage and degree of symptoms </li></ul><ul><li>Dysmenorrhea, dyspareunia, infertility are the main presenting complaints. </li></ul><ul><li>Dyspareunia is a key symptom in differentiating endometriosis from dysmenorrhea </li></ul>
  27. 37. ENDOMETRIOSIS Clinical Findings <ul><li>Change in bowel habits, cramping, rectal and pelvic pain, nausea vomiting </li></ul><ul><li>Dysuria, spotting, frank hematuria irregular menses, Infertility , backache, premenstrual - Less common plural pain if pulmonary & seizure from CNS lesions </li></ul>
  28. 39. ENDOMETRIOSIS <ul><li>DIAGNOSIS </li></ul><ul><li>- Physical Exam : Pelvic tenderness with uterine/ pelvic nodularity, ovarian enlargement & tenderness, pain upon uterine motion uterine may be fixed, retroverted due to adhesions. </li></ul><ul><li>- Can have cutaneous or extraperitoneal disease </li></ul><ul><li>Lab: CA 125 often elevated with extensive disease, </li></ul><ul><li>- Cytology is always negative </li></ul>
  29. 40. ENDOMETRIOSIS <ul><li>DIAGNOSIS </li></ul><ul><li>- Imagining Pelvic U/S have high false positives/ negatives. MRI/CT limited value </li></ul><ul><li>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 </li></ul><ul><li>Chocolate cyst present </li></ul><ul><li>- If many adhesions may need a laparotomy </li></ul>
  30. 47. ENDOMETRIOSIS <ul><li>TREATMENT </li></ul><ul><li>- Based on severity of symptoms, age, desire for childbearing. </li></ul><ul><li>Observation - Minimal symptoms </li></ul><ul><li>Hormonal therapy – interruption of the cycles using Depo Provera 150mg/mth*6mths </li></ul><ul><li>BCP double usual dose after 1 mth then increase </li></ul><ul><li>Pregnancy </li></ul><ul><li>- Danazol (Danocrine) 200 to 800 mg bid for 6 mths 80 to 95% effective pain relief and other symptoms </li></ul><ul><li>- </li></ul>
  31. 48. TREATMENT OF ENDOMITRIOSIS <ul><li>GnRH Agonists lupron IM 3.75mg/mth*6mth </li></ul><ul><li>Intranasal Nafarelin 200mg bid*6mth </li></ul><ul><li>Surgical indicated in severe disease, patients over 40 y/o and severe adhesion </li></ul><ul><li>Laparoscopic lysis of adhesions, laser ablation. </li></ul><ul><li>Total abdominal hysterectomy in severe and patients with no desire of childbearing. Bilateral salpingo-oophorectomy followed by HRT </li></ul>
  32. 49. Still Alive <ul><li>GYNECOLICAL REASONS FOR ABDOMINAL MASS OR CHRONIC PELVIC PAIN </li></ul>
  33. 50. <ul><li>Pelvic Pain Sources </li></ul><ul><li>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 </li></ul><ul><li>Hypogastric plexus Vaginal upper 1/3, cervix, lower segment, bladder trigone, uterosacral ligaments, lower ureters, posterior urethra, recto-sigmoid & dorsal external genital </li></ul><ul><li>Thoraco-lumbar plexus (T 11 - L 1 ) Fundus, Proximal 1/3 tube, Broad ligaments, upper bladder, appendix, cecum terminal large bowel </li></ul><ul><li>Superior Mesenteric plexus (T 5 - T 11 ) Ovaries, lateral 2/3 fallopian tube & upper ureters </li></ul>
  34. 51. <ul><li>Pelvic Pain Sources </li></ul><ul><li>Can be either sudden or gradual onset </li></ul><ul><li>May be associated with various type of abdominal pain </li></ul><ul><li>Epigastric Pain - Stomach, duodenum, pancreas, liver and gallbladder </li></ul><ul><li>Periumbilical Pain – Small intestines, appendix, upper ureters and ovaries </li></ul><ul><li>Hypogastric/suprapubic Pain – Colon, bladder lower ureters and uterus </li></ul><ul><li>Pelvic Pain – Cervix, ovaries and fallopian tubes </li></ul><ul><li>Shoulder Pain- Diaphragm or diaphragmatic irritation </li></ul>
  35. 52. <ul><li>Pelvic Pain Quality </li></ul><ul><li>Cramping or colicky pain - muscular contraction or intraluminal pressure of a hollow viscus </li></ul><ul><li>Constant pain – Inflammatory process, distention of a solid organ, ischemia </li></ul><ul><li>Intermittent pain – adnexal mass with partial torsion </li></ul><ul><li>Positional pain – mobile pelvic mass </li></ul><ul><li>Sharp pain – obstruction or acute peritoneal process </li></ul><ul><li>Dull pain – inflammatory process </li></ul>
  36. 53. <ul><li>Pelvic Pain Duration </li></ul><ul><li>Acute < 48 hours initial episode or chronic >48 hours or recurrent </li></ul><ul><li>Pelvic Pain Severity </li></ul><ul><li>Minor vs. major. Evaluate appearance and look for any associated pallor or toxicity </li></ul><ul><li>Associated symptoms </li></ul><ul><li>Vaginal bleeding, discharge, fever, chills, nausea, vomiting, anorexia, syncope, hypovolemia, dysuria, flank pain, dyspareunia or shoulder pain </li></ul>
  37. 54. <ul><li>Physical Exam </li></ul><ul><li>General appearance, orthostatic, activity level, anxiety, toxicity, LOC, posture </li></ul><ul><li>Chest look for abnormalities that often cause referred pain </li></ul><ul><li>Abdominal </li></ul><ul><li>Pelvic </li></ul><ul><ul><li>Inspection external genitalia vagina and cervix for trauma, infection, discharge, hemorrhage, asymmetry or masses </li></ul></ul><ul><ul><li>Palpate vaginal wall and cervix for location of any tenderness, cervical motion tenderness first without than with abdominal pressure </li></ul></ul><ul><ul><li>Palpate the adnexa for masses or tenderness </li></ul></ul><ul><ul><li>Presence of CVA tenderness </li></ul></ul>
  38. 55. <ul><li>Laboratory Test </li></ul><ul><li>CBC|with diff </li></ul><ul><li>UA with macro/micro </li></ul><ul><li>Urine culture </li></ul><ul><li>Qualitive β HCG may need serial quantitive levels </li></ul><ul><li>Cervical cultures </li></ul><ul><li>Possible Culdocentesis </li></ul><ul><li>Radiographs flat & upright right lateral decubitus for obstructions, free air, free fluid, fluid levels, calcifications or masses </li></ul><ul><li>Ultrasound abdominal/pelvic for IUP, fluid, masses & shifts </li></ul><ul><li>Laproscopy/Open laparotomy - Visualization </li></ul>
  39. 56. ETIOLOGY CHRONIC PELVIC PAIN
  40. 58. Fistulas
  41. 63. Salpingitis

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