1st discussion topic – O&G – menstrual disorders and pelvic pain

Posted: October 23, 2010 by yongchieh in O & G

Menstrual disorders

Amenorrhea

–          Divided into

a)      Primary

–  Absence of menstruation by 16 years old with present of secondary sexual characteristic or absence of menstruation by 14 years old without present of secondary sexual characteristic

b)      Secondary

–   > 6 months absence of menstruation with regular menses previously or > 12 months absence of menstruation without regular menses previously (oligomenorrhea)

–          Causes

Level Primary Secondary
CNS Functionala)      Anorexic 

b)      Excessive sport

c)       Malnourished

Tumors

Kallman’s syndrome

Prolactinoma

Aneurysm

Peter-Pan’s syndrome

HyperprolactinemiaSheehans syndrome 

* NORM

Pregnant

Menopause

Periphery Testicular feminization syndrome (androgen insenxitivity syndrome) 46, XYConstitutional delay 

Chronic systemic diseases (renal, heart, TB)

Thyroid, adrenal disorders

Chemo- or radio-therapy

Surgery

Thyroid dysfunction (hypothyroidism)Drugs 

a)      Post pill (COC)

b)      Progesterone

c)       Implants

Ovary POFa)      Idiopathic 

b)      Radiation

c)       Surgery

d)      Cytotoxicity

e)      Karyotype abnormal (45, XO)

PCOS

Gonadal dysgenesis

a)      Turner’s (45, XO)

b)      Swyers (46, XY or 46, XX)

POFPCOS 

Premature menopause

Mosaic-Turner (46, XX or 45, XO)

Uterus Meyer-Rokitansky-Kuster-Hauzes syndrome Ashermann’s syndrome
Outflow tract Imperforate hymenVaginal atresia 

Transverse vaginal septum

Cervical / vaginal agenesis

–          Diagnosis

a)      Primary

–  Secondary sexual characteristic ?

–   Sexual infantilism ?

–   US, anatomy ?

–   Virilism ? PCOS

b)      Secondary

–  Pregnancy test !

–   Breast feeding ?

–   Virilism ? PCOS + US

–   Hysteroscopy

–   Colposcopy

–   Progesterone challenge

–          Treatment

a)      FSH & LH

b)      Prolactin (norm till 20ug/L)

c)       TFT (prolactin increase, due to increase TRH)

d)      Serum testosterone (+ / -) : DHEAS

Pelvic pain

classification

– divided into 3 groups

1)      Cyclical – dysmenorrheal

2)      Associated with intercourse – dyspareuria – superficial

– Deep

3)      Chronic ( more than 6 months)

– divided into:

a) gynecological – endometriosis, Uterine fibroids, adenomyosis, Uterovaginal prolapsed, ovarian mass ( especially if twisted) chronic PID, maglinancy, pelvic congestion syndrome, residual ovary syndrome ( trapped ovary syndrome), ovarian remnant syndrome

b) non-gynecological:

– urological – UTI, cystitis, malignancy, etc.

– GIT – IBS, IBD, malignancy, chronic appendicitis, adhesions in abdomen / pelvis due to    infection, perforation and surgery.

– Muscularskeletal – trauma, prolapsed iv disc, osteoarthritis, spondylodisthesis

– Psychological –  physical / sexual / emotional abuse

Investigation

– Imaging importance! Ultrasound, CT, MRI, diagnostic laparascopy, hysteroscopy, saline infusion sonohysterography.( for intrauterine mass)

* by invasive procedure for diagnostic, may try medical therapy 1st

Eg. Suspect dysmenorrheal – COC, GnRH agonist.

IBS – antispasmodic, diet changes

* but if chronic pain – directly diagnostic laparascopy.

Dysmenorrhea

– lower abdomen / pelvic pain associated with menstruation. Onset may be prior, during or continue after cessation of menses.

– may be headache, nausea, vomiting, backache, diarrhea

a) Primary

– no obvious cause

– onset < 20% usually. Decreased with age.

– begins within a day of onset of flow, lasts 24-72hours, crampy

– Improves after childbirth.

b) secondary

– associated with pelvic pathology.

– onset > 20%. Increased with age.

– begins several days by menses, gradually increase in severity as menses approach.

– endometriosis, adenomyosis, polyps, fibroids, PID, IUD, obstructions, ovarian cysts, cancer.

– may be other symptoms associated with primary disease

history: past menstrual history

Investigation:

– ultrasound, MRI pelvis, diagnostic laparascopy( gold standard), diagnostic hysteroscopy, saline infusion sonohysterography.

– Final diagnostic: laparascopic uterine nerve ablation (LUNA)

Treatment

– Medical – paracetamol, NSAIDs, COX-2 inhibitor (mefenemic acid 0.5 TDS, naproxen 0.55 BD, ibuprofen 0.4 BD/TDS, diclofenac natrium 0.05 BD), buscopan 10mg TDS.

– COCs

– Depot MPA ( Depo Provera 3 mths)

– Laparoscopy

– presacral neurectomy, LUNA

– hysterectomy may be with BSO

ENDOMETRIOSIS

– presence of ectopic endometrial tissue outside the uterus.

History: chronic pelvic pain

Dysmenorrhea

Dyspareunia (due to rectovaginal / uterosacral involvement)

Intermenstrual bleeding may be premenstrual spotting

Infertility

Abdominal swelling(endometrioma)

If invasion GIT/ urology –present symptom of them

Common sites: ovaries, pelvic peritoneum, uterosacral ligaments, fallopian tubes, rectovaginal septum( can cause rectal/ vaginal bleeding cyclically), vagina(etc- urinary tract( ureter, bladder), GIT, abdomen, abdomen/ episotomy scar, abdominal organs, lungs.

Physical exam: pelvic mass & tenderness on bimanual & rectoveginal exam.

Lab test not helpful!

Gold standard – direct visualization via laparatomy/ laparascopy

US, MRI only useful in presence of mass. Ovary “ chocolate cyst”

Treatment

– NSAIDs

– induce pseudopregnancy/ pseudomenopause – progesterone

– surgery – destroy foci

Radical TAH +/ – BSO

* High recurrence rates

classification of endometriosis

Stage I (score 1-5) minimal

– isolated implants & no significant adhesions

Stage II (score 6 -15) mild

– shallow implants on the pelvic lining & 1 ovary; with filmy adhesion in the other ovary

Stage III (score 16-40) moderate

– deep implants on the pelvic lining & 1 ovary; dense adhesions in the other ovary

Stage IV ( score >40) severe

– deep implants on the ovaries, fallopian tube & pelvic lining

* stage – poor correlation with degree of symptom & fertility prognosis

Comments
  1. Dr sham says:

    hello there..I am soon going to graduate and start the working life as a ho.I came across few questions from the SPA interview.:1) a pregnant lady who has a bleeding
    2) a married couple approached you as the hv no kids..

    Could you please kindly help me to ANSWER BOTH OF THIS QUESTIONS.tq

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