Download Pelvic Pain – Dysmenorrhea and Endometriosis

Pelvic Pain – Dysmenorrhea and
Endometriosis
Case 1
• A 20 y.o. woman presents to her
gynecologist with a 4 year history of
increasing lower abdominal pain with her
menses. The pain begins on the first day of
her menses and lasts 2-3 days. She also
complains of lower back pain and nausea.
Menarche occurred at the age of 13 and her
menses occur every 28 days and last 5 days.
Physical and pelvic exam are normal.
Case 1
• How is dysmenorrhea diagnosed? How is it
distinguished from other types of pelvic
pain?
• What is the pathophysiology of
dysmenorrhea?
• What are reasonable approaches to
treatment?
Dysmenorrhea
• Dysmenorrhea – severe, painful cramping
sensation in the lower abdomen often
accompanied by other symptoms – sweating,
tachycardia, headaches, n/v, diarrhea,
tremulousness, all occurring just before or during
menses
- Primary: no obvious pathologic condition, onset
< 20 years old
- Secondary: associated with pelvic conditions or
pathology
Primary Dysmenorrhea
• Pathogenesis: elevated PG F2α in secretory
endometrium (increased uterine
contractility)
• Treatment: NSAIDs – PG synthetase
inhibitors – 1st line treatment of choice
• Other treatment options: OCPs, other
analgesics
Secondary Dysmenorrhea
• Etiologies
- Cervical Stenosis
- Endometriosis and Adenomyosis
- Pelvic Infection
- Adhesions
- Pelvic Congestion
- Stress and Tension
Secondary Dysmenorrhea
• Cervical Stenosis
- Severe narrowing of cervical canal may
impede menstrual outflow – congenital or
iatrogenic
- can cause an increase in intrauterine
pressure during menses
- can lead to endometriosis
Secondary Dysmenorrhea
• Cervical Stenosis
- Hx – scant menstrual flow, severe
cramping throughout menses
- Dx – inability to pass a thin probe through
the internal os OR HSG demonstrates thin
cx canal
- Tx – cervical dilation via D&C or
laminaria placement
Secondary Dysmenorrhea
• Pelvic Congestion
- Due to engorgement of pelvic vasculature
- Hx – burning or throbbing pain, worse at
night and after standing
- Dx – Laparoscopic visualization of
engorgement/varicosities of broad ligament
and pelvic sidewall veins
Evaluation of Pelvic Pain
• Detailed history, targeted physical exam, labs
(UA, UCx, CBC, HCG, tumor markers),
diagnostic imaging studies (US, MRI, CT) as
appropriate
• Consider age of patient
• “OLDCAAR”: onset, location, duration, context,
associated sx, aggravating/relieving factors
• Temporal characteristics: cyclic (e.g.
dysmenorrhea), intermittent (e.g. dyspareunia),
non-cyclic
• Risk factors
• GYN and Non-GYN causes
DDx Pelvic Pain - GYN
• GYN
- Uterus
- fibroids, adenomyosis, endometritis
- Fallopian tubes
- PID/salpingitis, hydrosalpinx, ectopic
- Ovaries
- cysts – functional, pathological, TOA,
torsion; mittleschmerz
- Other
- endometriosis, adhesions, IUD/infection,
severe prolapse
DDx Pelvic Pain – Non-GYN
• Urologic
- UTI/urethritis, interstitial cystitis (IC), OAB, urethral
diverticulum, nephrolithiasis, malignancy
• GI
- constipation, IBS, IBD (Crohn’s, UC), bowel obstruction,
diverticulitis, malignancy, appendicitis
• Musculoskeletal
- trigger points, fibromyalgia, hernias, neuralgia, low back
pain
• Other
- psychiatric – depression, somatization; abdominal
cutaneous nerve entrapment in surgical scar; celiac disease
Case 1
• At the age of 30, the patient presents with a 2 year
history of infertility. Her menses are still regular
but she has 2-3 days of spotting before her menses
are due. She also complains of pain with
intercourse and pelvic pain. In reviewing the
patient’s history, the gynecologist notes that over
the past year the patient was repeatedly treated by
her internist with antibiotics for recurrent
microscopic hematuria.
Case 1
• What is the most likely diagnosis?
• What are the main theories regarding the
pathogenesis in this case?
• How would you evaluate and treat this
patient?
Endometriosis - Symptoms
• Variable and unpredictable
- asymptomatic
- dysmenorrhea
- CPP
- deep dyspareunia
- sacral backache w/ menses
- dysuria +/- hematuria (bladder involvement)
- dyschezia/hematochezia (bowel involvement)
Endometriosis – Physical Exam
• Uterosacral nodularity
• Adnexal mass (endometrioma)
• Normal exam
Endometriosis - Incidence
•
•
•
•
•
7-10% of general population
20-50% of infertile women
70-85% in women w/ CPP
No racial predisposition
+Familial association with almost 10x
increased risk of endometriosis if affected
1st degree relative
Endometriosis - Pathogenesis
• Retrograde menstruation (Sampson)
• Hematogenous or lymphatic spread
(Halban)
• Coelomic metaplasia (Meyer/Novack)
• Iatrogenic dissemination
• Immunologic defects (Dmowski)
• Genetic predisposition
Endometriosis - Pathogenesis
• Retrograde menstruation (Sampson’s theory)
- Monkey experiments – sutured cervix closed to
create outflow obstruction  caused development
of endometriosis
- Clinical observation of retrograde menstrual flow
during laparoscopy in humans
- Increased risk of endometriosis in women with
cervical/vaginal atresia, other outflow obstruction
- Increased risk with early menarche, longer and
heavier flow
- Decreased risk with decreased estrogen levels
e.g. exercise-induced menstrual disorders,
decreased body fat, + tobacco use
Endometriosis - Pathogenesis
• Hematogenous or lymphatic spread
- Endometriosis found in remote sites – lung, nose,
spinal cord, pelvic lymph nodes.
Endometriosis - Pathogenesis
• Coelomic metaplasia
- Mullerian ducts are derived from coelomic
epithelium during fetal development
- Hypothesize that coelomic epithelium retains
ability for multipotential development
- Endometriosis seen in prepubertal girls, women
w/ congenital absence of the uterus, and RARELY
in men
Endometriosis - Pathogenesis
• Iatrogenic dissemination
- Endometriosis has been found in cesarean
section scar
• Immunologic defects
• Genetic predisposition
- polygenic, multi-factorial
Endometriosis - Diagnosis
• Laparoscopy with biopsy proven histologic
diagnosis – standard for dx of endometriosis
• Empiric medical treatment with improvement in
symptoms
• CA 125 – NOT considered to be of clinical utility
• Imaging – US, MRI, CT – only useful in the
presence of pelvic or adnexal masses
(endometriomas)
Endometriosis - Diagnosis
• Laparoscopy with biopsy proven histologic
diagnosis – standard for dx of endometriosis
- Extent of visible lesions do not correlate with
severity of sx, but depth of infiltration of lesions
seems to correlate best with pain severity
- classic powder-burn lesions, endometriomas
- lesions can be red, clear or white – more
commonly seen in adolescents
Endometriosis - Diagnosis
Endometriosis - Diagnosis
2 or more of the following histologic features are criteria for Dx:
1.
2.
3.
4.
Endometrial epithelium
Endometrial glands
Endometrial stroma
Hemosiderin-laden macrophages
Endometriosis - Diagnosis
• Imaging – US, MRI, CT – only useful in the
presence of pelvic or adnexal masses
(endometriomas)
- on US, endometriomas appear as cysts that
contain low-level homogeneous internal
echoes consistent with old blood (ddx
includes hemorrhagic cysts)
Endometriosis - Diagnosis
Endometriosis - Treatment
• Medications
- Progestins
- OCPs – continuous vs. cyclic – if no relief in 3
months, consider tx with Depo Provera or GnRH
agonist
- NSAIDs
- GnRH agonists – most expensive
- Danazol – appears to be as effective as GnRH
agonist for pain relief but with increased sideeffects
Endometriosis - Treatment
• GnRH agonists – create a state of relative
estrogen deficiency – vasomotor side effects
and potential decrease in bone density
- 12-month course of GnRH agonist therapy
associated with 6% decrease in bone density
- No data regarding extended treatment with
GnRH agonists beyond 1 year
Endometriosis - Treatment
• Add-back therapy is advocated for women
undergoing long-term therapy (i.e. > 6 months)
• Some evidence to suggest that immediate addback therapy may result in even less bone loss
- Add-back regimens: progestins alone, progestins
+ bisphosphonates, low-dose progestins +
estrogens, pulsatile PTH
Endometriosis – Treatment
Considerations in Adolescents
• GnRH treatment is NOT recommended for
patients < 18 years because the effects of
these medications on bone formation and
long-term bone density have not been
adequately studied
• Depo provera used for longer than 2 years
has been shown to decrease bone density in
adolescents – FDA warning against longterm use
Endometriosis – Treatment
Considerations in Adolescents
• If no improvement in symptoms after 3
months of empiric treatment with NSAIDs
and OCPs, diagnostic laparoscopy should
be offered
Endometriosis - Treatment
• Surgery
- Laparoscopic laser vaporization vs.
cauterization vs. excision
- Ovarian cystectomy for endometrioma
- Hysterectomy +/- BSO
Endometriosis - Treatment
• Medications vs. Surgery
- Lack of data to support surgery vs. medical
treatment for tx of pain symptoms due to
endometriosis
- Starting with empiric medical therapy is
appropriate
- Offer GnRH agonist therapy if initial medical
treatment with OCPs and NSAIDs not helping
- Cost of comparing empiric medical management
with definitive surgical diagnosis is difficult to
assess, but 3 months of empiric treatment is less
than a laparoscopic procedure
Endometriosis - Treatment
• Medications vs. Surgery
- Surgery is associated with significant
decrease in pain sx during the 1st 6 months
following surgery
- Approximately 40% experience recurrent
symptoms within 1 yr post-op
- Cumulative 5-yr recurrence rate of pain sx
after d/c GnRH tx is ~50%
Endometriosis - Treatment
• Medications vs. Surgery
- No evidence exists regarding effectiveness of
adjunctive tx w/ danazol, OCPs, or progestins
post-op in comparison with surgical treatment
alone in the management of endometriosis-related
pain
- However, 2 studies suuport the use of post-op
GnRH agonists to extend the period of pain relief
post-op
Case 2
• A 35 y.o. woman presents to your office
with persistent RLQ pain. Her past medical
history is unremarkable with the exception
of a ruptured appendix 1 year ago requiring
emergency surgery. Her abdominal and
pelvic exams are also unremarkable with
the exception of a well-healed
appendectomy scar.
Case 2
• What questions would be important to ask
in evaluating the patient?
• What is the most likely diagnosis?
• How would you treat this patient?
DDx Acute and Chronic Pelvic
Pain
• Acute
- GYN or Non-GYN etiology
- surgical emergency or not?
• Chronic
- GYN or Non-GYN etiology
- conservative/medical management or surgery?
DDx Pelvic Pain - GYN
• GYN
- Uterus
- fibroids, adenomyosis, endometritis
- Fallopian tubes
- PID/salpingitis, hydrosalpinx, ectopic
- Ovaries
- cysts – functional, pathological, TOA,
torsion; mittleschmerz
- Other
- endometriosis, adhesions, IUD/infection,
severe prolapse
DDx Pelvic Pain – Non-GYN
• Urologic
- UTI/urethritis, interstitial cystitis (IC), OAB, urethral
diverticulum, nephrolithiasis, malignancy
• GI
- constipation, IBS, IBD (Crohn’s, UC), bowel obstruction,
diverticulitis, malignancy, appendicitis
• Musculoskeletal
- trigger points, fibromyalgia, hernias, neuralgia, low back
pain
• Other
- psychiatric – depression, somatization; abdominal
cutaneous nerve entrapment in surgical scar; celiac disease
Pelvic Pain
• Pain is always subjective
• Chronic Pelvic Pain (CPP) – non-cyclic
pain of 6 or more months duration that
localizes to the anatomic pelvis, anterior
abdominal wall at or below the umbilicus,
the lumbosacral back, or the buttocks and is
of sufficient severity to cause functional
disability or lead to medical care
Pelvic Pain
• Approximately 15-20% of women aged 18-50
years have CPP of greater than 1 year’s duration
• 20-50% of women who receive care in primary
care practices have > 1 diagnosis
• Demographic profiles suggest no difference in
woman w/ CPP compared to women w/o CPP in
terms of age, race and ethnicity, education,
socioeconomic status, or employment status
Populations at Increased Risk of
CPP
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Physical and sexual abuse
PID
Endometriosis
IC
IBS
OB history
Past surgery
Musculoskeletal disorders
Populations at Increased Risk of
CPP
• Physical and sexual abuse
- 40-50% of women w/ CPP have a history
of abuse
- If a history of abuse is obtained, it is
important to ensure that the woman is not
currently being abused and in danger
Populations at Increased Risk of
CPP
• PID
- Approximately 18-35% of all women with
acute PID develop CPP
- Whether acute PID is treated with
outpatient or inpatient regimens does not
appear to significantly alter the odds of
developing subsequent CPP
Populations at Increased Risk of
CPP
• Endometriosis
- Diagnosed laparoscopically in approximately
33% of women w/ CPP (other dx – adhesions, no
visible pathology)
- Abnormal exam findings correlate in 70-90% of
cases w/ abnormal laparoscopic findings
- More than half of those w/ abnormal
laparoscopic findings have normal pelvic exams
Populations at Increased Risk of
CPP
• IC
- Chronic inflammatory condition of the
bladder characterized by voiding sx of
urgency and frequency in the absence of
another cause (such as infection)
- As many as 38-85% of women presenting
to gynecologists w/ CPP may have IC
Populations at Increased Risk of
CPP
• IBS
- One of the most common disorders
associated w/ CPP
- Chronic relapsing pattern of abdominopelvic pain and bowel dysfunction with
constipation or diarrhea
Populations at Increased Risk of
CPP
• OB history
- Pregnancy and childbirth can cause trauma
to the musculoskeletal system – lumbar
lordosis, delivery of a large infant, operative
vaginal delivery
- CPP also present in women with infertility
– endometriosis, PID, adhesive disease
Populations at Increased Risk of
CPP
• Past surgery
- Adhesive disease – e.g. ruptured appy
- Cervical stenosis from prior cervical
surgery
Evaluation of Pelvic Pain
• Detailed history, targeted physical exam, labs
(UA, UCx, CBC, HCG, tumor markers),
diagnostic imaging studies (US, MRI, CT) as
appropriate
• Consider age of patient
• “OLDCAAR”: onset, location, duration, context,
associated sx, aggravating/relieving factors
• Temporal characteristics: cyclic (e.g.
dysmenorrhea), intermittent (e.g. dyspareunia),
noncyclic
• Risk factors
• GYN and Non-GYN causes
Treatment of Pelvic Pain
• Acute
- GYN or Non-GYN etiology
- surgical emergency or not?
• Chronic
- GYN or Non-GYN etiology
- conservative/medical management or surgery?
DDx Pelvic Pain - GYN
• GYN
- Uterus
- fibroids, adenomyosis, endometritis
- Fallopian tubes
- PID/salpingitis, hydrosalpinx, ectopic
- Ovaries
- cysts – functional, pathological, TOA,
torsion; mittleschmerz
- Other
- endometriosis, adhesions, IUD/infection,
severe prolapse
Treatment of Pelvic Pain
• Medications
- Pain medications
- Hormonal Tx – progestins, OCPs, GnRH
agonists
- Antibiotics - inpatient vs outpatient – PID,
endometritis, TOA
- Antidepressants – insufficient evidence to
support tx w/ TCAs or SSRIs for CPP
Treatment of Pelvic Pain
• Surgery
- Emergent – incomplete sab with active
bleeding, ruptured ectopic, ovarian torsion,
ruptured TOA
- Laparoscopy - CPP is the indication for at
least 40% of all GYN laparoscopies – most
common findings are endometriosis,
adhesions, normal
- Hysterectomy +/- BSO
Treatment of Pelvic Pain
• Surgery
- Presacral neurectomy – innervation from
the superior hypogastric plexus (presacral
nerve) supplies the cervix, uterus and
proximal tubes – for primary
dysmenorrhea/midline pain
- Uterine nerve ablation – transection of
uterosacral ligaments at their insertions into
uterus – interrupts cervical sensory fibers
Treatment of Pelvic Pain
• Nonmedical/Alternative treatment
- Psychotherapy
- Exercise
- Physical therapy
- Accupuncture
- Herbals
Case 3
• A 28 y.o. woman presents with a 6 hour
history of severe RLQ pain, which began
suddenly on arising from bed. Since the
pain began, she has been nauseated and
vomited twice. She reports two other
episodes of similar pain in the past week,
both of which resolved within 30 minutes.
Case 3
• What other history would you find helpful?
• How would the physical exam findings
assist you with your differential diagnosis?
• What diagnostic tests would you order?
• What is your differential diagnosis?