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Pelvic Pain and Endometriosis

Pelvic Pain and Endometriosis. Dr. J ackie Hollett-Caines MD, FRCSC Associate Professor, Western University Department of Obstetrics and Gynecology. Differential Diagnosis of Pelvic Pain. Gynecologic Urologic Gastrointestinal Musculoskeletal Psychological General. Gynecologic.

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Pelvic Pain and Endometriosis

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  1. Pelvic Pain and Endometriosis Dr. Jackie Hollett-Caines MD, FRCSC Associate Professor, Western University Department of Obstetrics and Gynecology

  2. Differential Diagnosis of Pelvic Pain • Gynecologic • Urologic • Gastrointestinal • Musculoskeletal • Psychological • General

  3. Gynecologic • Ovarian • Fallopian Tubes • Uterus • Vulva

  4. Ovarian • Mittelschmerz (ovulation pain) • Ovarian Cysts (rupture, torsion) • Ovarian Remnant Syndrome

  5. Fallopian Tubes • hematosalpinx (after sterilization, ablation) • endosalpingiosis • ectopic pregnancy • Pelvic Inflammatory Disease

  6. Uterus • Primary Dysmenorrhea • Adenomyosis • Fibroids • Endometritis

  7. Vulvar • vulvodynia

  8. Urologic • interstital cystitis • urethral syndrome • Urinary tract infection • urinary tract calculi

  9. Gastrointestinal • Irritable bowel syndrome • Inflammatory bowel disease • chronic constipation • chronic appendicitis

  10. Musculoskeletal • myofascial pain • pelvic floor myalgia and spasms • nerve entrapment syndrome (neuropathic pain) • mechanical low back pain • disc disease • hernias

  11. Psychological • depression • physical or sexual abuse • sleep disturbance • psychological stress • substance abuse

  12. General Gynecologic • Endometriosis • Adhesions • Pelvic Congestion

  13. Endometriosis • definition • prevalence • causes • investigations (hx, PE, investigations) • management

  14. This picture shows a chocolate cyst, which can be quite common in more advanced endometriosis.

  15. This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or "chocolate", cyst. The hemorrhage from endometriosis into the ovary may give rise to a large "chocolate cyst" so named because the old blood in the cystic space formed by the hemorrhage is broken down to produce much hemosiderin and a brown to black color.

  16. These dense adhesions are commonly associated with advanced endometriosis. They can be treated with laparoscopy techniques, but are more likely to reform after surgery.

  17. Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance. Typical locations for endometriosis may include: ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, and laparotomy scars. Endometriosis may even be found at more distant locations such as appendix and vagina

  18. Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of "powder burns". Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas.

  19. What is Endometriosis? • Is defined as the presence of endometrial glands and stroma occurring outside of the uterine cavity • The most common sites of involvement are: • Ovaries • Pelvic peritoneum • Cul de sac • Uterosacral ligaments

  20. Prevalence • overall incidence in women of reproductive age is 5-10% • In infertile women, incidence is estimated to be 25-50%

  21. Risk Factors for Endometriosis • family history in a first degree relative • anomalous reproductive tracts • increased parity • nulliparity • subfertility • prolonged intervals between pregnancies

  22. Etiology – Many Theories • most accepted is Retrograde Menstruation • menstrual tissue refluxes through the fallopian tubes • it then implants on pelvic structures • does not explain why most women have reflux (100%) but only 5-10% of women have endometriosis

  23. Etiology of Endometriosis • Retrograde menstruation and implantation • Direct extension • Coelomic metaplasia • Induction theory • Embryonic rests/Mullerian Remnants • Lymphatic and vascular metastasis • Composite theory

  24. History • ask about any signs or symptoms of endometriosis • dysmenorrhea - painful menses • dyspareunia - painful intercourse • dysuria - painful urination • dyschezia - painful defecation • low back or abdominal pain • pelvic pain - suprapubic or LLQ/RLQ

  25. Atypical Presentations of Endometriosis • cyclic leg pain/sciatica • cyclic rectal bleeding • cyclic hematuria • cyclic dyspnea - catamenialhemothorax • some patients may be totally asymptomatic and it is found incidentially at time of surgery

  26. Physical Examination • pelvic digital exam • non-mobile uterus (fixed or frozen pelvis) • adnexal masses (endometriomas) • tender nodules on the uterosacral ligaments • May even see endometriotic deposits in the vagina on speculum exam

  27. Investigations • if suspect endometriomas, do an ultrasound • if dyschezia - colonoscopy • if dysuria - cystoscopy

  28. Diagnosis • gold standard is laparoscopy with histologically proven endometriosis on biopsy specimens • histology should show: • endometrial glands • endometrial stroma • hemosidern laden macrophages

  29. Treatment • laparoscopy is not required prior to treatment • overall risk of any complication with laparoscopy, minor or major, is 8.9% • injury to bowel, bladder, major blood vessel • risk of bleeding or infection • risk of anaesthetic

  30. Management • combined estrogen and progestin therapy • oral progestin therapy • depot progestin therapy • intrauterine progestin releasing system • danazol • GnRH agonists • aromatase inhibitors • analgesia

  31. Combined Estrogen and Progestin Therapy • Oral contraceptives are considered first line treatment • Get significant relief of dysmenorrhea within 4 months • There is some data that continuous administration of OCP may be more beneficial in terms of pain relief

  32. Oral Progestin Therapy • Norethindrone acetate – not available in Canada • Dienogest – Visanne • Micronor – progesterone only pill

  33. Dienogest • Has selective 19-nortestosterone and progesterone activity • Daily tablet of 2mg once a day • Efficacy comparable to GnRH agonist (lupron) in 6 month head to head study

  34. Depot Progestin Therapy • Depot provera is injected im every 3 months • As effective as lupron • Cons to treatment: • loss of BMD • prolonged delay in resumption of menses/ovulation • Breakthrough bleeding

  35. Intrauterine Progestin-Releasing System • Mirena - Contains Levonorgestrel 20 ug/day for 5 years • Results in amenorrhea in 60% of patients • 5% expulsion rate and 1.5% risk of pelvic infection

  36. Danazol • A weak androgen capable of suppressing gonadotropin secretion, thus leads to amenorrhea • Negative side effects include weight gain, acne, hirsutism, breast atrophy, virilization, impact on lipids

  37. GnRH agonists • For women who do not respond to OCP or progestins • Cannot be used longterm (> 1 year) without estrogen addback therapy (1mg estrace daily) • Induces hypoestrogenism which can result in hot flashes, insomnia, vaginal dryness, loss of libido, loss of BMD

  38. Aromatase Inhibitors • Still experimental • Use with either OCP or progestin therapies

  39. Analgesia • Used to make patient more comfortable until the primary medical management becomes effective • NSAIDS or opiates

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