Clinical Medicine 216 - Female Pelvic Pain
Patients with suspected gonorrhoea infection also should be treated for _________ infection.
Patients with _________ genital lesions should be considered to have a sexually transmitted disease (STI) and should be tested and treated accordingly.
An infection with chlamydia can also cause ________ .
Urethritis, cervicitis, epididymitis (male), prostatitis (male), proctitis, and pelvic inflammatory disease (PID)
Evidence of septic arthritis on examination of symptomatic joints may indicate ________ .
Gonococcal arthritis and disseminated gonococcal infection
Examination of the ________ may be an important component of examination, particularly in the case of syphilis or gonorrhoea.
Skin and lymph nodes
With a sexually transmitted infection, physical exam should focus on the _________ area, often the genitalia.
History taking of pelvic pain should include ________ consideration.
Gastrointestinal, urologic, psychological, and gynecologic
The most distressing symptom of interstitial cystitis is __________ .
Urgency and increased frequency of urination
Colicky flank pain that radiates to the anterior abdomen is suggestive of ________ .
Urinary stone disease
Radiation from the epigastrium or periumbilical area to the right lower quadrant is suggestive of ________ .
Chronic pelvic pain is usually _________ .
The most serious causes of pelvic pain usually present ________ .
What is a deep pain below the umbilicus that occurs with sexual intercourse?
What is chronic pelvic pain?
Non-menstrual pain below the umbilicus of at least 3 months in duration
What is acute pelvic pain?
Pain symptoms below the umbilicus that have been present for < 3 months
What is cyclic pelvic pain?
Pain below the umbilicus that is exacerbated before and during menses
What is dysmenorrhea?
Recurrent, crampy, lower abdominal pain during menses
The most serious causes of female pelvic pain present acutely (< 3 months) and can be classified as _________ .
Pregnancy-related causes, gynecological disorders, and non-reproductive disorders
In patients with chronic pelvic pain, it can be __________ (e.g., myofascial pain, irritable bowel syndrome) or _________ (e.g., depression, anxiety, somatization).
What are some pregnancy related causes of female pelvic pain?
Ectopic pregnancy, abortion, intrauterine pregnancy with corpus luteum bleeding
What are some gynecologic related causes of female pelvic pain?
Acute pelvic inflammatory disease (PID), endometriosis, ovarian cysts, adnexal torsion, uterine leiomyoma, and tumour
What are some nongynecologic/gastrointestional related causes of female pelvic pain?
Acute appendicitis, inflammatory bowel disease, mesenteric adenines, irritable bowel syndrome, and diverticulitis
What are some nongynecologic/urinary related causes of female pelvic pain?
Urinary tract infections and renal calculus
If the duration of pelvic pain is < 15 days consider ________ .
Appendicitis or acute pelvic inflammatory disease (PID)
If pelvic pain is accompanied with abnormal bleeding consider ________ .
Pelvic inflammatory disease (PID), endometriosis, ectopic pregnancy, acute appendicitis, or endometrial cancer in postmenopausal women
Excessive menstrual bleeding could be suggestive of _________ .
Uterine fibroids or adenomyosis
A patient history of dysmenorrhea and infertility suggests ________ .
Multiple sex partners increases the risk of ________ .
Pelvic inflammatory disease (PID)
The use of an _________ is a risk factor for pelvic inflammatory disease (PID) and ectopic pregnancy.
Intrauterine contraceptive divice (IUD)
Constant and burning pain is suggestive of ________ .
Neuropathic pain, such as pudendal neuralgia
What is pudendal neuralgia?
Pain in the area supplied by the pudendal nerve such as external genitalia, urethra, anus, and perineum
Patients with pelvic pain with urgency or increased frequency of urination suggests ________ .
Patients with pelvic pain and blood in the stool suggests ________ .
Inflammatory bowel disease
If rest makes the pelvic pain better a possibility is ________ .
Musculoskeletal or adnexal torsion
Just before menarche, there is a physiologic increase in _________, which is a normal change that sometimes worries a girl or her mother.
Lymph from the vulva and lower vagina drains into the __________ . Lymph from the internal genitalia, including the upper vagina, flows into the ________ , which are not palpable.
Inguinal nodes; pelvic and abdominal lymph nodes
What is a cluster of emotional, behavioural, and physical symptoms occurring 5 days before menses for three consecutive cycles called?
Premenstrual syndrome (PMS)
Unlike the normal dark red menstrual discharge, excessive flow tends to be ________ and may include “clots” (not true fibrin clots).
________ results from increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline.
Causes of ________ include endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease (PID), and endometrial polyps.
Premenstrual syndrome (PMS) includes ________ .
Emotional and behavioural symptoms such as depression, angry outbursts, irritability, anxiety, confusion, crying spells, sleep disturbance, poor concentration, and social withdrawal
________ refers to the absence of periods.
________ typically occurs between the ages of 48 and 55, peaking at a median age of 51. It is defined retrospectively as cessation of menses for 12 months, progressing through several stages of erratic cyclical bleeding.
Absence of ever initiating periods is called ________ ; cessation of periods after they have been established is ________ . Pregnancy, lactation, and menopause are physiologic forms of the secondary type.
Primary amenorrhea; secondary amenorrhea
Other causes of secondary amenorrhea include ________ .
Low body weight from any cause, including malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic–pituitary–ovarian dysfunction.
Amenorrhea followed by _______ suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation.
________ refers to an involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration during intercourse painful or impossible.
Acute pelvic pain in menstruating girls and women warrants immediate attention. The differential diagnosis is broad but includes life-threatening conditions such as ________ .
Ectopic pregnancy, ovarian torsion, and appendicitis
The most common cause of acute pelvic pain is ________ .
Pelvic inflammatory disease (PID), followed by ruptured ovarian cyst, and appendicitis
Endometriosis, from retrograde menstrual flow and extension of the uterine lining outside the uterus, affects ________ of women and girls with pelvic pain.
50% to 60%
Papanicolaou (PAP) smear has contributed to a significant decline in the incidence of, and mortality from, cervical cancer. Where is the cervical sample taken from?
The transformation zone
Two notable risk factors for cervical cancer include failure to ________, which accounts for roughly half of women diagnosed with cervical cancer, and ________.
Undergo screening; multiple sexl partners
_________ is linked to urethritis, cervicitis, pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain.
Risk factors for ________ include family history and presence of the BRCA1 or BRCA2 gene mutation.
Although ovarian cancer is relatively rare, it is the ________ leading cause of cancer-related death for women.
Two-thirds of women affected with ovarian cancer are over the age of ________ ; most are diagnosed when the disease is already metastatic to the peritoneal cavity or other organs. Five-year survival in these women is only 25%, compared to 80% to 90% for those with early stage disease.
If a chlamydial infection is left untreated, ________ of women will develop pelvic inflammatory disease (PID) and _________ will become infertile. A similar outcome is reported with gonorrhoea.
Recurrent vulvocandidiasis, concurrent STIs, abnormal PAP smears, and HPV infections are warnings for testing for ________ .
An ________ occasionally delays menarche. Be sure to check for this possibility when menarche seems unduly late in relation to the development of a girl’s breasts and pubic hair.
On cervical examination, raised, friable, or lobed wartlike lesions occur in ________ .
Condylomata or cervical cancer
A _________ on the endocervical swab suggests mucopurulent cervicitis, commonly caused by chlamydia, gonorrhoea, or herpes simplex.
________ and/or adnexal tenderness suggest pelvic inflammatory disease, ectopic pregnancy, and/or appendicitis.
Cervical motion tenderness
________ suggests pregnancy, uterine myomas (fibroids), or malignancy.
__________ years after menopause, ovaries are atrophic and usually nonpalpable. In postmenopausal women, investigate a palpable ovary for possible ovarian cyst or ovarian cancer.
3 to 5
The ________ has three primary purposes: to palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa; to screen for colorectal cancer in women 50 years or older; and to assess pelvic pathology.
A small, firm, round cystic nodule in the labia suggests an ________ . These are yellowish in color. Look for the dark punctum marking the blocked opening of the gland.
Warty lesions on the labia and within the vestibule suggest ________ . These result from infection with human papillomavirus (HPV).
A firm, painless ulcer suggests the ________ . Because most chancres in women develop internally, they often go undetected.
Chancre of primary syphilis
Slightly raised, round or oval, flat-topped papules covered by a gray exudate suggest condylomata lata. These constitute one manifestation of ________ and are contagious.
Shallow, small, painful ulcers on red bases suggest a _________.
An ulcerated or raised red vulvar lesion in an elderly woman may indicate ________ .
Vaginal discharge: Yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous is suggestive of ________ .
Vaginal discharge: White and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous is suggestive of ________ .
Vaginal discharge: Gray or white, thin, homogeneous, malodorous; coats the vaginal walls; usually not profuse, may be minimal is suggestive of ________ .
A ________ is a bulge of the upper two-thirds of the anterior vaginal wall, together with the bladder above it. It results from weakened supporting tissues.
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge of the anterior vaginal wall, a _________ is present.
A ________ is a small, red, benign tumour visible at the posterior part of the urethral meatus. It occurs chiefly in postmenopausal women and usually causes no symptoms.
Causes of a ________ include trauma, gonococci anaerobes like bacteroides and peptostreptococci, and Chlamydia trachomatis. Acutely, it appears as a tense, hot, very tender abscess. Look for pus coming out of the duct or erythema around the duct opening. Chronically, a nontender cyst is felt. It may be large or small.
Bartholin’s gland infection
A ________ is a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.
________ begins in an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflowerlike growth may develop.
Carcinoma of the cervix
________ are very common benign uterine tumors. They may be single or multiple and vary greatly in size, occasionally reaching massive proportions. They feel like firm, irregular nodules in continuity with the uterine surface.
Occasionally, a myoma projecting laterally can be confused with an ________ ; a nodule projecting posteriorly can be mistaken for a ________ .
Ovarian mass; retroflexed uterus
Submucous myomas project toward the ________ and are not themselves palpable, although they may be suspected because of an enlarged uterus.
_________ may be detected as adnexal masses on one or both sides. Later, they may extend out of the pelvis. Cysts tend to be smooth and compressible, tumors more solid and often nodular. Uncomplicated cysts are not usually tender.
Ovarian cysts and tumors
Diagnosis of ________ rests on exclusion of several endocrine disorders and 2 of the 3 features listed: absent or irregular menses; hyperandrogenism (hirsutism, acne, alopecia, elevated serum testosterone); and confirmation on ultrasound.
Polycystic ovary syndrome (PCOS)
________ is relatively rare and usually presents at an advanced stage. Symptoms include pelvic pain, bloating, increased abdominal size, and urinary tract symptoms.
A ________ spills blood into the peritoneal cavity, causing severe abdominal pain and tenderness. Guarding and rebound tenderness are sometimes associated. A unilateral adnexal mass may be palpable, but tenderness often prevents its detection. Faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage.
Ruptured tubal pregnancy
________ is most often a result of sexually transmitted infection of the fallopian tubes (salpingitis) or of the tubes and ovaries (salpingo- oophoritis).
Pelvic inflammatory disease (PID)
Acute pelvic inflammatory disease (PID) is associated with ________ , although pain and muscle spasm usually make it impossible to delineate them. Movement of the cervix produces pain. If not treated, a tubo-ovarian abscess or infertility may ensue.
Very tender, bilateral adnexal masses
Infection of the ________ may also follow delivery of a baby or gynecologic surgery.
Fallopian tubes and ovaries
Lower abdominal / pelvic pain can present with the following gastrointestinal conditions ________ .
Appendicitis, bowel obstruction, colitis, diverticulitis, IBD, irritable bowel syndrome, and peri-rectal abscess
Lower abdominal / pelvic pain can present with the following gynecological conditions ________ .
Ectopic pregnancy, fibroids, ruptured ovarian cyst, ovarian torsion, pelvic inflammatory disease (PID), endometriosis, mittelschmerz, dysmenorrhea, etc.
Lower abdominal / pelvic pain can present with the following musculoskeletal conditions ________ .
Hip joint pathology, hernia, and adhesions
Lower abdominal / pelvic pain can present with the following urinary conditions ________ .
Nephrolithiasis, pyelonephritis, cystitis, and interstitial cystitis
Lower abdominal / pelvic pain can present with the following other conditions ________ .
Dissecting aortic aneurysm, lead poisoning, malingnancy, porphyria, sickle cell crisis, somatization disorder — may have coexisting depression
What are the alarm symptoms of lower abdominal / pelvic pain?
Unexplained weight loss, hematochezia, peri-menopausal irregular bleeding, postmenopausal vaginal bleeding, and post-coital bleeding
What is vulvodynia?
Chronic pain of vulvar vestibule with no known cause
Possible unknown causes of vulvodynia are ________ .
Injury or irritation to nerves, pelvic floor muscle weakness or spasm, hypersensitivity, and heightened inflammatory response
What is the most common symptom of vulvodynia? Other symptoms include irritation; rawness while sitting, with intercourse, or insertion of tampon; and erythema or general inflammation.
What are 2 tests to help with the assessment of vulvodynia?
Tampon test and cotton swab test
What is vulvitis?
Non-specific inflammation the vulva
What is the etiology of vulvitis?
Can be related to allergies, external irritants, injury, skin disorders & sexually transmitted diseases/infections
What are the symptoms of vulvitis?
Burning, itching, redness, swelling, discharge, cracks or blisters, and scaly thick white patches. Scratching often exacerbates the primary condition.
What are some dermatologic disease of the vulva?
Eczema, psoriasis, vitiligo, and other skin infections
Vulva ________ presents with red patches, thin cracks, weeping, and crusts. Whereas, vulva _______ presents with thickened, scaly patches, pink patches with defined edges.
Vulva vitiligo presents with ________ .
Patchy loss of skin pigmentation (milky white) and lack of itching and pain
An abnormal condition characterized by white spots or patches on mucous membranes, especially of the mouth and vulva is known as ________ , caused by keratosis.
Leukoplakia (non-neoplastic epithelial disorder)
What is vulvar lichen sclerosis?
An uncommon condition that creates patchy, white skin that appears thinner than normal
What are the symptoms of vulvar lichen sclerosis?
Can present asymptomatically, which could then lead to aggressive onset of intense itching, burning, dyspareunia, tearing, anal fissures, and scarring, which can lead to dysuria, pain with defecation, and rectal bleeding.
Cigarette paper appearance is common with _________ .
Vulvar lichen sclerosis
Possible progression of vulvar lichen sclerosis:
The labia may become atrophic, stiffened, and distorted
Management for vulvar lichen sclerosis:
Vulvar biopsy (gold standard), swabs for culture, immunological work-up (ANA, thyroid panel, celiac)
What is lichen simplex chronicus?
Epithelial thickening with significant surface hyperkeratosis, usually due to the 'itch' scratch cycle'. An increase in mitotic activity with NO atypia
Lichen simplex chronicus presents with _______ .
White vulvar plaques, fissures, excoriations, and intense itching (especially while sleeping)
What is lichen planus?
An inflammatory autoimmune disorder with keratinized and mucosal surfaces.
Diagnosis of lichen planus is with?
Punch biopsy with immunofluorescence
What presents with itching, burning, postcoital bleeding, dyspareunia, pain, urinary symptoms, vaginal discharge; and when severe; glassy, white papule and plaques that can lead to erosion, ulceration, and later distortion?
What percentage of genital HPV infections are with types 6 and 11?
What is the most common form or virally sexually transmitted disease?
Genital HPV also affects the _________ .
Oropharyngeal and anogenital regions
What is the hallmark sign of Genital HPV (condylomata acuminata)?
Genital HPV (condylomata acuminata) presents with ________ histopathology.
Acanthosis with marked degrees of papillomatosis, hyperkeratosis, and parakeratosis, Rete ridges, increased vascularization, and kilocytes
Genital HPV (condylomata acuminata) presents with ________ .
Flesh-coloured, pink, or hyperpigmented; smooth, raised, or flat; coalescing to cauliflower-like lesions with verrucous appearance
The incubation period for genital HPV (condylomata acuminata) is ________ .
3 weeks to 8 months
Symptoms of genital HPV (condylomata acuminata) can be _________ or present with painless bumps, itching, burning, discomfort, and dyspareunia.
The assessment of genital HPV (condylomata acuminata) is done by ________ .
Visual inspection, acetowhite test, and biopsy (rare)
Vulvar carcinoma can present with ________ . It presents very similar to many non-cancerous diseases. Thus, you must create a comprehensive Ddx list.
Itching, white, and pigmented plaques on vulva.
What is leukorrhea?
Physiologic normal vaginal secretions consisting of cervical mucus + exfoliated cells + vaginal secretions (Skene’s, Bartholins, sweat) + lactobacilli
What pH is in the normal vagina?
3.5 to 4.5
Bacterial vaginosis is caused by _______ , and laboratory culture not required for diagnosis.
For bacterial vaginosis you need to meet 3 of 4 criteria on the ________ .
The Amsel's criteria is:
1. Clue cells (>20% of cells on saline prep)
2. Vaginal pH >5.0
3. Thick homogenous discharge
4. Fishy odour(+ Whiff Test)
Infectious vaginitis can be caused from _______ .
Yeast, parasitic infection, or bacterial infection
What causes infectious vaginitis with curdy white discharge, thin mucus with clumping, or normal mucus with no discharge?
Candida albicans has pseudohyphae and a vaginal pH of ________ .
4 to 4.5
Non-Candida albicans yeast infections have no ________.
Parasitic infection of infectious vaginitis is caused by ________ .
Infectious vaginitis due to Trichomonas vaginalis presents with ________ .
Bacterial vaginitis can be due to _________ .
Gonorrhoea (purulent), Chlamydia (often nothing), Group B Strep (GBS), and Group A Strep (GAS)
Atrophic vaginitis is associated with ________ .
Increasing age and menopause
Atrophic vaginitis can present with:
Vaginal dryness, dyspareunia, burning, itching no door, mustard-coloured/green discharge, pale vaginal and cervical mucosa, and submucosal hemorrhagic spots
Atrophic vaginitis has a pH of _______ .
Non-inflammatory vaginosis does not meet the criteria for bacterial vaginosis, has a vaginal pH of 4 to 5, and can present with ________ .
Increased vaginal discharge that is off-white, mild odour, and mild vulvovaginal irritation
Inflammatory vaginosis has no inflammatory markers on vaginal cervical mucosa, has a pH of 4.5 to 5.5, and presents with ________ .
Yellowish white discharge with subtle odour, mild vulvovaginal irritation, and lymphocytes
Lactobacillosis (cytolytic) has a vaginal pH of _______ , and presents with slightly increased premenstrual discharge (white, thin, pasty), mild vuvar irritation, itching, and normal vulva. It does not respond to anti-fungal treatment.
3.5 to 4.5
Non-infectious vaginitis can be due to _______ .
Irritants (chemical, allergic, contact dermatitis), autoimmune (lichen sclerosis), and malignancy
The meeting of the squamous and columnar epithelium of the cervix is called the _______ . It is an area of increased mitotic activity, where dysplastic changes may predispose to carcinogenic influences (e.g., HPV).
________ precedes carcinoma, and is often associated with HPV. Strains 16 and 18 are high risk, whereas, strains 6 and 11 are low risk.
Cervical intraepithelial neoplasia
Cervical intraepithelial neoplasia (CIN) grading:
1. CIN I (LSIL): Mild dysplasia
2. CIN II (LSIL/HSIL): Moderate dysplasia
3. CIN III (HSIL): Severe dysplasia; carcinoma in situ
With cervical carcinoma, a PAP test detects atypia before abnormality is seen. Precancerous changes may precede cancer by as many as ________ years. Most common is squamous cell carcinoma - 75%.
There are 3 distinctive patterns of cervical carcinoma, and they are _______ .
1. Fungating type (most common) - elevated mass
2. Ulcerating type
3. Infiltrative type
Staging of cervical cancer:
Stage 0: Carcinoma in situ (CIN III)
Stage I: Carcinoma confined to the cervix
Stage II: Carcinoma extends beyond the cervix but not onto the pelvic wall. Carcinoma involves the vagina but not the lower third
Stage III: Carcinoma has extended onto pelvic wall. The tumor involves the lower third of the vagina
Stage IV: Carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. Metastatic dissemination.
Follow-up to an abnormal PAP test is done with ________ . An abnormal PAP does not mean a patient has cervical cancer.
________ is uncommon, and arises after partition or miscarriage due to retained products of conception. It will have the presence of neutrophils and pharmaceutical intervention and/or D&C is required.
________ has the presence of plasma cells and lymphocytes, and often associated with a secondary condition such as gonorrhoea, TB, retained gestational tissue, and/or an IUD.
Pelvic inflammatory disease can affect any or all of the following structures _______ . It is a clinical syndrome caused by infection (e.g., chlamydia, gonorrhoea, and others).
Uterus (endometritis), fallopian tubes (salpingitis - most common), ovaries (oophoritis), and peritoneum (peritonitis)
Pelvic inflammatory disease should be suspected in at-risk patients with pelvic pain with no identifiable etiology, uterine or adnexal tenderness, and a ________ .
Positive cervical motion sign
Symptoms of pelvic inflammatory disease (PID) are:
Lower abdominal and pelvic pain, vaginal discharge, abnormal uterine bleeding, dysuria, and dyspareunia
Signs of pelvic inflammatory disease (PID):
Fever, uterine tenderness, adnexal tenderness, cervical motion tenderness, adnexal mass, and leukocytosis
What is leukocytosis?
An abnormally large increase in the number of white blood cells in the blood, often occurring during an acute infection or inflammation
Endometriosis often affects women in their _______ , whereas, adenomyosis often affects women in their ________ .
20s and 30s; 40s and 50s
What is the retrograde / regurgitation theory?
Menstrual back flow through fallopian tubes and subsequent implantation
What is the metaplastic theory?
Endometrial differentiation of coelomic epithelium
Premenstrual symptoms that stop after menses, severe pelvic pain, lower back pain, dyspareunia, pain with defecation and urination, and may also present with complaints of fertility issues
What is a uterine polyp?
Growth of the endometrium into the uterine cavity, it can block fallopian tubes and compromise fertility
What is the most common benign tumour of the uterus?
Symptoms of leiomyoma (fibroids) include:
Abnormal uterine bleeding, menorrhagia, metrorrhagia, pelvic pain, pressure-related symptoms, infertility/miscarriage, and is the most common reason for hysterectomy
What is menorrhagia?
Abnormally heavy or extended menstrual flow
What is metrorrhagia?
Bleeding from the uterus not associated with menstruation
What is dysfunctional uterine bleeding?
Abnormal bleeding in the absence of a well-defined organic lesion in the uterus
Dysfunctional uterine bleeding can be caused by _______ .
Failure of ovulation, inadequate luteal phase, contraceptive-induced bleeding, endomyometrial disorders, thyroid dysfunction, prolactinoma / hyperprolactinemia, and bleeding / clotting disorders.
What is endometrial hyperplasia?
Increased glandular tissue in the endometrium that is non-cancerous, but has malignant potential
Endometrial hyperplasia can be stimulated by ________ , and can present with abnormal uterine bleeding.
Assessment of endometrial hyperplasia is ________ .
Transvaginal ultrasound and biopsy
Endometrial carcinoma (adenocarcinoma) presentation is ________ .
Abnormal uterine bleeding or spotting, leukorrhea, dyspareunia, urinary difficulty, pelvic pain, and may or may not be palpable
Assessment of endometrial carcinoma is ________ .
Transvaginal ultrasound, biopsy, D&C, or hysteroscopy
What is leukorrhea?
A thick, whitish discharge from the vagina or cervical canal
Suppurative salpingitis is almost always _______ , and presents with suppuration, fever, pain, masses, pelvic inflammatory disease (PID), and possible infertility.
Bacterial (mainly gonorrhoea - 60%)
Implantation of ectopic pregnancies is most common in the _______ .
Risk factors for ectopic pregnancy are:
Endometriosis, scarring, birth defect, pregnant while using an IUD, and ART
Signs and symptoms of ectopic pregnancy are ________ , and this is an emergent referral.
Cessation of menses, elevation hCG, nausea, breast tenders, intense abdominal pain, acute abdomen, & shock.
Physiological cysts are known as ________.
Physiological cysts can be either ________ cysts.
Follicular or luteal
________ cysts develop during the first half of the cycle and fail to mature enough to rupture at ovulation, or may be cysts that fail to regress. These cysts are typically asymptomatic or present with Mittelschmerz pain.
________ cysts occur in the second half of the cycle after formation of corpus luteum, or may be cysts that fail to regress. These cysts are likely to rupture and cause pain on day 20 - 26 and contain blood (hemorrhagic cyst).
What is Mittelschmerz pain.?
Pain at the time of ovulation, midway between the menstrual periods.
Follicular and luteal cyst assessment:
Pelvic examination - palpable ovary, tranvaginal ultrasound, laproscopy, and CA-125.
What is CA-125?
Abbreviation for cancer antigen 125 and the test for it
Polycystic ovarian syndrome is the most common _______ affecting premenopausal women.
What is polycystic ovarian syndrome (PCOS)?
The accumulation of undeveloped ovarian follicles due to anovulation, which can increase ovarian androgen production.
According to the Rotterdam criteria, polycystic ovarian syndrome (PCOS) must meet at least 2 of:
1. Reduced or no ovulation (irregular cycles)
2. Signs of androgen excess
3. Polycystic ovaries (12+ follicles/ovary) (not required for diagnosis)
4. Exclusion of other related disorders
Presentation of polycystic ovarian syndrome (PCOS):
Irregular or absent menses, obesity, glucose dysregulation and insulin resistance, acanthosis nigricans, hirsutism, acne, and infertility.
Assessment for polycystic ovarian syndrome (PCOS):
Clinical presentation, thyroid panel, prolactin, testosterone, androgens, hCG, cortisol, IGF-1, glucose, insulin, 17-OH progesterone, FSH, LH, transvaginal ultrasound, CT or MRI
Some women with ovarian cancer never show elevated _______ .
Besides ovarian cancer, CA-125 is also elevated in _______.
Diverticulitis, endometriosis and fibroids, liver cirrhosis, normal menstruation, pelvic inflammatory disease, and pregnancy
Risk factors for tumours of the ovaries are:
Nulliparity and not breastfeeding, BRCA mutations and family history, and gonadal dysgenesis.
What is protective for ovarian cancer?
Oral contraceptives and tubal ligation
Classification of ovarian tumours:
1. Epithelial cell tumours (serous, mucinous, endometroid)
2. Germ cell tumours
3. Stromal cell tumours
Epithelial cell tumours tend to be low-grade cancers with ________ .
limited invasive potential
Serous tumours are the most frequent ovarian tumour, where the cells resemble ________. It is usually cystic in appearance, where an increased solid mass is predictive of malignancy.
Fallopian tube epithelium (columnar ciliated)
Mucinous tumours are analogous to serous tumours BUT epithelium appears like _______.
Endometrioid tumours may be solid or cystic and occasionally develop as a mass projecting from the wall of an endometriotic cyst filled with ________ .
Teratomas type of germ cell tumours arise in the first 2 decades of life. They are rare and _______ percent are benign.
Dermoid cysts are benign cystic teratomas of the ovaries, and is often filled with ________ , and usually manifest as an ovarian mass or found incidentally on X-ray.
Sebaceous secretions, matted hair, teeth, bone, cartilage, etc.
Immature malignant teratomas are bulky, solid or near solid, can contain areas of necrosis and can contain ________ .
Mature or barely recognizable areas of differentiation toward cartilage, bone, muscle, nerve, and other structures.
Stromal tumours are derived from cells that make ________ .
Signs and symptoms of stromal tumours are often asymptomatic until well advanced. Local symptoms are due to pressure causing:
Abdominal pain, distention and bloating; change in bowel habits; and possible abdominal, rectal, and vaginal bleeding
Diagnostic work-up for ovarian tumours:
Ultrasound (typically transvaginal), laproscopy, radiography, biopsy, CA-125
Ovarian torsion is the rotation of the ovary and often a portion of the fallopian tube. It is infrequent but a serious cause of ________ . 60% of ovarian torsions occur on the right.
Acute onset unilateral lower abdominal pain
Ovarian torsion is an _________, as reduced or impaired venous supply and lymphatic flow may infarct the ovary.