Women

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Womens Health - OB/gynweek 3

• Pelvic Pain, Pelvic Masses
• Amy Love, ND

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TOPICS

• Questions about previous material?
• Pelvic pain
• Pelvic masses

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PELVIC PAIN

• Acute
• Intense, sudden onset, sharp rise, short course
• Cyclic
• occurs in association with menstrual cycle
• Chronic
• greater than 6 months duration

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ACUTE PELVIC PAIN

• Rapid onset
• Associated with perforation or ischemia
• Colic or cramping
• Associated with muscular contraction or
  obstruction
• Generalized
• Associated with generalized reaction to an
  irritating fluid within the peritoneal cavity
• Eg. Ovarian cyst rupture

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DDX ACUTE PELVIC PAIN

• Complication of pregnancy
• Acute infections
• Adnexal disorders
• Ruptured ovarian cyst
• Torsion of adnexa
• Rare, twisting of ovary and sometimes also
  fallopian tube, usually due to ovarian swelling -
  cyst, tumor, fertility drugs
• GI, GU, musculoskeletal, CV causes

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Review of AnatomyWhat else could cause pain in
pelvis or lower abdomen?
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ECTOPIC PREGNANCY

• Implantation of fetus in site other than uterine
  cavity
• Sxs
• Amenorrhea, spotting, pelvic pain
• Dizziness, syncope if rupture with blood loss
• Left shoulder pain in 25 of ruptured ectopics
  (from blood into L hemidiaphragm)
• Signs
• Pulse may be up, BP down
• Abdomen tender, esp affected side
• Palpable adnexal mass
• Pos hCG or b-hCG
• Mass confirmed by US

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Ectopic Pregnancy

• Diagnosis
• Clinical signs and symptoms
• Positive Urine hCG
• Pelvic ultrasound
• Beta-hcg if US equivocal
• Serial beta-hCG to determine doubling times if
  necessary
• Repeat US if necessary

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MANAGEMENT OF ECTOPIC PREGNANCY

• Medical emergency
• Tx surgical removal of mass and possibly
  fallopian tube OR methotrexate
• CAM Tx adjunct support post op

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LEAKING OR RUPTURED OVARIAN CYST

• Sxs
• Sudden onset pelvic pain
• If blood loss, dizziness and syncope can occur
• Signs
• Rebound abdominal tenderness
• Pelvic mass if cyst is leaking, not ruptured
• Hypovolemia if blood loss
• Dx
• hCG, CBC, US, possibly culdocentesis

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MANAGEMENT OF RUPTURED CYST

• If significant bleeding, surgical removal of
  cyst/ovary
• If little bleeding, observation
• CAM Tx follow-up to prevent new cysts from
  forming
• Ovarian cysts grow in response to estrogen
  activity
• Reduce estrogen activity

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PID - pelvic inflammatory dz

• Polymicrobial infection of upper genital tract
• Usually associated with GC or CT infection
• Up to 50 also associated w polymicrobial
  infection of aerobes and anaerobes that make up
  normal vaginal flora

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PID

• Sxs
• Rapid onset pelvic pain
• Fever
• Purulent vaginal discharge
• Nausea/vomiting on occasion
• Signs
• Direct and rebound abdominal tenderness
• Cervical motion tenderness
• Bilateral adnexal tenderness
• Fever
• Leucocytosis
• Positive for WBCs and bacteria on culdocentesis

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PID

• Dx
• Made initially on clinical grounds
• Confirm with gram stain and positive tests for
  GC/CT
• Laparoscopy is definitive diagnosis, not usually
  necessary
• Tx
• Outpatient broad spectrum antibiotics
• Hospitalization if dx uncertain, abscess
  suspected, pregnant, or no response within 48
  hours to antibx
• CAM Tx
• Supportive after care
• Pro-biotics

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CYCLIC PELVIC PAIN

• Common causes
• Primary dysmenorrhea
• Secondary dysmenorrhea
• Endometriosis
• Adenomyosis
• Chronic functional cyst formation

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PRIMARY DYSMENORRHEA

• Very common - 75
• Usually in women lt 25
• Cause is hypoxia and ischemia from increased
  endometrial PG production --gt high amplitude
  uterine contractions resulting in decreased
  uterine blood flow
• Onset a few hours before or just after onset of
  menses
• Typically lasts 48-72 hours
• Sxs
• Suprapubic cramping and/or lumbosacral pain
  and/or radiation down anterior thigh
• Can have nausea/vomiting/diarrhea

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PRIMARY DYSMENORRHEA

• Dx
• Based on clinical history and a normal pelvic
  exam
• May want to R/O infection
• Tx
• Conventional
• NSAIDS or
• OCPs
• Initiate work-up for secondary dysmenorrhea if
  OCPs fail
• Codeine/hydrocodone if these fail
• Uterine nerve ablation or presacral neurectomy if
  all else fails

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PRIMARY DYSMENORRHEA

• CAM Tx
• Strategies
• Reduce prostaglandin production
• Improve blood flow to uterus
• Whole foods, low fat, vegetarian diet minimizing
  arachidonic acid intake and emphasizing omega-3
  EFAs
• Exercise

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PRIMARY DYSMENORRHEA

• CAM Tx continued
• Niacin 100 mg BID all month, q 2-3 hours during
  pain episodes
• Vitamin C and rutin increase effect of niacin
  300 mg/60mg qD
• Magnesium 400 mg/ Day
• Thiamin HCl 100 mg QD X 90 days
• Vitamin E 400-500 iu/d 2 days before menses
  through 3 days of menses
• EPA/DHA/EPO (fish oil) 2-3 grams qD
• Botanicals
• Valerian, viburnum o. and p., zingiber,
  cimicifuga, piscidia
• Progesterone cream ¼ tsp BID 3-12 days before
  menses
• TENS

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SECONDARY DYSMENORRHEA

• Usually occurs years after onset menses
• Onset 1-2 weeks before menses
• Lasts a few days beyond cessation of menses
• Less likely to respond to PG inhibitors or OCPs
• Most common cause is endometriosis, followed by
  adenomyosis, pelvic adhesions, pelvic infections,
  pelvic congestion

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Endometriosis

• Common medical condition characterized by the
  presence and growth endometrial tissue outside
  of the uterus
• Affects 10-15 of menstruating women between ages
  24-40 in the U.S.
• Found in approx. 33 women with chronic pelvic
  pain
• Found in 30-45 women with infertility

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Endometriosis

• Risk factors
• Increased estrogen levels
• Lack of exercise from an early age
• Women with menstrual cycles closer together and
  longer in length (e.g. bleeds 7 days every 25
  days)
• Heredity (main risk factor)
• Likelihood for mother to also have endometriosis
  is 8.1
• Sister 5.8

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Endometriosis (cont)

• Typical patient
• mid-30s
• Nulliparous
• Involuntarily infertile
• Dysmenorrhea
• Pelvic pain
• Dysparunea
• May be found in post-menopausal women (5
  incidence)
• Usually due to exogenous hormones/ HRT
• May occur prior to puberty

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Endometriosis etiology

• Theories of causation include
• Ectopic transplantation of endometrial tissue by
  retrograde menstruation
• Endometrial cells shed during menses may implant
  on other pelvic tissues grow as grafts under
  hormonal influence
• Frequently found in women with outflow
  obstruction of genital tract
• Supported by studies where cervix of monkeys
  sutured shut
• Most frequently found in areas immediately
  adjacent to openings of Fallopian tube

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Etiology continued

• Induction theory some undefined biochemical
  factor induces undifferentiated peritoneal cells
  to develop into endometrial cells documented in
  rabbits, not humans
• Metaplasia reversible replacement of one
  differentiated cell type with another mature
  differentiated cell type
• During embyronic development, cells that have the
  potential to become endometriosis are laid down
  in tracts, usually in the posterior pelvis.
• Tracts act as seeds that lie dormant until
  estrogen stimulation or other triggers
  (inflammation, immune mediators)
• Supporting examples presence of endometriosis in
  pre-pubertal girls, women with congenital absence
  of uterus, and rarely in men

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Etiology (cont)

• Lymphatic and vascular metastasis
• Explains endometriosis found in remote areas such
  as spinal column, nose
• 30 of women with endometriosis have affected
  pelvic lymph nodes
• Immunologic changes
• Abnormalities in both cell-mediated and humoral
  components of immune system
• Hyperactive macrophages secrete multiple growth
  factors and cytokines
• Iatrogenic dissemination
• After C-section, endometriosis discovered in
  anterior abdominal wall, incision scars

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Endometriosis etiology (cont)

• Environmental
• Endocrine disruptors
• PCBs (polychlorinated biphenyls) e.g. bisphenol-A
• Dioxins (found in tampons, among many other
  places)
• Pesticides/ Herbicies
• Detergents
• Household cleaners

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Diagnosis of Endometriosis

• Sxs
• Progressive dysmenorrhea that began years after
  menarche
• Occurs before menses, lasts beyond end of menses
• Subfertility
• Can occur outside of pelvis
• Can be asymptomatic
• Dysparunea
• seems to be due to immobility of pelvic organs or
  direct pressure on tissue with endometriosis
• Other possible symptoms
• intermittent constipation, diarrhea, dyschezia,
  urinary frequency, dysuria, hematuria
• Abnormal bleeding in 15-20 women
• Premenstrual spotting
• menorrhagia

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DX OF ENDOMETRIOSIS

• PE
• May be normal
• May find nodularity in uterosacral ligaments or
  cul-de-sac
• In advanced dz, may find fixed uterus, ovaries,
  tubes
• Dx confirmed with laparoscopy (gold standard) and
  biopsy of suspect tissue

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Endometriosis

• Diagnosis may be incidental
• Laparoscopy for different condition
• Infertility evaluation
• Pelvic pain not proportional to extent or amount
  of endometriosis
• Some patients may have large amounts and no pain
  (and may never be diagnosed!)
• Size and location of endometrial tissue and
  adhesions in pelvis is used to classify dz
• Stage I is minimal, stage IV is severe
• Dz is progressive in 30-60 of patients

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Endometriosis (cont)

• Great individual variability
• Does not follow a typical course
• Is benign, yet has characteristics of malignancy
  locally infiltrative, invasive, and widely
  disseminating
• Cyclic hormones usually cause growth while
  continuous hormones reverse growth pattern

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Endometriosis

• Pathology
• Endometrial implants are most commonly found on
  ovaries
• Involvement usually bilateral
• Other common sites pelvic cul-de-sac, peritoneum
  over uterus, uterosacral, round, and broad
  ligaments
• May penetrate deeply into other tissues (gt5mm)
  these represent a more progressive form of the
  disease

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Endometriosis

• Pathology
• Histological features ectopic endometrial
  glands, ectopic endometrial stroma, and
  hemorrhage into adjacent tissue
• Implants may bleed at same time as menstrual
  cycle or have cycles of their own!
• Disease may spontaneously regress
• Pathophysiology of progression from subtle to
  severe disease is unknown

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Common sites Rare sites
Ovaries Umbilicus
Pelvic peritoneum Episiotomy scar
Ligaments of the uterus Bladder
Sigmoid colon Kidney
Appendix Lungs
Pelvic lymph nodes Arms
Cervix Legs
Vagina Nasal mucosa
Fallopian tubes Spinal column
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Endometriosis

• Gross pathological changes
• Vary in color, size, shape depends on location,
  blood supply, amount of hemorrhage and fibrosis,
  degree of edema
• New lesions small (lt1cm diameter) and raised
  above surrounding tissues
• Older lesions become larger and assume light/dark
  brown color may be described as chocolate
  cysts or powder burn
• Most active lesions are red and blood-filled

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Treatment of Endometriosis

• Prevention
• Aerobic activity from an early age may reduce
  incidence
• Conventional Tx
• NSAIDs or narcotic analgesics
• OCPs
• Progestin injections
• Danazol
• GnRH agonists - Lupron
• Surgical excision or coagulation
• Recurrence rate for all txs 5-20 per year, and
  40 after 5 years

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Tx of Endometriosis

• CAM Tx
• Strategies
• Reduce stimulation of ectopic endometrial tissue
  by estrogen
• Optimize immune system function
• Reduce inflammation
• Provide pain relief

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ND TX ENDOMETRIOSIS

• Whole foods diet to reduce exogenous estrogens,
  optimize excretion of estrogen, and reduce
  arachidonic acid
• Avoid caffeine associated with endometriosis
• Aerobic exercise 30 minutes 5 X/wk
• EFAs to reduce inflammation
• Support liver function to optimize metabolism of
  estrogen
• Optimize gut flora
• Treat constipation

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ND TREATMENT ENDOMETRIOSIS

• Vitamin E - 1200 iu/d and Vitamin C 1000mg/d X 2
  months RCT
• Resulted in reduced pain
• Beta-carotene 50,000-150,000 iu/d
• Decreases IL-6 an inflammatory mediator recently
  implicated in endometriosis
• Botanicals for pain relief
• Valerian, piscidia, viburnum, cimicifuga
• Traditional tincture equal parts ½ tsp TID
• Vitex for estrogen balance
• Dandelion root for supporting liver function
• Prickly Ash to simulate blood flow through pelvis
• Motherwort as antispasmodic

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ND TX ENDOMETRIOSIS

• Progesterone cream 1/4-1/2 tsp BID days 8-28,
  or days 15-26, or week before menses
• Contrast pelvic hydrotherapy
• Pelvic sitz bath
• Hot 3 minutes
• Cold 1 minute
• Repeat 3X
• Pine Bark Extract (pycnogenol)
• N58, RCT, PBE vs Gn-RHa
• 30 mg caps BID X 48 weeks
• 33 reduction in sxs within 4 weeks
• Kohama T, J Reprod Med. 200752000-000.

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ADENOMYOSIS

• Endometrial tissue within the myometrium
• Sxs
• Dysmenorrhea and heavy or prolonged menstrual
  bleeding
• Can be asymptomatic
• Occurs up to a week before menses, resolves after
  cessation of menses

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ADENOMYOSIS

• Signs
• Uterus may be enlarged, soft and tender during
  menses
• Dx
• R/O pregnancy
• Based on clinical findings
• US, MRI, or HSG may be helpful
• Tx
• NSAIDs, narcotic analgesics,OCPs, progestins
• Hysterectomy if meds fail
• ND Tx
• See endometriosis tx

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CHRONIC PELVIC PAIN

• Broad category that includes many causes from GU,
  GI, musculoskeletal, urologic, psychologic
• Important to complete thorough Hx and ROS to sort
  through above DDX possibilities
• Most common gyn causes of chronic pelvic pain
• Endometriosis
• Pelvic adhesions
• visceral manipulation, oral enzymes
• Pelvic congestion
• contrast hydrotherapy, acupuncture, herbs

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KEY CONCEPTS of PELVIC PAIN

• Acute pelvic pain is often an emergency
• R/O ectopic, ruptured cyst with bleeding,
  infection
• Cyclic pelvic pain - usually primary or secondary
  dysmenorrhea
• Chronic pelvic pain associated with many DDXs
  from many different systems
• Gyn causes of chronic pelvic pain most commonly
  endometriosis, pelvic adhesion, pelvic congestion

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PELVIC MASS

• Most pelvic masses occur on ovary or in uterus
• Ectopic pregnancy, abscess, endometriosis, bowel
  masses are exceptions
• Ovarian masses
• Functional cysts
• Abscess
• Benign or malignant tumor
• Endometrioma
• Uterine masses
• Pregnancy
• Leiomyoma (fibroid)

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OVARIAN MASSES

• While ovarian mass is rare in prepuberty, if it
  occurs, 80 are malignant
• Functional ovarian cysts are common in
  adolescents
• Functional ovarian cysts and endometriomas are
  common in reproductive age women
• Malignant ovarian masses are most common in
  post-menopausal women

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UTERINE MASSES

• Uterine masses are rare in prepubertal and
  adolescent girls
• In adolescent girls, R/O pregnancy and
  PID/abscess
• Leiomyomas are the most common cause of uterine
  masses in reproductive age women
• Persistent leiomyomas may be found in
  post-menopausal women, but new ones are unlikely
  to appear

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EVALUATION OF PELVIC MASSES

• Complete history
• Pelvic and abdominal examination
• Labs pregnancy test if applicable, CA-125, CBC
  as indicated
• Imaging abdominal or vaginal US CT and/or MRI
  if US inconclusive
• If bleeding is occurring in patient with a pelvic
  mass, endometrial sampling is essential

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Dx of Uterine mass
PE enlarged uterus R/O pregnancy if this is a
possibility with urine hCG Imaging Pelvic or
Trans-vaginal ultrasound This will confirm
leiomyoma
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Leiomyomas (uterine fibriods)

• Aka fibroid or myoma
• Benign tumors of muscle cell origin
• Most frequent pelvic tumors
• Highest prevalence in women in 50s
• Majority found in body of uterus
• Symptomatic uterine leiomyomas account for 30 of
  all hysterectomies
• Vary in size from microscopic to filling entire
  abdomen
• May be single but more often multiple

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Uterine fibroids

• Etiology unkown
• Higher concentrations of estrogen and
  progesterone receptors in myoma than in
  surrounding tissue
• Growth stimulated by estrogen
• Rare prior to menarche
• Usually diminish after menopause
• Smoking decreases estrogen and smokers are found
  to have less fibroids

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Uterine Fibroids

• Location varies
• Subserosal outer uterus wall
• May protrude through cervix into vagina
• May be pedunculated on long stalk and mistaken
  for ovarian mass
• Intramural within uterine wall
• Submucosal- just under endometrium
• Only account for 5-10 of myomas, but are the
  most symptomatic (abnormal bleeding, fertility
  issues, abortion)

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Leiomyoma Symptoms

• Most are asymptomatic (50-80)
• Symptoms may include
• Discomfort / Pressure / Congestion of pelvis /
  abdomen
• Bloating
• Heaviness
• Dysparunea
• Urinary frequency
• Backache
• Abnormal bleeding in 30 of fibroids
• Menorrhagia usually due to intramural fibroids
  which enlarge the endometrial cavity and increase
  its surface area
• Metrorrhagia may be due to submucosal fibroid
  that ulcerates through endometrial lining

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Fibroid growth

• Fibroids generally have a poor blood supply
• With continued growth, will outgrow blood supply
• Eventually degenerate, rapidity with which this
  occurs determines the extent of degeneration
• Different types of degeneration from histological
  perspective (hyaline, myxomatous, calcific,
  cystic, fatty, red, necrosis)
• Red acute infarction causing severe pain
• Less than 1 are malignant
• Rapidly growing fibroids require special
  attention
• Initial management of fibroids is regular
  ultrasounds every 6-12 months

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Uterine Fibroid DDX

• Malignant ovarian tumor
• Pelvic abcsess
• Colon diverticulum
• Endometriosis
• Pelvic adhesions
• Congenital abormalities
• Rare pelvic kidney, retroperitoneal tumor

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Complications of fibroids

• Infertility in 2-10 of cases
• May interfere with implantation of fetus
• May decrease motility of sperm/ eggs
• May compress Fallopian tube
• In approx. 5 of cases, may compress ureter,
  which leads to enlarged kidney and may compromise
  kidney function

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Fibroids and Pregnancy

• During pregnancy (high levels of estrogen and
  progesterone)
• In some cases, blood flow diverted to fetus
• In other cases (esp. if large), fibroid may
  interfere with pregnancy
• Interfere with fetal growth
• Cause premature rupture of membranes
• Retained placenta
• Postpartum hemorrhage
• Abnormal labor

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MANAGEMENT OF FIBROID TUMORS

• Conventional tx
• Observation
• OCPs can reduce pain
• GnRH agonists or RU-486 short term
• Pre-op
• Close to menopause
• After cessation of therapy, fibroids usually
  return to original size
• Surgery - indications
• Bleeding, anemia, chronic pain, urinary symptoms,
  infertility
• Rapid enlargement of uterus may indicate uterine
  sarcoma developing in leiomyoma

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Natural Mgmt of Fibroids

• Difficult, varies with each individual
• Balance estrogen/ progesterone
• Liver support to help metabolize estrogen
• Good nutrition important
• Junk food, alcohol, caffeine, saturated fats and
  sugar interfere with estrogen metabolism
• Low saturated fat and high fiber diet improves
  circulating estrogen levels

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Dx ovarian mass

• PE enlarged ovary (ies)
• Pelvic or trans-vaginal ultrasound
• If ambiguous or suspicious for malignancy -
  laparotomy

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Ovarian Cysts

• Majority are asymptomatic
• Majority disappear or resorb spontaneously
• If they rupture, patient feels transient
  tenderness
• Patients respond differently to pain
• If persist over 2 months, need to rule out
  ovarian neoplasm

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Ovarian Cyst types

• Follicular cysts
• Most common type of ovarian cyst
• Frequently multiple
• Average 2.5-3 cm diameter
• Filled with straw-colored fluid
• Dominant follicle doesnt undergo atresia after
  ovulation, OR incompletely developed follicle
  doesnt resorb

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Ovarian Cyst types (cont)

• Corpus luteum cysts
• May be associated with prolonged progesterone
  secretion
• Average size 4 cm usually unilateral
• May be asymptomatic
• May cause massive intraperitoneal bleeding upon
  rupture bleeding may be slight or require
  transfusion
• When rupture, need to rule out ectopic pregnancy
• If grow and dont rupture, need to follow with
  ultrasound
• May resolve spontaneously or require surgery

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Ovarian Cyst types (cont)

• Theca lutein cysts
• Least common type of cysts
• Usually bilateral
• Moderate to massive enlargement of ovaries
• 1-10 cm diameter average
• Majority are asymptomatic
• May cause increased abdominal girth
• Felt upon palpation
• May be diagnosed with ultrasound
• Gradually regress
• Grow due to prolonged/excess ovarian stimulation
• Increased ovarian sensitivity
• Exogenous gonatotrophin stimulation, usually due
  to drugs used to induce ovulation

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MANAGEMENT OF OVARIAN MASS

• Ovarian masses suspicious for malignancy solid
  or complex
• Exploratory laparotomy
• Biopsy will confirm or R/O malignancy, ovaries
  taken out if malignant
• Functional ovarian cysts
• Conventional Tx
• OCPs - reduce recurrence
• ND Tx reduce estrogen activity

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OVARIAN CANCER

• 2/3 of patients diagnosed with ovarian cancer
  will have metastatic dz
• Peak incidence is 56-60 yrs
• Risk factors
• Infertility
• Low parity
• Early menarche, late menopause
• Talc use
• Galactose consumption
• Tubal ligation
• BRCA 1 and 2 (Ashkenazi, Icelandic women)
• Family hx of HNPCC

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OVARIAN CANCER

• Reduces risk
• Having at least one child
• OCPs
• Alpha and beta-carotenes
• Lycopene
• Green, black or oolong tea
• Selenium
• Low saturated fat diet
• Screening
• Currently no recommended screening tests
• Annual pelvic exam?

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DX OVARIAN CANCER

• Sxs - Usually asymptomatic
• May be vague and non-specific
• Abdominal discomfort, dyspareunia, bloating,
  constipation, increased abdominal size
• Signs usually only in advanced dz
• Firm, irregular, fixed pelvic mass
• Possible ascities
• Labs
• CA-125
• Confirm with exploratory laporotomy

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MANAGEMENT OF OVARIAN CANCER

• Cancer must be staged
• 5 yr survival rate for early stage dz is 70-90
• 5 yr survival rate for late stage dz is 20-30
• Conventional Tx
• Surgery remove tumor and other affected tissues
• Chemotherapy many protocols
• Hormonal tx tamoxifen
• Immunotherapy

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MANAGEMENT OF OVARIAN CANCER

• ND Tx
• Strategies
• Optimize immune function
• Reduce side effects of chemotherapy
• Provide anti-tumor agents
• Sample TX
• Whole foods diet smoothies
• Anti-oxidants, antiinflammatories
• CoQ10
• PSK - extract of mushroom trametes versicolor
• Green tea

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MANAGEMENT OF FIBROID TUMORS

• Surgical techniques
• Hysterectomy
• Laparoscopic myomectomy
• Vaginal myomectomy
• Hysteroscopic resection of small submucous
  fibroids
• Uterine artery embolization
• Focused ultrasound - sonication
• Non-invasive, MRI guided, Thermoablative
• Recurrence rate up to 50 after myomectomy

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MANAGEMENT OF FIBROID TUMORS

• ND Tx
• Strategies
• Reduce estrogen activity
• Optimize circulation in pelvis
• Reduce sxs of pain and bleeding
• Sample Tx
• Low estrogen diet
• Phytoestrogenic herbs
• Contrast pelvic sitz baths
• Maintain ideal weight
• Support liver and bowel function, flora
• Styptics trillium, capsella, geranium, cinnamon
• Analgesics viburnum, piscidia, cimicifuga

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KEY CONCEPTS PELVIC MASS

• Masses typically on ovary or in uterus
• Hx, PE, US are cornerstones of Dx
• Must R/O pregnancy in any reproductive age woman
• Bleeding along with mass requires endometrial
  sampling
• Ovarian cancer most common malignant pelvic mass