1
Fifth stage
Gynecology
Lec-4-5
د.سراب
2/3/2015
Chronic pelvic pain
Pain in the lower abdomen with or without valvar pain and more than 6 month duration.
Usually (not always) associated with dysmenorrhea or dyspareunia.
Evidence of this disease like that of asthma, headache, migraine, backache.
Also it occur in post-menopausal women.
Causes:
According to anatomical origin of pain:
1- Abdominal wall (muscles, bone, nerves).
2- Peritoneal (by stretching).
3- Viscera (urinary system, bowel, reproductive system).
4- Pain due to vessels (congestion, varicose veins).
According to nature of cause:
1- Inflammatory: infection (salpingitis), no infection (endometriosis).
2- Mechanical: genital prolapse, retroverted uterus, adhesions, ovarian cyst, torsion,
compression.
3- Functional: chronic cystitis, irritable bowel syndrome.
4- Neuropathic pain: post-surgery, nerve compression (in disc prolapse and nerve root
compression).
5- Musculoskeletal: muscle spasm, myalgia.
Assessment:
1- History:
Site: localized or generalized.
Onset and duration.
Aggravating factors: by intercourse.
Relieving factors: by analgesia or drugs or certain position.
Severity of pain: by interfering with quality of life.
Nature of pain.
2
Radiation of pain.
Associated with menstrual cycle:
o Primary (spasmodic) dysmenorrhea no underlying cause, started at
menarche, start at the beginning of menstrual cycle.
o Secondary (congested) dysmenorrhea there is underlying cause, start later in
life, start 7-10 days before menstruation.
o Dyspareunia:
Superficial (occur at vulva) or deep (occur at abdomen).
Do daily chart of pain.
Mood sometimes psychological cause of pain (so give antidepressant).
Quality of life (work, posture).
Physical and sexual abuse.
Review of other system:
o GIT IBS (bloating, frequency of stool, pain relieved by defecation).
o Renal chronic interstitial cystitis (hematuria, frequency, urgency).
Physical examination:
Gait or walking of patient could be referred pain form other area.
Neurological examination.
Abdominal examination:
o Inspection: scars.
o Tenderness due to nerve entrapment: Target point ((2 cm medial to iliac crest,
ovarian point which is 2cm above and lateral to symphysis pubis)).
Pelvic examination:
o Inspection: erythema (valvulitis), varicose veins in vulva.
o Digital examination: myalgia of pelvic muscles during insertion of finger.
o Palpation: Tenderness (infection), anteverted or retroverted uterus, mobility of
uterus, adhesions (tube or ovary), mass (pelvic abscess or endometriosis).
Investigations:
High vaginal endocervical swab (most common cause is chlamydia).
Radiology US (size of uterus and adnexa), MRI, Doppler.
Contrast radiology (diagnostic and therapeutic by doing embolization of vessels).
Diagnostic laparoscopy.
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Cystoscopy (chronic interstitial cystitis).
Bowel endoscopy (sigmoidoscopy).
Treatment:
Multi discrepancy: gynecologist, general surgeon, radiologist, psychologist.
Medical treatment:
Infection: antibiotics, anti-TB.
Endometriosis: progesterone.
Depression: antidepressant (amitriptyline, SSRI), gabapentin.
Nerve entrapment: local anesthetics (long acting).
Analgesics: paracetamol.
Surgical treatment:
Adhesion: adhenolysis.
Ovarian cyst: removal.
Endometriosis: early (ablation), later (endometrectomy).
Nerve surgery.
Hysterectomy and oophorectomy give GnRH agonist, if respond do hysterectomy.
Other:
Magnetic.
Phototherapy.
Writing therapy.
Radiological therapy (embolization of vessels).
Psychological therapy.
4
Gestational trophoblastic disease
It is uncommon complication of pregnancy.
Could be changed to malignancy but it is treatable malignancy.
Occur only in married women (sexually active).
Classification:
o Premalignant: partial mole and H.mole.
o Malignant: invasive mole and choriocarcinoma.
Association:
Younger age group less than 16 years and more than 40 years.
Areas: Asians.
History of previous mole.
Nutritional factors: carotene deficiency.
Partial mole:
Triploid (3 sets of chromosome = 69).
Due to fertilization of 2 sperms to one ovum or fertilization of one divided sperm to one
ovum.
Fetal vessels and placenta present.
There is focal hydropic degeneration in placenta.
Presentation: abortion.
Diagnosed by histopathological study.
Need for chemotherapy (0.5%).
H.mole:
46 chromosome.
Only paternal chromosome (2 sperms or one divided sperm).
Usually xx.
No feral vessels.
Presence of villi with hydropic degeneration.
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Presentation: excessive symptoms of pregnancy like pre-eclampsia, thyroid
enlargement, large uterus.
50% need chemotherapy.
Diagnosed by US snow storm appearance due to excessive cystic lesions.
Management of partial mole and H.mole:
Evacuation:
Preparation: prepare blood, investigation (CBC, Hb, blood group, cross match, B-hCG).
General ansthesia.
Suction method if evacuation.
If bleeding occur not use oxytocin but use ergometrine at the end of evacuation.
Follow up:
Twice weekly for 6 months.
Avoid pregnancy to avoid confusion.
Better not use COCP cause slower lowering of B-hCG.
Better not use IUCD or progesterone they lead to bleeding and confusion.
Best method is condom.
Contraception for 6 months if not use chemotherapy.
Contraception for 1 year if use chemotherapy.
Chemotherapy:
Indications of chemotherapy:
Biochemical:
o If B-hCG above 20000 IU after 4 weeks of evacuation.
o If increased in 2 readings.
o If plateau for 3 measures or readings.
o If decreased at beginning then increased.
Histopathology: choriocarcinoma.
Clinically:
o Bleeding: hematuria, vaginal bleeding, hemoptysis, peritoneal bleeding all with
elevated B-hCG.
o Focal symptoms.
B-hCG is tumor marker
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Choice of chemotherapy:
High risk patient (more than 6 score) multiple therapy (EMA-CO).
Low risk (less than 6 score) single chemotherapy:
o Give intensive dose every 2 weeks.
o Methotrexate is the drug.
o Give folinic acid after methotrexate by 30 hours.
o Give every 48 hours I.M.
o Side effects of methotrexate:
GIT problems.
Bone marrow (anemia, thrombocytopenia, low WBC lead to infections).
Loss of hair.
Dermatological problem.
Pleurisy.
o Do follow up by B-hCG.
o Give contraception for one year to avoid malformation in baby.
Figo scoring or staging:
Age of patient less than 40 years is low risk, more than 40 years is high risk.
Previous pregnancy before the mole H.mole (low risk), abortion (moderate risk),
normal pregnancy (high risk).
Duration between H.mole and pregnancy less than 3 months (low risk), more than 1
year (high risk).
Level of B-hCG 1000 (low risk), 1000000 (high risk).
Site of metastasis lung (low risk), brain (high risk).
Number of metastasis large number (high risk), low number (low risk).
Size of metastasis small size (low risk), large size (high risk).
Previous chemotherapy if not take (low risk), if take (high risk).
=== Figo scoring: less than 6 (give one chemotherapy), more than 6 (give multiple
chemotherapy).