Women’s Health - OB/gynweek 3

Pelvic Pain, Pelvic Masses

Amy Love, ND

TOPICS

• Questions about previous material?

• Pelvic pain

• Pelvic masses

PELVIC PAIN• Acute

– Intense, sudden onset, sharp rise, short course

• Cyclic – occurs in association with menstrual cycle

• Chronic – greater than 6 months duration

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

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 *

Review of Anatomy:What else could cause pain in pelvis or

lower abdomen?

ECTOPIC PREGNANCY• Implantation of fetus in site other than uterine cavity• Sx’s

– 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

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

MANAGEMENT OF ECTOPIC PREGNANCY

• Medical emergency

• Tx – surgical removal of mass and possibly fallopian tube OR methotrexate

• CAM Tx – adjunct support post op

LEAKING OR RUPTURED OVARIAN CYST

• Sx’s– 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

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

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

PID• Sx’s

– 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 WBC’s and bacteria on culdocentesis

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

CYCLIC PELVIC PAIN• Common causes

– Primary dysmenorrhea– Secondary dysmenorrhea

• Endometriosis• Adenomyosis

– Chronic functional cyst formation

PRIMARY DYSMENORRHEA• Very common - ~75%

– Usually in women < 25

• Cause is hypoxia and ischemia from increased endometrial PG production --> 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• Sx’s

– Suprapubic cramping and/or lumbosacral pain and/or radiation down anterior thigh

– Can have nausea/vomiting/diarrhea

PRIMARY DYSMENORRHEA• Dx

– Based on clinical history and a normal pelvic exam– May want to R/O infection

• Tx– Conventional

• NSAIDS or• OCP’s• Initiate work-up for secondary dysmenorrhea if

OCP’s fail• Codeine/hydrocodone if these fail• Uterine nerve ablation or presacral neurectomy if all

else fails

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 EFA’s

– Exercise

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

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

OCP’s• Most common cause is endometriosis,

followed by adenomyosis, pelvic adhesions, pelvic infections, pelvic congestion

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

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%

Endometriosis (con’t)• Typical patient:

– mid-30’s– 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

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

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

Etiology (con’t)– 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

Endometriosis etiology (con’t)

– Environmental• Endocrine disruptors:

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

Diagnosis of Endometriosis• Sx’s

– 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

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

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

Endometriosis (con’t)• 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

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 (>5mm); these represent a more progressive form of the disease

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

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

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 (<1cm 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

Treatment of Endometriosis• Prevention

– Aerobic activity from an early age may reduce incidence

• Conventional Tx– NSAID’s or narcotic analgesics– OCP’s– Progestin injections– Danazol– GnRH agonists - Lupron– Surgical excision or coagulation

• Recurrence rate for all tx’s 5-20% per year, and 40% after 5 years

Tx of Endometriosis• CAM Tx

– Strategies• Reduce stimulation of ectopic endometrial

tissue by estrogen• Optimize immune system function• Reduce inflammation• Provide pain relief

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• EFA’s to reduce inflammation• Support liver function to optimize metabolism of

estrogen• Optimize gut flora• Treat constipation

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

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)– N=58, RCT, PBE vs Gn-RHa– 30 mg caps BID X 48 weeks– 33% reduction in sx’s within 4 weeks

• Kohama T, J Reprod Med. 2007;52:000-000.

ADENOMYOSIS• Endometrial tissue within the

myometrium• Sx’s

– Dysmenorrhea and heavy or prolonged menstrual bleeding

– Can be asymptomatic– Occurs up to a week before menses,

resolves after cessation of menses

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– NSAID’s, narcotic analgesics,OCP’s, progestins– Hysterectomy if meds fail

• ND Tx– See endometriosis tx

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…

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 DDX’s from many different systems

• Gyn causes of chronic pelvic pain most commonly endometriosis, pelvic adhesion, pelvic congestion

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)

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

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

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

Dx of Uterine mass

PE – enlarged uterusR/O pregnancy if this is a possibility with urine hCGImaging – Pelvic or Trans-vaginal ultrasound

This will confirm leiomyoma

Leiomyomas (uterine fibriods)

• Aka fibroid or myoma • Benign tumors of muscle cell origin• Most frequent pelvic tumors• Highest prevalence in women in 50’s • 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

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

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)

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

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

Uterine Fibroid DDX

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

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

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

MANAGEMENT OF FIBROID TUMORS

• Conventional tx• Observation• OCP’s – 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

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

Dx ovarian mass• PE – enlarged ovary (ies)

• Pelvic or trans-vaginal ultrasound

• If ambiguous or suspicious for malignancy - laparotomy

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

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 doesn’t undergo atresia

after ovulation, OR: incompletely developed follicle doesn’t resorb

Ovarian Cyst types (con’t)• 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 don’t rupture, need to follow with

ultrasound– May resolve spontaneously or require surgery

Ovarian Cyst types (con’t)• 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

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

• OCP’s - reduce recurrence

– ND Tx – reduce estrogen activity

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

OVARIAN CANCER• Reduces risk

– Having at least one child– OCP’s– Alpha and beta-carotenes– Lycopene– Green, black or oolong tea– Selenium– Low saturated fat diet

• Screening– Currently no recommended screening tests– Annual pelvic exam?

DX OVARIAN CANCER• Sx’s - 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

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

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

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

MANAGEMENT OF FIBROID TUMORS

• ND Tx– Strategies

• Reduce estrogen activity• Optimize circulation in pelvis• Reduce sx’s 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

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