If someone spotting in first half of cycle (proliferative phase)- what might new pill have? More estrogen or less? More progesterone or less? You want more estrogen- healing capability and cause build up

If someone spotting in first half of cycle (proliferative phase)- what might new pill have? More estrogen or less? More progesterone or less?

You want more estrogen- healing capability and cause build up

What if spotting day 14/15 and spot for next two weeks- what pill do u choose?

What do you want to increase ni pill if pt is complaining of acne?

What do you want to increase if pt complaining of heavy bleeding?

If acne? More estrogen

Bleeding to heavily- add progesterone

•Primary dysmenorrhea-caused by an excess of prostaglandins leading to painful uterine muscle activity

•Secondary dysmenorrhea-caused by clinically identifiable causes (not caused by Prostglandins)

What does this describe?

applied to pelvic discomfort (not solely associated with menstruation) of more than 6 months duration/ can be during menstruation or anytime

What is the incidence of primary dysmenorrhea at its highest? (ie. whta age range?

When is secondary dysmenorrhea common?

•The incidence of primary dysmenorrhea is greatest in women in their late teens to early twenties and declines with age

•Secondary dysmenorrhea becomes more common as a woman ages

•Prostaglandins cause uterine contractions

•Prostaglandins can cause contractions in smooth muscles elsewhere in the body, resulting in nausea, vomiting and diarrhea

•Prostaglandin production is under the influence of progesterone and arachidonic acid derived form necrotic endometrial cells

Patients describe monthly spasmodic lower abdominal pain, occurring on days 1 to 3 of menstruation.

•Located over lower abdomen and suprapubically, often radiating to the back

•Pain described as “coming and going” or labor like

•Pain often accompanied with nausea, vomiting and or diarrhea

•Fatigue, low backache and headache are also common

•Many report using hot water bottle, heating pad or assuming the fetal position to relieve pain

What could it be?

True or False:

Dyspareunia is generally not found with primary dysmenorrhea and should suggest a secondary cause

Endometriosis

Tumors (benign or malignant)

inflammation

adhesions

psychogenic

These are what type of secondary amenorrhea causes?

adenomyosis

leiomyomata

These are what type of secondary causes of amenorrhea?

Leiomyomata

polyps

IUD

Infection

Cervical stenosis and lesions

These are all what type of causes of secondary amenorrhea?

leiomyomata-“fibroids,” benign uterine tumors/ can go in wall and cause pain; or can be in endometrial cavity and have polyps and uterus trying to expel foreign product causing cramping

• Physical examination is directed toward uncovering possible causes of secondary dysmenorrhea such as:

•Adenomyosis-boggy, symmetrically enlarged tender uterus

•Fibroids-enlarged irregular uterus

•Inflammatory process-fever, chills, malaise

• Endometriosis or PID- may be associated with infertility

•Others

True or false.

Physical examination of patients with primary dysmenorrhea should be normal.

Dysmenorrhea Therapy

•Heat, exercise, psychotherapy,

•*Patients with primary dysmenorrhea generally experience exceptional relief with NSAID’s; mefenamic acid (Ponstel), ibuprofen (Motrin) diclofenac (Voltaren), Cox-2 inhibitors.

•Life threatening cardiovascular and GI events associated with COX-2 inhibitors and NSAID’s. 

•Endocrine therapy (oral contraceptives)

how do u decrease pressure? make opening bigger? Or reduce flow (ie. oral contraceptives)

Gynecologic Causes

•Adnexal

•Uterine

•Urologic

Gastrointestinal

•Inflammatory

•Mechanical

Other

•Aneurysm

•Musculoskeletal

•Biochemical

•Neurologic

•Psychosocial

Chronic Pelvic Pain Management

•Therapeutic challenge

•Analgesics (NSAIDS) (Acetaminophen)

•Frequent follow-up and separate from pain episodes (see pt when they’re not menstruating/not in pain)

•Ovulation suppression

•Surgical therapies

What is this called?

A benign disease defined by the presence of ectopic (endometrial tissue outside the endometrial canal) endometrial glands and stroma

Where is endometriosis commonly found?

What is associated?

• Most commonly located on the ovaries and or pelvic peritoneum (abdominal lining)

•Reacts similarly to endometrial tissue

•Prone to progression, regression  and recurrence

•Often associated with pelvic pain and infertility

What is this called?

•Collection of endometriosis on or in the ovary

•Filled with chocolate colored fluid consisting of hemolyzed blood and desquamated endometrium.

Endometrioma

What is adenomyosis?

•Adenomyosis -  endometrial implants (endometriosis ) within the myometrium

•Results in symmetrically enlarged, boggy uterus

•Menses are especially uncomfortable

Incidence of endometriosis:

•Exact incidence unknown

•3-10% of women in the _______

•5-20% of women with _______

•25-35% of ________

•4/1000 women aged 15-64 hospitalized each year

Incidence of endometriosis

•Exact incidence unknown

•3-10% of women in the reproductive age group

•5-20% of women with pelvic pain

•25-35% of infertile women

•4/1000 women aged 15-64 hospitalized each year

Who gets endometriosis?

•Mean age 25-30

•Rare in pre-menarchial girls

•Identified in >50% of adolescents and young women < age 20 with complaints of chronic pelvic pain or dyspareunia.

•5% of postmenopausal women, most had received estrogen therapy.

What is this called:

Spontaneous change in mesothelial cells derived from the coelomic epithelium (located in the peritoneum and pleura).

Coelomic Metaplasia-Mullerian Metaplasia

These findings could all be due to what?

-Pre-menarchial women

                -Women who have never menstruated

                -Pleura and pulmonary endometriosis

                -Rare cases in men treated with estrogen

Coelomic Metaplasia-Mullerian Metaplasia

What is the most commonly reported symptom with new onset of endometriosis?

What is the most common presenting complaint in women with symptomatic endometriosis?

What is the most commonly reported symptom with new onset of endometriosis? dysmenorrhea

What is the most common presenting complaint in women with symptomatic endometriosis? chronic pelvic pain

Pt presents with the follow sxs.

what could it be?

•Dysmenorrhea

•Deep dyspareunia

•Change in menstrual flow

•Rectal, ureteral, bladder symptoms

•Infertility

•Little or no pain or symptoms

Diagnosis of Endometriosis

What would be on your differential for endometriosis?

•Chronic pelvic pain- PID, pelvic adhesions, GI disorders, urologic disorders and musculoskeletal disorders.

•Dysmenorrhea

•Dyspareunia-symptomatic uterine retroversion, chronic PID, ovarian cysts

•Neurological 

•Psychiatric

•Abnormal bleeding-anovulation, hypothyroidism, hyperprolactinemia,

•Infertility

Clinical Diagnosis for Endometriosis:

what would you find on

external genitalia

speculum exam

uterus

adnexa

uterosacral area

•External genitalia is typically normal

•Speculum examination may reveal blue-colored implants or red proliferative lesions that bleed on contact, usually in the posterior fornix

•Uterus is fixed or retroverted

•Adnexa fixed or enlarged

•Uterosacral nodularity and focal tenderness- easier to detect during menses

How do you diagnose endometriosis?

What confirms the diagnosis?

•Traditional Diagnosis best made via direct visualization and biopsy ideally with histological confirmation of ectopic endometrial glands and stroma

•Rigid definition not always used because of varying appearance of lesions and the natural progression of the disease.

•Positive histology confirms the diagnosis, but negative histology does not exclude it.