Notes

Laparoscopy can be both diagnostic and therapeutic in this patient in whom you suspect endometriosis.
Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder, which is clinically characterized by recurrent irritative voiding symptoms of urgency and frequency, in the absence of objective evidence of another disease that could cause the symptoms. Pelvic pain is reported by up to 70% of women with IC and, occasionally, it is the presenting symptom or chief complaint. Women may also experience dyspareunia. The specific etiology is unknown.
Diagnosis is based on the Rome II Criteria for IBS, which includes at least 12 weeks (need not be consecutive) in the preceding 12 months of abdominal discomfort or pain that has two of three features: 1) relief with defecation; 2) onset associated with a change in frequency of stool; or 3) onset associated with a change in stool form or appearance.
Danazol, a 17-alpha-ethinyl testosterone derivative, suppresses the mid-cycle surges of LH and FSH.
It is estimated that chronic pelvic pain is the principal preoperative indication for 10-12% of hysterectomies. Since the patient had a tubal ligation and does not desire any more children, the best option is removal of ovaries with or without a hysterectomy. Repeat laparoscopy with treatment of endometriosis and adhesions can be helpful; however, the patient will continue to be at increased risk of recurrent disease. An endometrial ablation or wedge resection of ovaries alone would not be very helpful in the setting of non-cyclical pain.
Given the patient’s age, nonspecific abdomino-pelvic symptoms, recent postmenopausal bleeding episode and family history of ovarian cancer, a transvaginal ultrasound is the next best step as it is more sensitive than CT for evaluation of the uterus and adnexa.
Ovarian remnant syndrome occurs following surgical removal of the ovaries, with subsequent development of cyclical pain due to ovarian tissue that was left behind inadvertently.
Pelvic congestion syndrome is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities. The unique characteristics of the pelvic veins make them vulnerable to chronic dilatation with stasis leading to vascular congestion.
Nerve entrapment syndrome is a commonly misdiagnosed neuropathy that can complicate pelvic surgical procedures performed through a low transverse incision. The nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve. The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis. The ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh. Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh.
Fibroadenomas are common and are usually firm, painless and freely movable
Accurate prolactin levels are best obtained in the fasting state. If still elevated, then a TSH level and brain MRI would be indicated to rule out a pituitary tumor.
Fibrocystic breast changes are the most common type of benign breast conditions and occur most often during the reproductive years. Fibrocystic disease is often associated with cyclic mastalgia, possibly related to a pronounced hormonal response. Caffeine intake can increase the pain associated with fibrocystic breast changes, so recommending that she decrease her caffeine intake may be helpful.
Even though the mass decreased in size after aspiration, the bloody discharge obtained obligates an excisional biopsy be performed to rule out breast cancer. If clear discharge is obtained on aspiration and the mass resolves, reexamination in two months is appropriate to check that the cyst has not recurred.
Puerperal mastitis refers to mastitis occurring during pregnancy and lactation.
Most postpartum mastitis is caused by staphylococcus aureus, so a penicillin-type drug is the first line of treatment. Dicloxacillin/Keflex(Cefalexin) is used due to the large prevalence of penicillin resistant staphylococci. Erythromycin may be used in penicillin allergic patients.
A specimen obtained on fine-needle aspiration (FNA) is examined both histologically and cytologically. An excisional biopsy should be performed when the results are negative, due to the possibility of a false-negative result.
The most recent consensus guidelines (ASCCP-2013) state that management of LSIL is initial colposcopic examination (unless the woman is pregnant, postmenopausal or an adolescent). An excisional procedure, such as cold knife biopsy or LEEP, is not warranted without a tissue diagnosis of dysplasia.
Endometrial biopsy is typically an office procedure which does not cause extreme discomfort for the patient. It results in information necessary to tailor the patient’s care, such as presence of endometritis, endometrial polyps or endometrial carcinoma. In a patient with significant risk factors for endometrial carcinoma, this should be done prior to a hysterectomy or ablation, if at all possible. A hysterectomy or endometrial ablation would be incorrect, as further workup is needed prior to taking the patient for one of these procedures. In addition, this patient potentially has a treatable condition, such as endometritis, an endometrial polyp, endometrial hyperplasia or an enlarging submucosal fibroid, which could all be treated with either medical therapy or a less radical procedure.
Complications from a LEEP include infection, bleeding, cervical stenosis, persistent disease, and possibly risk for preterm delivery
The patient does not require treatment at this time. She requires follow up Pap smear in one year. Excisional or ablative procedures are not indicated for LSIL. Indications for cold knife conization (CKC) include: positive endocervical curettage; HSIL lesion too large for LEEP; patient not tolerant of examination in office; lesion extending into the endocervical canal beyond vision; or to rule out invasive cancer (classify the depth of invasion if biopsy shows invasion).
A hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment for a patient with pelvic pain due to endometriosis. In 60% of cases, when a patient with endometriosis undergoes a simple hysterectomy without bilateral salpingo-oophorectomy for pelvic pain, re-operation for continued pain will be necessary. Even if the patient requires hormone replacement therapy postoperatively, her pain is unlikely to return. A laparoscopy is indicated in the workup of pelvic pain in order to determine the etiology of the pain. If endometriosis is noted, it may be excised, fulgurated or burned by laser. This may offer some relief of the patient’s pain; however, relief is usually temporary in a pre-menopausal female. An endometrial ablation is an acceptable treatment for menorrhagia and will likely not be helpful in this patient.
A pelvic ultrasound would be the best way to begin a workup for an incidental finding of an adnexal mass.
Asherman's syndrome (AS) or Fritsch syndrome, is a condition characterized by adhesions and/or fibrosis of the endometrium particularly but can also affect the myometrium. It is often associated with dilation and curettage of the intrauterine cavity
The normal and predictable sequence of sexual maturation proceeds with (thelarche) breast budding, then adrenarche (hair growth), a growth spurt and then menarche. Menarche average around 12 yo (Normal age for menarche is between nine and 17.)
Kallmann syndrome is characterized by olfactory tract hypoplasia and the arcuate nucleus does not secrete GnRH. Therefore, these females have no sense of smell and do not develop secondary sexual characteristics. Treatment is pulsatile GnRH therapy.
McCune AlBright: Cafe au lait spots, Early puberty(premature menses before breast and pubic hair development), Abnormal Bones (Fibrous Dysplasia)
True precocious puberty is manifested by premature secretion of GnRH hormone in a pulsatile manner. Treatment would include GnRH agonist to suppress pituitary production of follicular-stimulating hormone and luteinizing hormone.
Congenital adrenal hyperplasia of the 21-hydroxylase type results in the adrenal being unable to produce adequate cortisol as a result of a partial block in the conversion of 17-hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens. This leads to precocious adrenarche. Treatment includes steroid replacement. Idiopathic isosexual precocious puberty is GnRH dependent and leads to an appropriate (although early) order of pubertal events.
Renal anomalies occur in 25-35% of females with Mullerian agenesis. The uterus and cervix are absent, but the ovaries function normally and, therefore, secondary sexual characteristics are present. You would expect the karyotype in this patient to be 46,XX and testosterone levels in the female range.
Lower genital tract malformations occur in 1 in 10,000 females and are most commonly an imperforate hymen where the genital plate canalization is incomplete. Amenorrhea and abdominal pain are also associated with isolated atresia of the vagina or cervix. The menstrual blood will collect in the vagina and uterus causing pain. Treatment involves surgical correction.
Anorexia nervosa or significant weight loss may cause hypothalamic-pituitary dysfunction that can result in amenorrhea. A lack of the normal pulsatile secretion of gonadotropin releasing hormone (GnRH) leads to a decreased stimulation of the pituitary gland to produce follicle stimulating hormone (FSH) and luteinizing hormone (LH). This leads to anovulation and amenorrhea
****Amenorrhea workup ?? - ?? TSH, prolactin, FSH ****
Oral contraceptives (OCPs) are the most appropriate treatment for this patient who most likely has the diagnosis of polycystic ovarian syndrome (PCOS). The constellation of findings support this clinical diagnosis (irregular cycles, obesity, and hirsutism).
The patient’s symptom of dyspareunia is likely caused by vaginal dryness, which is associated with estrogen deficiency. (amenorrhea with premature ovarian failure)
In Mϋllerian agenesis, or Mayer-Rokitansky-Kϋster-Hauser syndrome, there is congential absence of the vagina and usually an absence of the uterus and fallopian tubes. Ovarian function is normal and all the secondary sexual characteristics of puberty occur at the appropriate time.
Asherman’s syndrome can be caused by curettage or endometritis. The intrauterine synechiae or adhesions result from trauma to the basal layer of the endometrium, which causes amenorrhea.
Because of the chronic unopposed estrogen exposure that accompanies women with PCOS, these individuals carry a higher risk of developing endometrial hyperplasia and cancer. PCOS is considered to increase the risk of ovarian cancer.
This patient most likely has idiopathic hirsutism. Oral contraceptives are actually used for the treatment of hirsutism because they establish regular menses and lower ovarian androgen production. Additionally, they cause an increase in SHBG (sex hormone binding globulin) which allows more testosterone to be bound and unavailable at the hair follicle.
Acanthosis nigricans is associated with elevated androgen levels and hyperinsulinemia.
Postpartum telogen effluvium (hair loss) affects 40-50% of women postpartum. High estrogen levels in pregnancy increase the synchrony of hair growth. Therefore, hair grows in the same phase and is shed at the same time. Occasionally, this can result in significant postpartum hair loss at 1 to 5 months postpartum with 3 months after delivery being most common time. In the non-pregnant state, asynchronous hair growth occurs such that a portion of hair is in one of the three hair growth cycles at all times
The most likely diagnosis in this patient is a testosterone-secreting ovarian tumor. Sertoli-Leydig cell tumors are commonly diagnosed in women between the ages of 20-40, and are most often unilateral. Rapid onset of hirsutism and virilizing signs are hallmarks of this disease, and include many of the findings in this patient including acne, hirsutism, amenorrhea, clitoral hypertrophy, and deepening of the voice. Abnormal laboratory findings include suppression of FSH and LH, marked elevation of testosterone, and presence of an ovarian mass. The constellation of findings is most consistent with a testosterone-secreting tumor, and a pelvic ultrasound will confirm the presence of an ovarian mass
The likely cause of this patient’s sudden onset of symptom is an increase in androgens due to a tumor. Hirsutism is often the result of a benign condition, however, may be a sign of significant disease if sudden in onset and coupled with virilization. Virilization in the female may be manifested by frontal hair thinning, oily skin or acne, deepening of the voice, clitoral enlargement, menstrual irregularities, and increased muscle strength. Possible causes of virilization include PCOS, hypothyroidism, androgen producing tumors (ovarian, adrenal, or pituitary), and anabolic steroid use. A rare cause may be late onset congenital adrenal hyperplasia.
Hyperthecosis is a more severe form of polycystic ovarian syndrome (PCOS). It is associated with virilization due to the high androstenedione production and testosterone levels. In addition to temporal balding, other signs of virilization include clitoral enlargement and deepening of the voice. Hyperthecosis is more difficult to treat with oral contraceptive therapy. It is also more challenging to achieve successful ovulation induction.
Spironolactone, an aldosterone antagonist diuretic, can also be used in addition to the oral contraceptives for hirsutism. Danazol is primarily used for the treatment of endometriosis and may actually worsen hirsutism and acne
Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice.
Intermenstrual bleeding is frequently caused by structural abnormalities of the endometrial cavity, such as myomas, polyps or malignancy. An ultrasound would be helpful as the next step in diagnosis. Although an HSG might reveal structural abnormalities, it is too invasive as the next step.
This patient likely has polycystic ovarian syndrome (PCOS). PCOS patients have testosterone levels at the upper limits of normal or slightly increased. Free testosterone (biologically active) is elevated often because sex hormone binding globulin is decreased by elevated androgens. LH is increased in response to increased circulating estrogens fed by an elevation of ovarian androgen production. Insulin resistance and chronic anovulation are hallmarks of PCOS. Prolactin levels may be elevated in amenorrhea but are not elevated in patients with PCOS.
Mid-cycle bleeding at the time of ovulation is due to the drop in estrogen.
Dysmenorrhea or painful menstrual cramps is often incapacitating. Oral contraceptives will not only relieve primary dysmenorrhea, but also provide more reliable contraception. Copper IUD’s have the potential to cause heavier and more painful periods.
The US Preventive Services Task Force recommends chlamydia and gonorrhea screening for all sexually active patients, age 25 and younger.
Classically, endometriosis looks like dark brown “powder burn” spots within the pelvis. expect to see endometrial glands/stroma with hemosiderin-laden macrophages.
Hyperplastic overgrowth of endometrial glands/stroma is consistent with endometrial polyps.
This is a typical presentation of adenomyosis (presence of endometrial glands and supporting tissues in the muscle of the uterus). Boggy enlarged uterus. The gland tissue grows during the menstrual cycle and, at menses, tries to slough, but cannot escape the uterine muscle and flow out of the cervix as part of normal menses.
******Well-circumscribed, non-encapsulated myometrium confirms the diagnosis of fibroids. Hyperplastic overgrowth of endometrial glands/stroma is consistent with endometrial polyps. Decidual effect on the endometrium are seen during pregnancy. Invasion of endometrial glands into the myometrium is seen with adenomyosis.******