– History –
- CC:
- Site: where? Unilateral\bilateral? Radiates anywhere else?
- Onset: first time? When? Sudden\gradual? Continuous\intermittent? What were you doing?
- Duration: how long does it last?
- Timing: specific time of the day\night? Cyclic? How frequent?
- Character: dull, sharp, stabbing, burning, pressure-like?
- Aggravating\relieving factors: menses, defecation, urination, intercourse, position, painkillers?
- Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, fatigue, weight loss, chills, night sweats, appetite?
- Gyn: vaginal discharge, painful menstruation, PMS, post-coital pain\bleed?
- Urine: dysuria, hematuria, urinary incontinence\retention?
- GI: N\V, diarrhea\constipation, pain with defecation, blood in stool?
- Obstetric Hx:
- Gravida? Para? Abortions? Living?
- If prev: mode of delivery? Fetal\maternal complications?
- Gravida? Para? Abortions? Living?
- Gynecological Hx:
- Menstrual Hx: age of menarche? Regular\heavy\painful periods? Intermenstrual bleeding?
- Contraception use, IUCD?
- Gynecological procedures, IVF\induction of ovulation?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM\GDM, DLP)
- Malignancy, infections
- Gyn (STDs, PID, fibroids, endometriosis)
- Medications: abx, steroids, anticoagulants, folate, herbal
- Surgery, hospitalization, trauma
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, sexual activity, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx
- Diet, exercise
– Physical Exam –
- WIPE, blah blah, chaperone
- Vital signs: pulse, BP, temperature
- General inspection: weight, distress, pallor
- Abdominal exam: inspection, palpation, percussion, auscultation
- Vaginal exam:
- Inspect: ulcers, scars, urethral\vaginal discharge, swellings
- Palpate: Bartholin’s gland (5-7 O’clock of labia minora)
- Speculum exam:
- Inspect: erosions, erythema, discharge\bleeding, polyps
- Obtain a pap smear
- Bimanual exam:
- Vaginal walls: tone, moisture, temperature -> “normal tone, moist, warm”
- Cervix: character, mobility, texture, tenderness -> “firm, mobile, smooth, non-tender”
- Uterus (by placing the other hand on the lower abdomen): size, position, mobility, tenderness -> “normal size, anteverted, mobile, non-tender”
- Adnexa (ovaries + oviducts): enlargement, tenderness
- Remove fingers to check of discharge or blood
- To complete -> rectovaginal exam
– Differential Diagnosis –
Gynecological | Non-gynecological |
– PID
– Endometriosis – Ectopic pregnancy – Ovarian torsion\cyst rupture |
– Cystitis
– Appendicitis – Diverticulitis – IBD\IBS |
– Investigations –
- Pregnancy test: urine\serum B-hCG
- CBC
- U\A, urine culture
- Vaginal wet mount
- NAAT (chlamydia, gonorrhea)
- Imaging: transvaginal US, CT\MRI
– Endometriosis Overview –
Physical signs:
- Tender nodularity of uterosacral ligament
- Tender cul-de-sac on rectovaginal exam
- Retroverted uterus
- Firm, fixed adnexal mass (endometrioma)
Definitive diagnosis via laparoscopy:
- Direct visualization of typical lesions:
- Mulberry spots (most common): brownish-black hemosiderin deposits
- “Powder-burn” lesions on peritoneal surfaces (old hemorrhage nodules)
- White lesions: fibromuscular scarring
- “Chocolate cyst” of the ovaries: endometrioma
- Biopsy and histology -> 2 or more of:
- Endometrial epithelium\glands\stroma, hemosiderin-laden macrophages
Treatment:
- Medical:
- NSAIDs
- 1st line:
- OCP (estrogen-progestin)
- IM medroxyprogestrone
- Mirena IUS
- 2nd line:
- GnRH agonist (leuprolide)
- Use for < 6 mo due to bone loss. But can be used > 12 mo w\ add-back progestin or estrogen
- SE: hot flashes, vaginal dryness, reduced libido
- Danazol (weak androgen)
- SE: wt gain, fluid retention, acne, hirsutism, voice change
- GnRH agonist (leuprolide)
- Surgical:
- Conservative (preserves fertility): laparoscopy -> adhesion lysis, ovarian cystectomy of endometrioma
- Best time to get pregnant? Immediately after conservative surgery
- Definitive (fertility not desired): bilateral salpino-oophorectomy ± hysterectomy
- Conservative (preserves fertility): laparoscopy -> adhesion lysis, ovarian cystectomy of endometrioma