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Gynecology Case Correlates

Barrera, Diana Jane


Atanga, Pascal
E.E.
38 year-old housewife

Chief Complaint

Increased amount and duration of


menses with menstrual pains
History of Present Illness
27 months PTA • Increased in amount and duration of menses

– from 3 pads moderately soaked to 5 pads


fully-soaked /day
– from 3 days to 7 days

• Accompanied by menstrual pain, grade 8/10,


relieved by Mefenamic acid, 250 mg

• NO consultation.
History of Present Illness
22 months PTA• There was persistence of above symptoms,
not relieved by Mefenamic acid.

• Consulted a gynecologist (Dr. Jimenez?) at


Westmin Hospital (Mindoro)
– Abdominal and pelvic exam: unremarkable
– TVS: “makapal na matres”
– Advised hysterectomy; Patient did not
consent; lost to follow-up

Since then, self-medicated with Naproxen


Sodium( Flanax) 550mg/tab which afforded
relief of dysmenorrhea.
History of Present Illness
2 weeks PTA • Persistence of above symptoms
– Further increased in amount of menses
• From 5 pads fully soaked (regular napkin) to 5 pads fully-
soaked (maternity napkins)

• Progressive dysmenorrhea, grade 10/10,


not relieved by Naproxen Sodium( Flanax) 550mg/tab
• Consulted at OPD, USTH
– Abdominal/ pelvic exam: suprapubic tenderness on
palpation, uterus enlarged to 2 1/2 m size
– Laboratory work-up: CBC
– Transvaginal Ultrasound was done.
Results showed: Ultrasound
• Patient was admitted for hysterectomy.

Admission:

Admission
Review of Systems
• General: No significant weight changes. No fatigue or body
weakness.
• Skin: No rashes or pigmentation. No pallor, generalized skin
scaliness, excessive sweating, or pruritus. No easy bruising.
• HEENT: No history of head injury. No blurring of vision. No eye
redness or lacrimation. No hearing loss or tinnitus. No bleeding gums
or sore throat.
• Neck: No lumps, goiter, pain. No swollen glands.
• Respiratory: No cough. No hemoptysis. No wheezing.
• Cardiovascular: No hypertension.
• Gastrointestinal: No change of appetite. No occasional vomiting. No
hematemesis, dysphagia or indigestion. Regular bowel movements.
No diarrhea or bleeding. No pain, jaundice, gallbladder or liver
problems.
Review of Systems
• Urinary: No oliguria. No frequency or urinary incontinence. No
recent flank pain.
• Peripheral Vascular: No history of phlebitis or leg pain.
• Musculoskeletal: No muscle pain. No joint stiffness and pain.
• Psychiatric: No history of depression or treatment for psychiatric
disorders.
• Neurologic: No seizures, fainting, motor or sensory loss. Has a
good memory.
• Hematologic: No bleeding gums. No bruises. No history of anemia.
• Endocrine: No excessive sweating, heat or cold intolerance. No
polyuria, polydipsia or polyphagia;
Personal ,Family and Social
History
• Patient:
Religion: Born Again
Occupation: fish vendor, house-wife
– non-smoker
– non-alcoholic drinker,
– denied illicit drug use

Father :
stroke, heart attack, and hypertension at 67.
Past Medical History
• Childhood Illnesses:
– Asthma; no other forms of allergy.

• Adult Illnesses:
– Medical: UTI, 1996, treated. No bleeding problems.

• Psychiatric: None
Obstetric/Gynecologic History
Menstruation history

• Menarche: 14 years old,


• Interval: 28-29 days
• Duration: 3 days
• Amount : 3 pads/day, fully-soaked
• Symptoms: no dysmenorrheal symptoms.

• LMP: February 12-18, 2009


• PMP: January 10-14, 2009

Sexual History
• first sexual contact: at 18
• single partner, fisherman
• No post coital bleeding or dyspareunia
Obstetric/Gynecologic History
G5P4 (4016)
• G1, January 1992, girl, 7lbs. term NSD, uncomplicated home delivery by TBA.

• G2, August 1992, aborted at 3 months, dilatation and curettage was done (St.
Joseph)

• G3, 1994, girl ,10 lbs. term,NSD, uncomplicated home delivery by TBA.

• G4, 1996,
– caesarian section, triplets, 5.4, 5.7, 6.6 lbs. term
– At St. Joseph’s Hospital..
– Pregnancy Complications: UTI, unknown medication, completely treated.
– Gestational hypertension, unknown medication, well-managed.

• G5, 1999, boy, 6.0 lbs. term, NSD, uncomplicated home delivery by TBA
Family planning: none
Physical examination
• General: conscious, coherent, ambulatory, not in cardio-respiratory distress
• Vital Signs: Height: 163 cm Weight: 63 kg BMI: 24
• BP: 110 60 supine, PR 80/min RR: 21 /min T-37.2 C
• Skin: Warm and smooth, no jaundice, no active dermatoses. Nails without clubbing or cyanosis
• HEENT: Pink palpebral conjunctiva, anicteric sclera
• No retained cerumen, no tragal tenderness, no hyperemic external auditory canal
• No nasal discharge, nasal septum midline
• Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged.
• Neck: Supple neck, no palpable cervical lymphadenopathy, thyroid not enlarged. Neck veins not distended.
Physical examination
• Thorax and Lungs: Symmetric chest, no chest wall deformities, no retractions, no
lagging, no tenderness, no palpable masses, equal tactile vocal fremiti, resonant on
percussion, vesicular breath sounds, no crackles, no wheezes, no rhonchi.
• Cardiovascular: JVP 3 cm at 30 degrees. CAP, rapid upstroke, gradual
downstroke, Negative for carotid bruit. Adynamic precordium, AB 5th LICS AAL, no
lifts, heaves or thrills, S1>S2 at apex, S2>S1 at the base. No murmurs.

• Breast: symmetrical, no skin lesions, no dimpling; non-tender on palpation, no


palpable masses or lumps. No discharge.

• Abdominal: Flabby abdomen, with striae of pregnancy and vertical infraumbilical


laparotomy scar; normoactive bowel sounds; with tenderness on low abdominal
area on deep palpation; liver and spleen not palpable, no palpable intra-abdominal
masses. tympanitic on percussion
Physical examination
Pelvic Exam:
• On External inspection:
• pubic hair triangular distribution;
• no gross lesions of external genitalia
• On Speculum Examination:
• the cervix is smooth, long, firm and
closed with minimal whitish mucoid
discharge.
• On internal Examination:
• Uterus is symmetrically enlarged to
about 2 ½ month size,midline, movable,
and anteverted, soft with slight
tenderness on palpation.
• No adnexal masses
• No nodularities in cul de sac.
Physical examination
Pelvic Exam:
• On External inspection:
• pubic hair triangular distribution;
• no gross lesions of external genitalia
• On Speculum Examination:
• the cervix is smooth, long, firm and
closed with minimal whitish mucoid
discharge.
• On internal Examination:
• Uterus is symmetrically enlarged to
about 2 ½ month size,midline, movable,
and anteverted, soft with slight
tenderness on palpation.
• No adnexal masses
• No nodularities in cul de sac.
Salient Features
• 38 years old, G5P4 (4016) with • Uterus symmetrically enlarged to
multiple gestation 21/2 month size, midline and
movable, soft, tender on palpation
• Menorrhagia
• Tenderness on lower abdominal
• Progressive dysmenorrhea area in deep palpation.

• No drug use especially hormones, • No signs and symptoms of


OCP’s anemia

• Caesarian section
• Dilatation and curettage

• No GIT and urinary symptoms

• No bleeding tendency/disorders
Differential Diagnosis
Secondary Dysmenorrhea with
Menorrhagia
Clinical Condition: ADENOMYOSIS ENDOMETRIOSIS LEIOMYOMA
Age of onset •Reproductive age group •Reproductive age group •Reproductive age group
•30 and 50 •Earlier, 20-40

table
•Median age 40 years

Characteristic of pain •Cyclic •Cyclic •Mostly asymptomatic


•usually premenstrual and •usually premenstrual and menstrual
menstrual

Signs •Uterus is diffusely enlarged, •Uterus not enlarged •Enlargement of uterus is


•<14 cm in size, •Retro-verted uterus with asymmetric, pelvic mass
•Soft and tender, at the time of •tender nodules in the uterosacral •May occur singly but often are
menses. region or thickening of the cul-de- multiple.
•Mobility not restricted, sac
•No associated adnexal pathology •No rebound tenderness Adhesions
•Direct tenderness are common

Symptoms •Excessively heavy or prolonged •Abnormal bleeding tends to be •Abnormal bleeding, pelvic pressure
menstrual bleeding, premenstrual spotting •BUT
•dysmenorrhea •dysmenorrhea •Usually asymtomatic
•Associated GI symptoms

Risk Factors •Multiparity •Never given birth •Obese women


•Cesarean sections •Endometriosis in mother •Diet
•D and C •menstrual cycles < 27 days •exercise
•tubal ligations
• bleeding > 8 days
•normal passage of menses.
•the pelvis by previous
•Being white or Asian
Impression
Given a patient who is
of the reproductive age group …
with regular menstrual cycle…
presenting with menorrhagia and secondary dysmenorrhea…
and a symmetrically enlarged uterus…

ADENOMYOSIS
ADENOMYOSIS
• a condition where endometrial glands and supporting
tissues are found in the muscular wall of the uterus
Adenomyosis
• The reported prevalence of adenomyosis in the literature
ranges from 20% to 30%
• This condition typically affects women in the fourth and fifth
decades of life.
• Menorrhagia and dysmenorrhea have been reported to
occur in 40% to 50% and 15% to 30% of patients,
respectively,
• approximately one-third being asymptomatic.
• Metrorrhagia, nonmenstrual pelvic pain, and dyspareunia
may also be present.

Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North
Am 1989;16:221–235.
Adenomyosis
• The diagnosis is made histopathologically
• Endometrial stroma and glands are observed at least 2 to 3 mm below
the endometrial surface within the myometrium.
• The cause of the pain associated with this condition is not known.
• Ultrasonography and hysterosalpingography are not useful in the
diagnosis of adenomyosis.
• However, magnetic resonance imaging (MRI) can be used to diagnose
adenomyosis.
• Hysterectomy has consistently been shown to be successful in treating
and controlling the symptoms associated with adenomyosis.

Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North


Am 1989;16:221–235.
ADENOMYOSIS
Incidence

- 20.6 % of the specimen studied


- total of 296 hysterectomy specimen (dysfunctional uterine bleeding)

Incidence of adenomyosis in hysterectomies. Anwar Ali. Department of Pathology, Saidu Medical


College, Swat.Pakistan J. Med. Res.Vol. 44 No.1, 2005
Risk factors ADENOMYOSIS
“Women who smoked tended to be at decreased risk of the condition: in
comparison with women who had never smoked, the risk for current smokers was
0.7 (0.3- 1.3)”
“The frequency of adenomyosis was higher in parous women: in comparison with
nulliparae, the odds ratio of the disease were 1.8 [95% confidence interval (CI) 0.9-
3.4] and 3.1 (95% CI 1.7-5.5) respectively in women reporting one and two or more
births (chi2 trend 20.71, P < 0.01).”
“ ..women reporting one or more spontaneous abortions had an odds ratio of 1.7
(95% CI 1.1-2.6) for adenomyosis, in comparison with those reporting no
spontaneous abortion.

Risk factors for adenomyosis. F Parazzini, P Vercellini, S Panazza, L Chatenoud, S


Oldani and PG Crosignani Centro Medicina della Riproduzione,Clinica Ostetrico
Ginecologica Universita di Milano, Italy.

• Others: uterine surgery


Work-ups

• CBC

• Transvaginal Ultrasound
Transvaginal Ultrasound

Why do we request ?

• confirm the cause of enlarged uterus


• location and extent of lesion
• assessment of endometrial lining
• assess the ovaries
Transvaginal Ultrasound

The subendometrial halos a


thin hypoechoic band
(arrows).

The endometrium is
uniformly echogenic
NORMAL
6-8cm 3-5 cm
7-
14m
m
Transvaginal Ultrasound
ADENOMYOSIS characteristics
• Heterogeneous myometrial echotexture
• Ill defined hypoechoic areas
• Small anechioc lakes
• Symmetrical uterine enlargement
• Indistinct endometrial-myometrial border
• Posterior wall involvement
Transvaginal Ultrasound

Brosens and co- Uterine dimensions


workers assessed
ultrasonographic details
of adenomyosis such Symmetry of myometrium
as:
Echogenicity of the
myometrium

They found that the most predictive is the ill-defined


heterogeneous echotexture within the myometrium.
BACK

pix
Work-Up Results: TVS
Cervix: 4.12 x 3.9 cm
Uterine Corpus: 8.64 x 8.85 x 8.26 cm*
Anteverted
Inhomogenous
Endometrium: 0.84 cm
Isoechoic
Ovaries
Right: 2.75 x 1 x 1.94 cm
Follicles: <10 mm
Left: 2.59 x 2.06 x 2.4 cm
Follicles < 10 mm
Other Findings: Cul-de-sac: Minimal fluid
*Coarse area noted at the anterior wall – 4.42 x4.03 cm (adenomyosis)
*Hypoechoic nodule noted at the lower anterior wall – 1.33 x 1.03 x 1.14 cm
REMARKS:
ENLARGED UTERUS WITH ADENOMYOSIS AND
INTRAMURAL MYOMA
PROLIFERATVE ENDOMETRIUM
NORMAL – SIZED OVARIES
Ultrasound Correlations
Management
• Surgical
Abdominal Hysterectomy
– Age, no desire for child-bearing anymore
– Definitive treatment

• Medical
- if young and desire for child bearing
- poor surgical risk, with co morbidities, etc
- hormones are mainstay of medical treatment
- not definitive, signs and symptoms recur upon withdrawal
Management
Problems Goals

Adenomyosis • Definitive removal of the


- Menorrhagia and lesion and relieve of
secondary dysmenorrhea symptoms

Anemia • Correction of anemia (prior


to operation)
Management

TOTAL ABDOMINAL HYSTERECTOMY


Management
PREOPERATIVE
• Informed consent
• Laboratory: CBC, BT, Blood typing and cross-matching ,RBS
• Kidney function test – urinalysis, BUN, Creatinine
• Liver Function Test - TPAG
• Chest X-ray
• ECG – cardio-pulmonary clearance
• Correct ANEMIA
• Bowel preparation (simple hysterectomy)
- Light dinner, NP0 (8 hours)
– Cleansing enema
• Prophylactic antibiotics (first gen. cephalosporin)
• IV fluids
Intraoperative
back
Management
Post-operative
• Vital signs monitoring
• IV fluids
• NPO to clear to soft diet
• Analgesics
• Prevent complications
– Pneumonia
– DVT
– Bedsores
– SSI
The diagnosis can only be proven by the
pathologists
But a good gynecologist may suspect
adenomyosis based on the clinical factors, but
the final diagnosis usually has to wait until
hysterectomy is performed
THANK YOU
BACK UP SLIDES
Work-Up Results: CBC

BACK
Work-Up Results: TVS
Cervix: 4.12 x 3.9 cm
Uterine Corpus: 8.64 x 8.85 x 8.26 cm*
Anteverted
Inhomogenous
Endometrium: 0.84 cm
Isoechoic
Ovaries
Right: 2.75 x 1 x 1.94 cm
Follicles: <10 mm
Left: 2.59 x 2.06 x 2.4 cm
Follicles < 10 mm
Other Findings: Cul-de-sac: Minimal fluid
*Coarse area noted at the anterior wall – 4.42 x4.03 cm (adenomyosis)
*Hypoechoic nodule noted at the lower anterior wall – 1.33 x 1.03 x 1.14 cm
REMARKS:
ENLARGED UTERUS WITH ADENOMYOSIS AND
INTRAMURAL MYOMA
PROLIFERATVE ENDOMETRIUM
NORMAL – SIZED OVARIES
Medical Management: Medical

• GnRH- agonists is efficient in reducing the


adenomyotic uterine size.
• GnRH-alpha treatment before laparoscopic
surgery greatly decreases surgical difficulties
and blood loss in certain cases.

Gonadotropin releasing hormone agonists in the treatment of adenomyosis.


Obstetricts and Gynecology Hospital, Shanghai Medical University, Shanghai 200011
Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6 BACK
Management: Uterine Artery Embolization

UAE procedures were performed in 23 patients with adenomyosis. After treatment the
symptoms and uterine volume of all patients were investigated.

All clinical symptoms of 23 patients relieved.


•Dysmenorrhea completely disappeared in 19 patients, significantly alleviated in 2
patients. But in other 2 recurred.
•The uterine volume shrunk significantly [(50 +/- 18)%] vs [(100 +/- 0)%].
•The blood flow within the uterine and lesions detect by color doppler flow imaging
decreased immediately after UAE.
•Low-abdominal pain and slight fever were seen after treatment and recovered within
1 - 2 weeks.

Uterine arterial embolization in the treatment of adenomyosis .Chen C, Liu P, Lu


J, Yu L, Ma B, Wang J, Liu P
Zhonghua Fu Chan Ke Za Zhi 2002 Feb.
Management: Uterine Artery Embolization

UAE is an effective and safe


method in the treatment of
adenomyosis.
BUT the recurrence rate is not yet
evaluated.