Term
| what characterizes acute pelvic pain? |
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Definition
| acute pelvic pain usually has usually sudden onset, is mostly localized, has an associated event, lasts 2-3 months, can be treated conservatively, and is reproducible. |
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Term
| what characterizes chronic pelvic pain? |
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Definition
| chronic pelvic pain usually lasts 6+ months (duration may be arbitrary), lacks empirical validation, behavioral/emotional/biomechanical changes occur, and a combination of medical/sx/psychological care may be necessary. |
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Term
| what is sub acute pelvic pain? |
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Definition
| not acute or chronic, lasts between 2-6 months, mostly localized and intermittent and can be reproducible (even if etiology is unknown). |
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Term
| what structures are often involved w/female pelvic pain? |
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Definition
| uterus, fallopian tube, ovary and surrounding peritoneum |
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Term
| what are pelvic pain "imitators"? |
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Definition
| GI disorders, musculoskeletal abnormalities, CNS/PNS disease, vulvar vestibulitis/vulvodynia, and ureteral/bladder/urethral syndromes. |
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Term
| what GI disorders can cause pelvic pain? |
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Definition
| IBS, lactose intolerance, small bowel bacterial overgrowth, IBD, diverticular disease, levator ani syndrome, and endometriosis affecting the bowel |
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Term
| what is the connection between IBS and dysmenorrhea? |
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Definition
| 61% of women w/dysmenorrhea have had some kind of functional bowel disorder (FBD), while only 20% w/dysmenorrhea had FBD. women w/IBS report increased symptoms w/menses. 50% of pts referred to gyn docs for pelvic pain have IBS (not good). |
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Term
| does IBD have a relationship with menses? |
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Definition
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Term
| can endometriosis affect the bowel? |
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Definition
| yes - pts w/endometriosis report painful bowel movement and in severe cases, endometriosis can cause bowel obstruction |
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Term
| what musculoskeletal abnormalities can be associated with pelvic pain? |
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Definition
| pelvic floor abnormalities, thoracolumbar syndrome, iliopectineal bursitis, fibromyalgia, myofascial pain syndromes, degenerative joint disease of the hip, pubic separations/strains, sacroiliac sprains/strains/displacements, diastasis recti (midline raphe of muscle is separated), and coccydynia |
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Term
| what is the typical pelvic pain posture? |
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Definition
| anteriorly tilted pelvis, increased lumbar lordosis, hyperextended knees, and center of gravity displaced anteriorly |
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Term
| what is the function of the pelvic floor? |
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Definition
| the pelvic floor supports the pelvic viscera by counteracting gravitational and intraabdominal forces |
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Term
| what are symptoms of pelvic floor dysfunction (PFD)? what are they due to? |
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Definition
| decreased strength, hypo/hypertonicity, and the levator ani (iliococcygeus/pubococcygeus) may also be involved. disuse and denervation appear to be the major factors in development of PFD - sedentary western lifestyles promoted prolonged sitting which stretches pelvic floor muscles (leads to hypotonicity), while squatting does not. |
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Term
| what is the path of the pudendal nerve? |
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Definition
| the pudendal nerve comes off S2,3,4 and goes through alcock's canal, and then innervates the pelvic floor muscles/sphincters. |
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Term
| what peripheral nerves can get entrapped in the pelvis? |
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Definition
| ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, epigastric |
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Term
| what is the most common cause of peripheral neuropathy? |
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Definition
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Term
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Definition
| areas of nerve irritability where they penetrate muscle or are stuck in fascia which can mimic visceral pain disorders such as: heartburn, appendicitis, PID, ovarian cysts, dyspareunia, cholecystitis, bladder abnormalities, hernia, and peptic ulcer. |
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Term
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Definition
| a form of non-articular rheumatism which shares characteristics w/myofascial pain syndrome and pts will often complain of coccygeal/pelvic pain, constipation, and diarrhea. global anxiety is also common to develop in these pts. |
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Term
| what urinary tract abnormalities can cause pelvic pain? |
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Definition
| post coital UTIs, urethritis (acute/chronic), urethral syndrome, urethral diverticulum, and interstitial cystitis |
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Term
| what are the irritative voiding syndromes? |
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Definition
| dysuria, frequency, suprapubic pain, and urgency |
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Term
| what is interstitial cystitis? |
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Definition
| a disease process usually found after numerous sx, workups w/CTs, etc that is characterized by *urgency/frequency/pelvic pain*. it is a dx of exclusion and diagnosed with a positive potassium sensitivity test and cystoscopy (petechiae may be seen along the bladder mucosa). this more often affects women. |
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Term
| what are symptoms of urethral syndrome? |
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Definition
| dysuria, frequency, urgency, suprapubic discomfort, voiding discomfort, and stranguria (painful, slow urination due to bladder/urethral spasms). often times there is no underlying pathology. |
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Term
| who does urethral syndrome occur in? |
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Definition
| women who have hypoestrogenism. also spasms from inflammatory problems/HSV. |
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Term
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Definition
| ducts located at 4 & 8 o'clock outside the urethra which can get obstructed. |
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Term
| what are the vulvar pain syndromes? |
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Definition
| cyclic vulvovaginal candidiasis, vulvar vestibulitis, and essential vulvodynia. |
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Term
| what is cyclic vulvovaginal candidiasis? |
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Definition
| this is recurrent (most women respond to typical tx) and can result in pelvic pain/discomfort |
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Term
| what is vulvar vestibulitis? |
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Definition
| hyperesthesia of the vulva (limited to the vestibule - edge marked by hart's line), which occurs mostly in *younger women and erythema typically co-presents. these pts have pain w/sex, inserting a tampon, wearing tight jeans, riding horses, and riding a bicycle |
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Term
| what is essential vulvodynia? |
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Definition
| this is usually seen in *more mature women (perimenopausal), and its hallmarks include diffuse burning/itching/stinging. it is chronic and may be exacerbated by some kind of trauma (only a symptom - not a disease). dyspareunia is not a major problem. vulvar dermatoses (lichen sclerosis/planus and simplex chonicus) may initiated these symptoms, but once treated the vulvodynia may persist. |
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Term
| what is dysesthetic vulvodynia? |
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Definition
| end stage for no cause determined pudendal neuralgia |
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Term
| what is IBS treated with? |
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Definition
| medical management is directed toward the most predominant symptom (diarrhea or constipation). tricyclic antidepressants can help with spasms, *probiotics, psychological and OMT can also help. |
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Term
| what is IBD treated with? |
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Definition
| sulfas, steroids, sometimes segmental resection |
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Term
| how is diverticular disease treated? |
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Definition
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Term
| how can pelvic floor dysfunction be treated? |
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Definition
| education (muscular relaxation/contraction), biofeedback (EMG/skin electrodes), manual soft tissue massage (OMT, friction, thiels massage), trigger point injections (lidocaine, cortisone), magic spray'n'stretch, functional electrical stimulation (helps pts determine what muscles they need to work on relaxing/contracting), US, heat/ice, medication, and tricyclic antidepressants (improve sleep disturbances) |
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Term
| what is one effective way of preventing pelvic pain? |
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Definition
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Term
| how are myofascial pain syndromes treated? |
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Definition
| same as pelvic floor dysfunction (cortisone, marcaine, vapocoolant, OMT, functional electrical stimulation, and US) |
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Term
| how is urethral syndrome treated? |
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Definition
| if antibx don't work - can try urethral calibration/dilation, topical estrogen (in menopausal women), DMSO, anti-inflammatories, and muscle relaxants. |
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Term
| can interstitial cystitis be cured? |
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Definition
| no, therapy is only palliative and includes: amitriptyline, gabapentin, intravesical cocktails, electrical stimulation/nerve blocks, botox, and interstim (wires implanted in S2/S3 foramina which pt can activate to relax the bladder) |
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Term
| what is one tx for vulvar vestibulitis? |
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Definition
| vestibulectomy (includes hymenal ring out to labia) |
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Term
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Definition
| a painful chronic disease where endometrial tissue (glands+stroma) grow outside the endometrium and proliferate during the secretory phase of the menstrual cycle. it is a benign but progressive disorder and usually starts in the 3rd-4th decade of life. remission is the goal of tx. |
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Term
| what structures does endometriosis involve? what can happen to them? |
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Definition
| the ovaries, fallopian tubes, ureters, peritoneum surrounding the pelvis, bladder, and bowel. more rarely: the lungs, C-section scars, appendix/appendectomy scars, episiotomy, cervix and vaginal cuff (in hysterectomy pts). any of these structures can develop peritoneal implants, fibrosis, adhesions, and formation of endometriomas |
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Term
| what do women w/endometriosis report more of? |
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Definition
| emotional distress, dysmenorrhea, infertility, emotional distress, depression, and dyspareunia |
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Term
| what is the pathogenesis of endometriosis? |
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Definition
| endometrial tissue implants on extra-endometrial tissue. when the menstrual cycle goes from proliferative to the luteal phase, these glands swell and increase blood supply = bleeding and eventually fibrosis/endometrioma formation (enveloped glandular tissue). |
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Term
| where is the most common place for endometriosis to develop? |
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Definition
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Term
| what are the theories for endometriosis pathogenesis? |
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Definition
| retrograde menstruation (menses efflux out of fallopian tubes -> peritoneum), metaplasia, embryonic rests of mullerian tissue (genetic), vascular/lymphatic transport, and immune dysfunction |
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Term
| what factors may increase propensity for endometriosis? |
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Definition
| cell invasiveness, immune system dysfunction, endocrine dysfunction, and higher numbers of endometrial cells reaching the peritoneal cavity. |
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Term
| what signs/symptoms are associated with endometriosis? |
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Definition
| dysmenorrhea (muscles and hormones are not in sync), dyspareunia (due to scarring on uterosacral ligaments), and infertility (scarring in fallopian tubes). pain and discomfort is determined by the areas of involvement. |
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Term
| when are symptoms the most severe w/endometriosis? |
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Definition
| endometriosis symptoms tend to be most severe a week prior to and during the menstrual cycle (improve after secretory phase and when menstruation occurs). some start at ovulation. severity of symptoms does not always correlate w/the extent of disease. |
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Term
| what should be focused on in dx/tx of endometriosis? |
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Definition
| need to discern/delineate goals, such as immediate fertility. focus attention on menstrual cycle, intercourse, and other activities which increase/affect pain. |
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Term
| are staging and pain due to endometriosis related? |
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Definition
| no - there is an inverse relationship between staging and pain. |
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Term
| what does pain due to endometriosis depend on? |
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Definition
| location, depth of invasion, inflammation, and whether there is stretching/scarring of tissue |
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Term
| what are the types of endometriosis? |
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Definition
| active (clear or red) and inactive (dark/gunpowder) |
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Term
| what is medical management of endometriosis? |
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Definition
| NSAIDs, OCPs (suppress ovulation), progestins (depo provera), and GnRH agonists |
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Term
| what is surgical management of endometriosis? |
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Definition
| consider preop US to ID endometriosis, operate in proliferative phase/suppress ovaries, administer bowel prep (may require bowel resection), acquire consent for possible laparotomy (if adhesions), ID all anatomy (check ureters, bowel, vessels, *diaphragm, *appendix, bladder, *cul-de-sac, *uterosacral ligaments), have a plan on method of tissue removal (cauterize/excise/ablate), and attempt adhesion prevention |
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Term
| what is it called if diffuse pelvic endometriosis causes ovarian engorgement w/blood? |
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Definition
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Term
| how are superficial endometriotic lesions treated w/ablation? deep lesions? |
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Definition
| superficial: destroy w/laser/elctrosx/thermal energy. deep: outline w/laser, pull up and undercut w/laser. |
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Term
| what are likely areas of complications w/endometriosis? |
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Definition
| bowel, ureters, vascular (superficial/deep epigastrics, iliac and great vessels), and bladder. (have a back up plan, b/c mistakes are going to occur) |
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Term
| what is laparoscopic uterine suspension? |
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Definition
| if the uterus is folded backwards into the cul-de-sac (retroverted uterus), endometriosis is more likely to cause pain, so this procedure lifts the uterus to prevent endometriosis/pain in that area by shortening the round ligaments via plication. |
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Term
| what characterizes results with diagnostic sx for endometriosis? |
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Definition
| a certain number of people have improvement, but pain quickly returns |
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Term
| what characterizes results with resection/ablation for endometriosis? |
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Definition
| about 50% are still improved 1 yr later |
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Term
| what stage of endometriosis responds best to sx? |
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Definition
| stage III (harder to see lesions in earlier stages) |
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Term
| what are reasons for pain recurrence after sx for endometriosis? |
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Definition
| depth of residual disease and microscopic/atypical lesions |
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Term
| what *postop methods can enhance outcome of endometriosis sx? |
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Definition
| OCPs/progestins, danazol (synthetic testosterone), and lupron - a GnRH agonist (MOA: negative feedback). sx only partial tx, so postop tx is recommended unless these pts want to get pregnant immediately. |
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Term
| why does postop endometriosis tx involve lupron (leuprolide) more and more? how long is this tx? |
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Definition
| rather than hysterectomy or oopherectomy, GnRH agonists can suppress estrogen production better via negative feedback. tx is 3-6 mos (longer than which, bone loss is a concern). |
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Term
| is laparotomy in endometrial sx a failure? |
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Definition
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Term
| what characterizes sx for endometriosis? |
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Definition
| sx is cytoreductive - not curative |
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Term
| what are some examples of uterine adhesions, another source of pelvic pain? |
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Definition
| omental adhesions/C-section scarring |
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Term
| what characterizes uterine fibroids as a source of pelvic pain? |
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Definition
| these are common (20-30% of women) and can cause inflammation/adhesion. they may be intramural/submucous/subserosal. |
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Term
| what characterizes ovarian torsion as a source of pelvic pain? |
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Definition
| peristalsis of the bowel can twist the ovaries - particularly w/PCOS |
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Term
| what can omental adhesions cause in terms of pelvic pain? |
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Definition
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