bladder, urinary incontinence, urinary frequency/urgency, bladder “splinting” to accomplish voiding
• Bowel: constipation or feeling of rectal
... [Show More] fullness or blockage, difficult defecation, stool or flatus incontinence
• Urgency: manual “splinting” of posterior vaginal wall to accomplish defecation
• Pain & Bulging: vaginal, bladder, rectum; pelvic pressure, bulging, pain, lower back pain
• Sexual: dyspareunia, decreased sensation, lubrication, arousal
▪ Tx:
• Kegel exercises
• Estrogen to improve tone and vascularity of fascial support
• Pessary
• Weight loss
• Avoidance of constipation
o Polycystic ovarian syndrome
▪ Most common cause of anovulation and ovulatory dysfunction in women.
▪ Defined as having at least two of the following three features: irregular ovulation, elevated levels of androgens
(testosterone), and the appearance of polycystic ovaries on ultrasound.
▪ Polycystic ovaries do not have to be present to diagnose PCOS, and conversely their presence alone does not establish the diagnosis.
▪ Initial identification of genes involved in steroid biosynthesis, androgen biosynthesis, and insulin receptors within the ovary indicates genetic involvement.
▪ A hyperandrogenic state is a cardinal feature in the pathogenesis of PCOS.
▪ However, glucose intolerance/insulin resistance and hyperinsulinemia often run parallel to and markedly aggravate the hyperandrogenic state, thus contributing to the severity of signs and symptoms of PCOS.
▪ Excessive androgens affect follicular growth, and insulin affects follicular decline by suppressing apoptosis and enabling follicles to persist.
▪ Weight gain tends to aggravate symptoms, whereas weight loss may ameliorate some of the endocrine and metabolic events and thus decrease symptoms.
▪ Women with PCOS tend to have increased leptin levels. Leptin influences the hypothalamic pulsatility of GnRH and consequent interaction along the entire HPO axis.
▪ In PCOS there is dysfunction in ovarian follicle development. Inappropriate gonadotropin secretion triggers the beginning of a vicious cycle that perpetuates anovulation.
▪ Typically, levels of FSH are low or below normal and LH levels and LH bioactivity are elevated. An increased frequency of GnRH pulses appears to cause increased frequency of LH pulses. Persistent LH elevation causes a increase in the levels of androgens. Androgens are converted to estrogen in peripheral tissues, and increased testosterone levels cause a significant reduction in SHBG, which in turn causes increased levels of free estradiol.
▪ Elevated estrogen levels trigger a positive-feedback response in LH and a negative-feedback response in FSH.
▪ The accumulation of follicular tissue is various stages of development allows an increased and relatively constant production of steroids in response to gonadotropin stimulation. Thus PCOS is characterized by excessive production of both androgen and estrogen.
▪ In turn, persistent anovulation causes enlarged polycystic ovaries characterized by a smooth, pearly white capsule. This characteristic appearance is caused by an increase of surface area and increased volume of up to 2.8 times,
doubling of growing and atretic follicles, thickening of the tunica by 50%, increasing cortical stromal thickening by one-third and a fivefold increase in subcortical stroma, and escalating hyperplasia.
▪ Manifestations:
• Usually appear within 2 years of puberty but may present after a variable period of normal menstrual function and possibly pregnancy.
• Symptoms are related to anovulation, hyperandrogenism, and insulin resistance and include dysfunctional bleeding or amenorrhea, hirsutism, acne, acanthosis nigricans, and infertility.
▪ Eval & Treatment:
• Diagnosis is based on evidence of androgen excess, chronic anovulation, and sonographic evidence of polycystic ovaries with at least 2 of the 3 criteria present.
• Tests for impaired glucose tolerance are recommended.
• Evidence of hyperandrogenism must be present before PCOS is diagnosed in an adolescent female.
• Goals of tx: reversing signs and symptoms of androgen excess, instituting cyclin menstruation, restoring fertility, and ameliorating any associated metabolic or endocrine, or both, disturbances.
• First line: combined oral contraceptives for management of symptoms and to establish regular menses.
• For those women with PCOS who are overweight or obese, lifestyle modifications including regular exercise and weight loss, also are considered first- line treatment.
o Testicular cancer and conditions that increase risk
▪ Highly treatable, usually curable cancer that most often develops in young and middle-aged men
▪ 90% of testicular cancers are germ cell tumors arising from the male gametes.
▪ In addition, testicular tumors can arise from specialized calls of the gonadal stroma. These tumors, which are named for their cellular origins are Leydig cell, Sertoli cell, granulosa cell, and theca cell tumors and constitute less than 10% of all testicular cancer.
▪ Risk factors: history of cryptorchidism, abnormal testicular development, human immunodeficiency virus (HIV) and AIDS, Klinefelter syndrome, and history of testicular cancer.
▪ Manifestations:
• Painless testicular enlargement is usually the first sign.
• Enlargement is usually gradual and may be accompanied by a sensation of testicular heaviness or dull ache in the lower abdomen.
• Lumbar pain may be present and usually is caused by retroperitoneal node metastasis.
• Signs of metastasis to the lungs: cough, dyspnea, hemoptysis
• Supraclavicular node involvement: dysphagia, neck swelling
• Metastasis to CNS: alterations in vision, mental status, papilledema, and seizures
o Symptoms that require evaluation for breast cancer
▪ The first sign of breast cancer is usually a painless lump. Lumps caused by breast tumors do not have any classic characteristics.
▪ Chest pain (lung metastasis)
▪ Dilated blood vessels
▪ Dimpling of the skin
▪ Edema
▪ Edema of the arm
▪ Hemorrhage
▪ Local pain
▪ Nipple/areolar eczema
▪ Nipple discharge in nonlactating woman
▪ Nipple retraction
▪ Pitting of the skin (peaud’orange)
▪ Reddened skin, local tenderness, and warmth
▪ Skin retraction
▪ Ulceration
o Signs of premenstrual dysphoric disorder
▪ >/= 5 symptoms below: occur in most cycles during the week before menses onset, improve within a few days after menses onset, and diminish in the week postmenses
• Marked affective lability
• Marked irritability or anger or increased interpersonal conflicts
• Marked anxiety, tension
• Decreased interest
• Difficulty concentrating
• Easy fatigability, low energy
• Increase or decrease in sleep
• Feelings of being overwhelmed
• Physical symptoms: breast tenderness, muscle or joint aches, “bloating” or weight gain
o Dysfunctional uterine bleeding (Abnormal uterine bleeding)
▪ Bleeding that is abnormal in duration, volume, frequency, or regularity and has been present for the majority of the previous 6 months.
▪ May be acute or chronic and is classified by PALM-COEIN system:
• Polp
• Adenomyosis
• Leiomyoma
• Malignancy
• Hyperplasia
• Coagulopathy
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Not-yet classified
▪ In premenstrual or menopausal women, any bleeding is considered abnormal. Therefore bleeding more frequently than every 21 days or less frequently than every 35 days, is considered to be abnormal. Menstrual bleeding for longer than 7 days also is considered abnormal.
▪ AUB is the leading reason for hysterectomy.
▪ Perimenopausal women are most commonly affected.
▪ The majority of AUB is due to lack of ovulation. Normal, regular periods are the result of complex interplay between the hypothalamus, pituitary, ovary, and the uterine endometrium. Disruptions in this system can affect the amount and structure of the uterine endometrium, causing it to shed irregularly or heavily.
▪ If a follicle forms but never releases the ovum, the follicle may continue to produce estrogen, encouraging endometrial proliferation beyond the normal 14-day time window. In addition, the lack of progesterone causes the thickened endometrium to be unable to shed in a predictable fashion without excessive blood loss. Women who fail to ovulate experience irregularities in their menstrual bleeding related to the lack of progesterone and, in some cases, an excess of estrogen.
▪ Without ovulation, menstrual flow may become irregular, excessive, [Show Less]