Harrison's Internal Medicine Chapter 51. Menstrual Disorders and Pelvic Pain
Menstrual Disorders and Pelvic Pain: Introduction
Menstrual dysfunction can signal an underlying abnormality that may have long-term health consequences. Although frequent or prolonged bleeding usually prompts a woman to seek medical attention, infrequent or absent bleeding may seem less troubling, and the patient may not bring it to the attention of the physician. Thus, a focused menstrual history is a critical part of every female patient encounter.
Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology but may require surgical or gynecologic intervention. Conservative management is an important consideration for ovarian cysts, if torsion is not suspected, to avoid unnecessary pelvic surgery and the subsequent risk of infertility due to adhesions. The majority of unruptured ectopic pregnancies are now treated with methotrexate, which is effective in 84–96% of cases. However, surgical treatment may be required.
Cute pelvic pain is a common presenting com-plaint in women. The diagnosis of pelvic pain in women can be challenging because many symp-toms and signs are insensitive and unspecific. Prompt diagnosis and effective management pre-vent complications and may help preserve fertility .
The International Association for the Study of Pain: ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential other non-painful symptoms from the same organ tissue damage, or described in terms of such or area. Chronic pain arising from the pelvic organs damage’.
Role of the hypothalamic-pituitary-gonadal axis in the etiology of amenorrhea. Gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus stimulates follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secretion from the pituitary to induce ovarian folliculogenesis and steroidogenesis. Ovarian secretion of estradiol and progesterone controls the shedding of the endometrium, resulting in menses and, in combination with the inhibins, provides feedback regulation of the hypothalamus and pituitary to control secretion of FSH and LH.
Algorithm for evaluation of amenorrhea. β-hCG, human chorionic gonadotropin; PRL, prolactin; FSH, follicle-stimulating hormone; TSH, thyroidstimulating hormone.
Hypogonadotropic Hypogonadism Low estrogen levels in combination with normal or low levels of LH and FSH are seen with anatomic, genetic, or functional abnormalities that interfere with hypothalamic GnRH secretion or normal pituitary responsiveness to GnRH. Although relatively uncommon, tumors and infiltrative diseases should be considered in the differential diagnosis of hypogonadotropic hypogonadism (Chap. 333).
Polycystic Ovarian Syndrome: Treatment The major abnormality in patients with PCOS is the failure of regular, predictable ovulation. Thus, these patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia associated with unopposed estrogen exposure. Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, or prometrium, 200 mg daily for 10–14 days of each month).
Menstrual dysfunction can signal an underlying abnormality that may have longterm health consequences. Although frequent or prolonged bleeding usually prompts a woman to seek medical attention, infrequent or absent bleeding may seem less troubling, and the patient may not bring it to the attention of the physician. Thus, a focused menstrual history is a critical part of every female patient encounter. Pelvic pain is a common complaint that may relate to an abnormality of the reproductive organs but may also be of gastrointestinal, urinary tract, or musculoskeletal origin.
Tuyển tập báo cáo các nghiên cứu khoa học quốc tế ngành y học dành cho các bạn tham khảo đề tài: Defining a minimal clinically important difference for endometriosis-associated pelvic pain measured on a visual analog scale: analyses of two placebo-controlled, randomized trials
Tuyển tập báo cáo các nghiên cứu khoa học quốc tế ngành y học dành cho các bạn tham khảo đề tài: Quality of life associated to chronic pelvic pain is independent of endometriosis diagnosis-a crosssectional survey
Tuyển tập các báo cáo nghiên cứu về hóa học được đăng trên tạp chí hóa học đề tài : Defining a minimal clinically important difference for endometriosis-associated pelvic pain measured on a visual analog scale: analyses of two placebo-controlled, randomized trials
Local pain is caused by stretching of pain-sensitive structures that compress or irritate sensory nerve endings. The site of the pain is near the affected part of the back.
Pain referred to the back may arise from abdominal or pelvic viscera. The pain is usually described as primarily abdominal or pelvic but is accompanied by back pain and usually unaffected by posture. The patient may occasionally complain of back pain only.
Pain of spine origin may be located in the back or referred to the buttocks or legs. Diseases affecting the upper lumbar spine tend to refer pain to the lumbar...
The pelvic floor consists of muscles and connective tissue. In the past, the components’
relative contribution to the structural support of the pelvic floor and its functions has been a
subject of controversy (Corton 2009). With increasing age women can develop vaginal and
pelvic organ prolapse as well as symptoms such as stress urinary incontinence, voiding
dysfunction, urgency and frequency and nocturia, and may also develop fecal incontinence,
obstructive defecation and pelvic pain (Petros 2010).
Referred Pain from Visceral Disease
Diseases of the thorax, abdomen, or pelvis may refer pain to the posterior portion of the spinal segment that innervates the diseased organ. Occasionally, back pain may be the first and only manifestation. Upper abdominal diseases generally refer pain to the lower thoracic or upper lumbar region (eighth thoracic to the first and second lumbar vertebrae), lower abdominal diseases to the midlumbar region (second to fourth lumbar vertebrae), and pelvic diseases to the sacral region.
The stomach is located in the epigastrium and the main physiological function of stomach is
reservoir of food and drink, then food and drink are fermenting and grinding by action of
the stomach so disturbance of these functions of the stomach will cause poor appetite,
capacity for only small amount of food, and pain in the epigastric region. Of course, only in
cooperation with the spleen's function digesting and transforming food and drink can be
performed successfully by the stomach's function of receiving, to receive, digest and
transform the food and drink.
Endometriosis is the extrauterine occurrence of endometrial glands and stroma, most often involving the ovaries or dependent visceral peritoneal surfaces. Although benign, endometriosis is progressive, tends to recur, may be locally invasive, may have widespread disseminated foci (rare), and may exist in pelvic lymph nodes (30%). The etiology is unknown, but several mechanisms may be important in pathogenesis. Endometriosis is a significant gynecological problem, occurring in 7%–10% of the general population and up to 50% of premenopausal women.