og integrated teaching
TRANSCRIPT
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Case no. 2
Ashwin. R
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A 30 yr old lady presented to the gynaec OPD
with her husband with complaints of not
conceiving even after 3 years of marriage.
She also complaints of dysmenorrhea and
bilateral pelvic pain which was more on the
left side.
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30 yrs not conceiving
bilateral pelvic pain (L)Dysmenorrhea
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She attained her menarche at the age of 13. she
was having regular menses without dysmenorrhea
till 25 yrs of age. After that she started having
dysmenorrhea which begins before the onset of
menses, continuing throughout the cycle and the
severity is more nowadays
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30 yrs not conceiving
bilateral pelvic pain (L)Dysmenorrhea X 5y
onset / progress / relation to the cycle TYPE ?
VARIETY ?
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Dysmenorrhea - types
PRIMARY SECONDARY
ONSET Within 2 yrs of menarche 20-30 yrs,
pre/postmenstrual
SYMPTOMS NVD, headache , fatigue Dyspareunia,
infertility, menstural
disorders
PAIN Cramping hypogastrium,
inner thigs, back
Dull aching - variable
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Dysmenorrhea - varieties
Spasmodic : cramping pains, more in the 1st
and 2nd day of menstruation
Congestive : increasing pelvic discomfort and
pain few days before the menses
Membranous : painful uterine cramps at
menstruation
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30 yrs not conceiving
bilateral pelvic pain (L)Dysmenorrhea X 5y
Secondary
congestive
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Endometriosis
Chronic PID
ovarian tumour (B/M) Uterine myomas -
can be ruled out with a transvaginal USG
Differential diagnoses
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Husbands seminogram shows normal
findings.
TVS (colour doppler) of the lady shows a left
adnexal mass, 5cm in size, with homogenous
internal echoes and increased vascularity at
the ovarian hilus
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TV USG / Colour doppler
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USG again
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Endometriosis of the ovary
Chronic PID with TO mass
ovarian tumour (B/M) Uterine myomas
Differential diagnoses
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PID ? Why not ?
TV USG findings
Features of PID Low grade fever with acute episodes (A/C)
lassitude
Foul smelling discharge per vagina
Colour doppler findings in this patient
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low resistance flow, Increased vascularity at
the hilus
Ovarian carcinoma ??
Age Associated features of Ovarian CA ?
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ENDOMETRIOMA LEFT OVARY
Chocolate cyst
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Endometriosis - sites
Most common site ,ovaries (~60%)
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The scenario
A 30 yr old lady who has come with pain and
has to conceive
A moderately large ovarian chocolate cyst (5cm) in the left side
No other probable sites of involvement
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Management
To cover
Pelvic pain
Ovarian endometrioma infertility
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For this patient ,
Discuss regarding the different options & cost
NSAIDs for immediate pain relief
Start on GnRH analogue
Goserelin acetate (Zoladex) 3.6 mg depot X 3mths
Evaluate for infertility meanwhile
Laparoscopic cyst excision (preferably) after 3months
Post operative hormone therapy for residual tissue
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Lap cyst excision
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