GYN #1 Importance of Documenting Reproductive Anatomy with Dr. Lesley Breech

Global cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone, I'm M. Godi, research fellow at Cincinnati Children's Hospital Medical Center. Today we have a guest from the pediatric gynecology department here at Cincinnati Children's, Dr. Lesley Breach, and she will talk about the importance of documenting reproductive anatomy and guide us how to evaluate patients for endometriosis. The biggest pitch that I initially had is asking for all of you surgeons to document reproductive anatomy when able. You're all doing many laparoscopic procedures and just really we're asking you to take a look down in the pelvis. And if you see something that looks amiss, really taking a video or taking some pictures would be awesome. The main reason is it's important, especially in patients with other anomalies. In patients with a renal anomaly, you can have about a 30% chance of having an associated Mullerian anomaly as well. A fair amount of those are obstructive in nature. And so if you know about it ahead of time, the patient can be followed. This is a condition that we call Ova, or an obstructed hemi vagina with an ipsilateral renal agenesis. So, it's occurs on the same side where there is an absent kidney. You can find an obstructed hemi vagina on that side and that would then need to be managed. And here's a paper reference, which validated the 30% association of those Mullerian anomalies with patients with a renal anomaly. Endometriosis is very common in patients with chronic pelvic pain. So it's really important to be thinking about it before you go to surgery. Anywhere between 25 to 40% of adolescence with chronic pain may have associated endometriosis. As gynecologist, when patients present with dysmenorhea, we're going to start with a trial of perhaps something like oral contraceptive pills to treat the dysmenorhea. And then, if that's unsuccessful or inadequate, maybe they need to take a look laparoscopically. In general, about 5% of the reproductive age individuals with uterus will have endometriosis. 95% of girls do not have endometriosis. So really we're not going to take every patient with dysmenorhea who seems to be inadequately treated with Ensets to the OR right away. In addition, patients who have endometriosis can have an associated component of acyclic pain. So, for us, we keep both the dysmenorhea portion as well as the acyclic pain in our mind prior to going to the OR. Infertility is a long-term association with endometriosis, but it's not well documented if it's really about the disease burden or other cytokines that might be associated with the condition. So our main goal in caring for patients is to improve the patient's quality of life. So, I think when we're looking in the OR, if we saw the areas that you see here, we would definitely want to do a tissue biopsy. We send the um specimen in formalin, but it could also be sent as a fresh specimen as I know many of the surgeons send their specimens fresh. These are like little white vesicles that you can see on the peritonal surface. When you're looking at these images and see that this area here is much more red, what we more consistently see in younger patients. It takes much more time and these lesions are much more advanced and mature. And they will look darker like sort of powdered burns that you may have seen in your training when looking for endometriosis in adults. And these red lesions are also much more sensitive to medications like Ensets. So even if these patients just use Ensets with timing and take them regularly during their menses, will have the significant benefit. So again, one of my pieces of advice is if you're there and you're perhaps doing an appendectomy, which may be associated with pain either acutely or more chronically, it would be great to take a a look around the pelvis, some photography, some video, looking for these types of lesions. Usually they look in the posterior cold sac, dependent portions of the pelvis. So looking behind the uterus, if they don't see any obvious disease, they would usually biopsy uterosacral ligaments because you can have microscopic disease and can come with pain and discomfort. There are many different treatment strategies for treating endometriosis, resection of lesions is one form. We often use laser ablation as well. Cautery is another opportunity for treating them. So all of those are standard treatment methods. There are different individual perceptions about how their pain is, but it's definitely a condition that would need to be managed all throughout their life. Historically, to the surgical care of patients with endometriosis, you might reflect on hysterectomies being a primary pride of that care. However, I think when we're thinking about the young patient population and potential for fertility for the future, we think about some different therapies now. In fact, progesterone containing IUDs are have a more and more prominent role in caring for patients with endometriosis. One, it's much more comfortable to the patient. Two, progestin therapy is excellent in treating endometriosis, and the IUD is right there in the pelvis. In summary, it's important to document reproductive anatomy in laparoscopic procedures, particularly to detect endometriosis and Mullerian anomalies. When dealing with adolescents experiencing chronic pelvic pain, always consider the possibility of endometriosis. Treatment approaches for endometriosis typically involves hormonal management and laparoscopic investigation with the goal of enhancing the patient's quality of life and ensuring long-term care. As a part of treatment plan, IUD placements for progesterone therapy can also be considered. Thanks for watching this video. Don't forget to subscribe to the staycurrent MD YouTube channel. Follow our social media channels and download the staycurrent MD app for tons of content in pediatric surgery. Global cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.