18. Benign Conditions of Uterus, Cervix and Ovary/FT Flashcards
(84 cards)
1
Q
What embryonic changes do we see in female development?
A
[Absence of Y chromosome] and [Mullerian-Inhibiting Substance] =>
- Fusion of the mullerian (paramesonephric) ducts
- Degeneration of the mesonephric ducts
2
Q
Most common congenital cervical anomalies are a result of what?
A
Malfusion of the paramesonephric ducts, with varying degrees of septation (didelphys cervix and septate cervix)
3
Q
Failure of the paramesonephric (Mullerian) ducts to fuse causes:
A
- Uterus didelphysis => 2 seperate uterus with their own cervix attached to a fallopian tubes and vagina.
- Bicornuate uterus
- Bicornuate uterus with a double cervix
4
Q
2 causes of uterine and cervical anomalies.
A
- Most occur spontaneously
- Early maternal exposure to DES
5
Q
Early maternal exposure to DES can cause uterine/cervical anomalies?
A
- Small T-shaped endometrial cavity
- Cervical collar deformity
6
Q
What is the most common neoplasm of the uterus and what does it arise from?
A
Uterine leiomyomas “fibroids”
- Benign tumors (rarely malignant) derived from local proliferation of smooth muscle cells of myometrium
7
Q
70% of women will have a _____ by 50YO.
A
Fibroids
8
Q
Uterine leiomyomas “fibroids” are mostly asymptomatic, but if symptomatic, what sx’s are seen and this is the most common indication for what?
A
- Excessive [uterine bleeding, pelvic pressure, pain and infertility]
- Most common indication for hysterectomy
9
Q
4 risk factors for developing uterine leiomyomas “fibroids”
A
- ↑ age during reproductive years
- African American W
- Nulliparity
- Family hx
10
Q
When do fibroids typically enlarge?
A
- 40% enlarge during pregnancy bc growth is stimulated by estrogen
- Rarely form BEFORE menarche
- Rarely enlarge AFTER menopause
11
Q
What are the gross characteristics of uterine fibroids?
A
- Gross: Spherical, well-circumscribed, white firm lesions
- Cut section: whorled
12
Q
What is the most common subtype of uterine fibroids; arise where?
A
INTRAMURAL, arising within myometrium
13
Q
Which type of uterine fibroid is more at risk of becoming a parasitic fibroid?
A
Subserosal (beneath serosal surface) fibroid = Loosely connected to uterus and rarely attaches to BS or bowel mesentary.
14
Q
Which type of fibroid causes more prolonged or heavy bleeding?
A
Submucosal fibroid = located beneath endometrium and can become pedunculated and go through cervical os
15
Q
What is the most common presenting sx of uterine leiomyomas “fibroids?”
A
Prolonged or heavy bleeding (mostly with submucosal or intramural fibroids), but 80% are asx
16
Q
Which type of fibroid is most likely to cause infertility?
A
Submucosal fibroid
17
Q
What are some of the signs of a uterine fibroid on bimanual exam; how is the degree of enlargement characterized?
A
- Enlarged, irregularly shaped uterus. If a palpated mass moves => FIBROID UTERUS
- Degree of enlargement is described in “week size” used to estimate equivalent gestational size
18
Q
What is used to distinguihs [adnexal masses vs lateral leiomyomas]?
A
US
19
Q
What is the typically the 1st line of therapy for uterine leiomyomas?
A
- Combination (estogen + progesterone) –> OCP’s and rings
20
Q
When are GnRH agonist (Depo-Lupon) used to treat uterine leiomyomas?
A
Used to ↓ fibroid size to alter route of surgery
21
Q
How is uterine artery embolization used to treatment fibroids?
A
Microspheres/polyvinyl alcohol particles are introduced into the uterine a. => thrombose & occlude the artery feeding the fibroid –> necrosis of the fibroid => shrink 40-60%
22
Q
Performing a myomectomy (cut the fibroid out) to treat the fibroid will result in what 2 things?
A
- If enter endometrial cavity => all future bbs must be delivered by c-section
- Fibroids often grow back
23
Q
What is a endometrial polyp?
A
- Soft friable protrusion into endometrial cavity.
24
Q
What may be seen on ultrasound with endometrial polyps; which type of imaging allows for better detection?
A
- Focal thickening of the endometrial stripe
- Saline hysterosonography and hysteroscopy*** allow for better detection
25
How are **endometrial polyps** managed clinically?
Need to **_remove_** via **_hysteroscopy_** because they COULD be endometrial hyperplasia and carcinoma.
26
Most **endometrial polyps** are _benign/malignant_ hyperplastic masses.
**benign**
27
What are **Nabothian cysts?**
* NL **[yellow/blue mucus-filled cysts]** on the cervix that occur due to squamous metaplasia, where a layer of superficial squamous epithelium entraps a layer of columnar cells beneath, which still makes and secretes mucus.
28
What are the most common **benign growths** on the cervix?
**Ectocervical/endocervical** polyps
29
How do **endocervical polyps** differ from **ectocervical polyps;** which is most common?
- **Endocervical** **polyp**= **more common**; beefy **red** in color; arise from endocervical canal
- **Ectocervical polyp** = **less** common; **pale** in appearance
30
Symptoms and clinical management of **cervical polyps**
1. **Sx**
1. None
2. Coital bleeding (bleeding after sex)
3. Menorrhagia (heavy periods)
2. **Management**
1. Remove in office bc rarely malignany
31
What is **endometrial hyperplasia** caused by?
**Persistant unopposed estrogen**
1. **PCOS** and **anovulation**
2. **Granulosa theca cell tumors,** which make estrogen
3. **Obesity**
32
**Endometrial hyperplasia** is a precursor to \_\_\_\_\_\_\_\_\_\_.
**Endometrial carcinoma**
33
Common symptoms of **endometrial hyperplasia**?
1. **Intermenstrual bleeding**
2. **Unexplained heavy** or **prolonged bleeding**
34
Which finding of the US is indicative of **endometrial hyperplasia** and what is the next step?
* Endometrial lining **_\>_ 4mm** in a **post-menopausal** F.
* =\> do a **biopsy**
35
What are the 4 types of **endometrial hyperplasia** and what % progress to cancer?
1. Simple hyperplasia W/O atypia (1%)
2. Complex hyperplasia W/O atypia (3%)
3. Simple hyperplasia WITH atypia (9%)
4. Complex hyperplasia WITH atypia (27%)
36
What is the treatment for ***simple*** and ***complex* endometrial hyperplasia** with and without atypia?
- **Without atypia =\>** progestin and resample in 3 months
- **With atypia =\>** hysterectomy
37
In 46 XY, **complete androgen insensitivity syndrome** / **testicular feminization,** how do we treat?
Remove functioning gonads (testes) bc they have malignant potential.
38
What are the **functional cysts** of the _ovaries_?
1. **Follicular** cyst
2. **Lutein** cyst
3. **Hemorrhagic** cyst
4. **Polycystic** cyst
39
Which functional cyst of the ovary is **more likely to cause symptoms**?
**Hemorrhagic cysts**
40
Are **theca-lutein cysts** (bi-/unilateral) and what are distinguishing characteristics?
- Usually **bilateral,** **large** (\>30 cm) cysts filled w **straw-colored fluid** due to **excessive hCG** and **regress when levels fall.**
41
When are **theca-lutein cysts** most common?
**When hCG is high**
1. Pregnancy
2. Choriocarcinoma or hydratiform molar pregnancy
3. Undergoing ovulation induction
42
Functional ovarian cysts, **pregnancy luteomas**, are caused by what?
* **Pregnancy ovarian cysts (red/brown nodule)** that form bc prolonged hCG causes _hyperplastic rxn of the ovarian theca cells._
* Goes away spontaneously after PG.
43
**PCOS (polycystic ovarian cysts)** is can cause what 4 things?
1. Anovulatory infertility
2. Menstrual abnormalities (amenorrhea)
3. Hyperandrogenism (hirtuism, acne, deep voice)
4. Insulin resistance (T2DM)
44
What causes **PCOS**?
* _Multiple ovarian follicular cysts in enlarged ovary_ form due to **hormone imbalance (increase LH; low FSH)**
* LH =\> theca cells =\> androgen =\> 1. hirtuism (body hair); 2. goes to adipose tissue and is converted to estrone (estrogen)
* Estrone then feedbacks and decreases FSH from AP =\> - granulosa cells =\> decrease in estradiol
* =\> follicle does not mature =\> **cystic degeneration of the follicle.**
45
What is a complication of **PCOS**?
* Increase risk of **endometrial hyperplasia** =\> **endometrial carcinoma** (d/t high levels of estrone)
46
Classic presentation of a pt with PCOS
Obese young W with infertility, oligomenorrhea and hirtuism, with insulin resistance and may develop T2DM years later.
47
What are the most commons **benign surface epithelial ovarian tumors?**
1. Serous tumors
2. Mucinous tumors
3. Brenners tumors
48
What are the most commons benign **sex cord-stroma** ovarian tumors?
1. **Fibromas**
2. **Granulosa - theca cell tumors**
3. **Sertoli-Leydic cell tumors**
49
What are the most common benign **germ-cell** ovarian tumors?
1. **Cystic teratoma (dermoid)**
50
What is the single most common benign ovarian neoplasm in a **PREMENOPAUSAL** female?
**Cystic teratoma (dermoid)** = germ cell tumor
51
What is the most common type of **epithelial ovarian tumor**?
**Serous cystadenoma (75%)**, which are benign (70%), BL or malignant (20-25%)
52
Malignant **serous cystadenocarcinomas** will often have what histologic finding?
**Psammoma bodies**
53
Treatment of **serous cystadenoma?**
* Surgery depends on if you want to maintain fertility
* =\> cystectomy
* =\> oophorectomy
* =\> hyst with bilateral oopherectomy
54
Which type of **epithelial ovarian tumor** is _multiloculated_ can _attain a huge size_, sometime filling the entire pelvis and abdomen?
Benign/maligant?
**Mucinous** **cystadenoma** (2nd most common epithelial tumor), *80% benign*
55
**Mucinous cystadenomas** are associated with _________ and can *rarely* lead to \_\_\_\_\_\_\_.
* **Mucocele of the appendix**
* **Pseudomyxoma peritonei** = \> benign implants are seeded onto surface of bowel and peritoneal =\> make alot of mucus
56
What is a **Brenner tumor?**
**Small**, **smooth**, **solid** ovarian neoplasm made up of **fibrotic componen**t that surrounds **bladder-like** transitional cells that is usually **benign**.
57
**33% of Brenners tumors** are associated with _______ epithelial elements.
**Mucinous**
58
IF the ultimate differentiation of cell types in the tumor are **feminine**, then the tumor is what?
**Feminine** =\>
1. Granulosa cell tumor
2. Theca cell tumor
1. or
3. Granulosa- theca cell tumor
59
IF the ultimate differentiation of cell types in the tumor are **masculine**, then the tumor is what?
**Sertoli-leydig tumor**
60
**Granulosa-theca cell ovarian tumors**
* Occur when?
* Sx and signs
* Malignant potential
* **Any age** =\> produce estrogen =\> femininzing signs
* **B4 puberty** =\> precocious puberty (menarche and thelarche = dev of boobs), premanarchal uterine bleeding
* **Reproductive ag**e =\> meorrhagia
* **Postmenopause** =\> endometrial hyperplasia/cancer and post-menopausal bleeding
* Low
61
**Sertoli-leydig ovarian tumors**
* Histo
* Sx and signs
* Malignant potential
* **Sertoli cells** make tubules and **leydig cells** make Reinke crystals
* Makes androgenic components
1. Hirtuism/baldness/ deep voice
2. Clitormegaly
3. Defeminzing F body =\> muscular build
62
What is the most common benign **solid** ovarian tumor?
**Fibroma** (sex cord-stromal tumor)= benign tumor of fibroblasts but does NOT secrete sex steroids
63
**Ovarian _fibromas_** can be associated with what syndrome?
1. **Meigs syndrome:** _ascites_ =\> (flows into R pleural cavity)=\> _right pleural effusion (hydrothorax)_
64
What is the most common ovarain neoplasm found **in women of all ages**?
Germ cell tumor --\> **Cystic Teratoma**
65
What is a **Cystic teratoma?**
* -MC-
* -Unilateral/bilateral-
* -size-
* **Benign cystic tumor** made up of fetal tissue from all 3 embroyological layers, mainly ectodermal tissue
* 80% occur in reproductive years (30YO)
* Bilateral (10%)
* Slow growing, most \< 10cm.
66
What is the appearance of the **Cystic Teratoma?**
What happens if it ruptures?
* **Multicystic** with hair, teeth, sebaceous material
* Ruptures =\> **chemical peritonitis**
67
**Rokintanksy's protuberance** is seen with what type of ovarian tumor?
What is it^?
**Rokintanksy's protuberance =** prominence at the junction of the [teratoma and NL ovarian tissue]. If found, can have malignant cells.
**Cystic teratoma (germ cell tumor)**
68
**Benign ovarian tumors** are often asymptomatic, but can be painful in what situations?
1. If tumor twists on its pedicle (**torsion**)
2. **Rupture of the cys**t --\> **pain** + **peritoneal inflammation**; can occur spontaneously, with trauma, during bimanual exam, or with intercourse
69
Which is preferable for diagnosis of **benign ovarian tumors**, laparotomy or laparoscopy?
**Laparotomy,** is preferable unless the mass can be removed without rupture bc laparoscopy can be used to distinguish between [uterine fibroids vs ovarian tumors vs hydrosalpinx]/
70
What can US help us with when diagnosing **Benign ovarian tumors?**
* Simple vs complex in nature
* **ID Dermoid cyst:** will look like a tooth-like calcification
71
What tumor marker is used to diagnose **benign ovarian tumors** and who is it best in?
CA 125 =\> post-menopausal W
72
Can a **persistent** ovarian neoplasm be assumed benign?
**No**, must be proven by **surgical exploration** and **pathologic exam**
73
If **surgery** is warranted for ovarian neoplasm, what 2 things must be done?
1. - **Collect pelvic washings** for cytologic examination
2. - Obtain **frozen section** for histologic diagnosis
74
How are **benign _epithelial_ ovarian tumors** typically managed; what if the diagnosis is a *_mucinous_* type?
- Typically managed w/ **unilateral salpingo-oophorectomy**
- If mucinous, perform an **appendectomy** bc there may be a appendiceal mucocele
75
What is appropriate management of **epithelial ovarian neoplasm** in young nulliparous patients vs. older women?
- **Young** = may perform a _cystectomy_ to preserve ovaries
- **Older** = _total abdominal hysterectomy_ w/ _bilateral salpingo-oophrectomy_
76
What is appropriate management and steps for benign **mature cystic teratomas "dermoid?**"
1. Can be tx w/ _ovarian cystectomy_
2. Carefully _evaluate other ovary_ since they are bilateral in 15-20% of case
3. _Irrigate pelvis_ to avoid chemical peritonitis
77
How are **stromal cell tumors** MC treated?
**Unilateral salpingo-oophorectomy**
78
What is **hydrosalpinx** vs. **pyosalpinx**?
- **Hydrosalpinx** = _fluid filled_ FT's from _previous_ infection
- **Pyosalpinx** = _purulent filld_ tube from _active_ infection
79
What is more common in fallopian tubes: benign/malignant tumors.
**Benign (infectious or inflamm)**
Malignancy is rare
80
What is one of the most common gynecologic emergencies?
**Ovarian torsion** = rotation of ovary on ligaments, which can impede blood supply
81
What is the **primary risk factor f**or ovarian torsion?
**Ovarian mass ≥5 cm**
82
What is the classic presentation for **ovarian torsion?**
- **ACUTE** onset of **unilateral pain**
- **Nausea** and possibly **vomiting**
83
How is diagnosis of **ovarian torsion** made?
- **US** = first line imaging study to identify mass
- Definitive dx is made by **direct visualization**
84
What is treatment for **ovarian torsion**; how does this change if ovary is necrotic or you suspect malignancy?
- **Detorsion** and **ovarian cystectomy** to preserve ovaries
- **Salpingo-oophorectomy** is performed if ovary is necroticor you suspect malignancy
