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CM III Exam III > Benign Uterine and Ovarian Disease > Flashcards

Benign Uterine and Ovarian Disease Flashcards

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1
Q

Where do Leiomyomas (fibroids) arise from?

A

Myometrium, the muscular layer of the uterus

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2
Q

What’s the most common pelvic tumor in women of childbearing age?

A

Fibroid/leiomyomas

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3
Q

Etiology of leiomyomas?

A

No clue. unknown

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4
Q

What population is more likely to get a leiomyomas & subsequently a hysterectomy

A

Black women. AA»>WW

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5
Q

How do leiomyomas feel on a bimanual exam?

A

Firm and smooth. They’re benign tumors, it’s just the normal tissue that’s there plus a lil’ extra

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6
Q

4 Locations we might see a leiomyoma/what’s the most common one?

A

1) Intramural myoma (most common)
2) Subserosal myoma
3) Cervical myoma
4) Submucosal myoma

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7
Q

What does it mean if a fibroid is an intramural myoma?

A

Means it’s completely within the muscular layer

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8
Q

What is the only fibroid visible w/o cutting into the uterus?

A

Serosal fibroids

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9
Q

Pathognomonic symptom for fibroids

A

Heavy or prolonged menstrual bleeding. We’ll see increased clots and dysmenorrhea

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10
Q

Other, less common symptoms for fibroids

A 
Most are small and asymp, but we can have things like
Pelvic pressure & pain
Urinary freq
Difficulty emptying bladder completely
Reproductive dysf
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11
Q

Working up a fibroid

A

Palpable with bimanual exam, uterus will be enlarged/irregular. +/- tenderness.

Confirm w/ transvag US

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12
Q

What is fibroid treatment based on?

A

Symptomatic relief! Bleeding? stop it. Big enough to push on the bladder and cause issues? Get it out.

We’ll usually try out tx in this order

1) Watchful waiting
2) Rx management
3) Surgery

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13
Q

What does menopause do to fibroids?

A

Causes them to shrink and reduces symptoms. That’s why We’ll sometimes use GnRH and do an artificial menopause to lessen symptoms

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14
Q

Rx management of fibroids

A

1) NSAIDS - for dysmenorrhea
2) OCP
3) IUD
4) GnRH- induces temporary menopause. We’ll do this for preop to reduce the size

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15
Q

Indications for surgical management of fibroids

A

abnormal uterine bleeidng, bulk related symptoms, infertility, recurrent miscarriages

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16
Q

Surgical options for fibroids

A

1) Hysterectomy
2) Myomectomy (only for submucosal since they’re the only ones visible thru the muscle)
3) Uterine artery ablation (clot the artery feeding the fibroid)
4) Endometrial ablation

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17
Q

What is adenomyosis?

A

Ectopic endometrial tissue that grows backwards into the myometrium. Makes you have this huge boggy uterus

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18
Q

Adenomyosis on exam

A

Diffusely enlarged uterus, will feel “boggy”.

This tissue is not well differentiated from the surrounding tissue, just kind of looks like a giant endometrium. This makes it really difficult to excise. Tissue can be diffuse or local

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19
Q

Caveat of diagnosing adenomyosis

A

We can make a clinical observation, but it’s not a true diagnosis until a sample is sent down and pathology makes the call based on the histology

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20
Q

Epidemiology of adenomyosis

A

40-50yo, coexists with endometriosis and fibroids, most common w/ parous women w/ a hx of c-section or D&C

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21
Q

Adenomyosis sx

A

Heavy menstrual bleeding
Dysmenorrhea
Chronic pelvic pain
Diffusely enlarged boggy uterus

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22
Q

Key words to working up adenomyosis on US

A

1) Assymmetric thickening of the myometrium
2) Linear striations
3) Loss of clear endomyometrial border
4) Increased myometrial heretogeneity

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23
Q

Only guarenteed tx for adenomyosis

A

Hysterectomy

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24
Q

Hormonal tx for adenomyosis

A

GnRH analogs or Amoratase inhibitors

They will inhibit estrogen and do a little baby chemical menopause. Will work for a little bit but the patient can’t stay on these guys for too long, they’ve got nasty SE

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25
Endometriosis is a ______ dependent disease
Estrogen! Menopause leads to resolution of symptoms
26
What is endometriosis?
It's when the normal endometrial tissue is implanted in locations other than the uterus. Wicked painful and fairly common. Consider this diagnosis when NSAIDS are ineffective for txing a woman with pelvic pain (since it's estrogen dependent)
27
RF for endometriosis
``` Fx hx Nullpar Early menarche Short menstrual cycles (packing a lot of hormones in a short time) Long duration of menstruation Heavy menstrual bleeding ```
28
Most common site for endometriosis implantation
Ovaries!
29
Sx of endometriosis
``` Can be asymptomatic Dysmenorrhea Heavy or irregular bleeding Pelvic pain Lower abd pain/back pain Dyspareuria ```
30
Endometriosis on PE
Non specific. Localized tenderness in pouch of douglas (posterior) Endometrioma (palpable tender nodule in douglas) Pain with movement of uterus Severe abd pain if ruptured endometrioma
31
What should we consider if a pt comes in w/ severe pain and a hx of endo?
Ruptured endometrioma
32
What is an endometrioma? Where is it most commonly found?
Chocolate cyst. Most commonly found on the ovaries
33
Besides an endometrioma, what are some other complications of endometriosis?
Adhesions Pain Infertility
34
Gold standard for diagnosing endometriosis (not necessarily first line)
Laparoscopy w/ bx. We'll see the classic "blue black/power burned appearance" lesions in the vagina
35
Pathognomonic findings in the vagina for endometriosis
Blue back/powder burned appearance
36
For line for working up endometriosis
Transvag US! We can r/o the scary differentials real quick and then get to work on what's actually going on
37
Is most endo surgically or medically managed?
Most are medical! 95% are successfully medically managed. However 50% of those women will report return of symptoms following medical management.
38
Medical management options for endometriosis
1) OCPs (combo or solo prog) 2) GnRH analog --> medical menopause. Only 6 mo though 3) Danazol (androgenic steroid)
39
Surgical options for hysterectomy
1) Hysterectomy w or w/o bilateral oopherectomy (w/BSO is considered definitive tx) 2) Laproscopic uterine nerve ablation 3) Lap and surg endometrial implant ablation (high reop rate, 50%)
40
Endometriosis Staging
Stage 1: Minimal, only superficial lesions and a few adhesions Stage 2: Mild, superficial & deep lesions present in douglas. No adhesions Stage 3: Moderate, multiple implants + endometriomas Stage 4: Severe, multiple implants, large endometriomas, and extensive adhesions
41
What is a cyst
Sac filled with fluid or semiliquid material
42
What age group to ovarian cysts target
None! These suckers can happen at any age, including neonatal/infancy phase. Just slightly less likely to happen to post-menopausal women.
43
Most common type of cystic ovarian lesion
Functional ovarian cyst. These guys are so lowkey, most ovarian cysts are found incidentally.
44
Types of functional ovarian cysts
Follicular Corpus luteal cyst Theca lutein cyst Endometrioma
45
Simple cyst
Full of simple fluid with a thin wall.
46
Complex cyst
Filled with fluid and gunk, like debris and blood. These guys can have thick walls, and are a bit more problematic since they can trigger sepsis or hemorrhagically rupture.
47
What triggers development of a follicular cyst
When the rupture of a mature follicle doesn't occur
48
Description of a follicular cyst on US
"Simple unilocular anechoic cysts with a thin, smooth wall"
49
Should we be worried about follicular cysts?
Nah. These guys will resolve on their own in about 2-3 months 80% of the time
50
When does a corpus luteal cyst occur
After ovulation
51
Corpus luteal cyst on US
"Ring of fire" on doppler. Because these guys can be vascular, we worry about hemorrhages with these.
52
What causes a theca lutein cyst?
Ovarian hyperstimulation! These guys are wicked rare. Seen more when mom is on hormonal IVF therapy, rarely seen in singleton pregnancy.
53
Theca lutein cysts on US
Septations do now show enhancement on US. Whatever the heck that means
54
What is an endometrioma
It's a cyst formed with endometrial tissue. These are our "chocolate cysts".
55
What population of women get endometriomas
These are our women in their reproductive years. Oftentimes these will be your chronic pelvic pain patients
56
How do we treat an endometrioma
Hormones! These guys are hormonally responsive. Do yearly fu w/ US or surgically remove them if this doesn't work
57
What is another name for a mature cystic teratoma (MCT)
Dermoid! These guys are benign germ cell tumors
58
What are MCTs (mature cystic teratoma) associated with?
Ovarian torsion
59
Mature cystic teratoma cyst contents
Calcifications, fat, sebaceous tissue, hair, even teeth. These are our classic teratomas
60
Two types of cystadadenomas
Serous and Mucinous
61
What is a serous cystadenoma? What is it filled with
Benign ovarian tumor, common in postmenopausal women. Filled with simple serous fluid
62
What is a mucinous cystadenoma?
Large cystadenoma, filled with mucinous material (protein & debris). Found in premenopausal women
63
Which is more the more common type of cysadenoma?
Serous!
64
Who gets cysadenofibroma (rare as they are)
any menstruating women
65
Cysadenofibroma tx?
Oopherectomy
66
Signs and symptoms for any kind of ovarian cyst/benign ovarian tumors
Can be asymptomatic Abd pain Discomfort in lower abd/pelvis Fullness, heaviness, pressure, bloating, Irregular bleeding or abnormal vaginal bleeding
67
If a woman has a history of ovarian cyst/benign ovrian tumor and they come in with sudden onset severe sharp pain?
Think rupture of an ovarian cyst
68
Big complication of an ovarian cyst/benign tumor
Ovarian torsion. These guys can grow big enough to compress the ovary and cause torsion
69
Typical presentation of an ovarian torsion secondary to an enlarged cyst/tumor
Woman 20-39yo, sharp sudden pain, then waxing/waning. N/V
70
Besides ovarian torsion, what is another complication of an ovarian cyst and what cyst is the most common culprit of this
Hemorrhage. Corpus luteal cysts love to do this on days 20-28 of the cycle
71
Tx for ovarian torsion secondary to an enlarged cyst/tumor
Emergent lap detorsion for the adnexa and ovarian salvage. Time is ovary
72
Imaging for working up cyst/benign tumor
1) US- helps you rule out anything scary 2) CT pelvis (only for malignancy staging) 3) MRI (done after US only if needed. Can help with evaluating complex masses. Do not delay care because you haven't gotten an MRI yet)
73
What cancer antigen might we order a serology of when working up a possible ovarian carcinoma?
CA125. This is a board question and a question for the test. In reality, this is hardly ever used to make a diagnosis.
74
US management of a mass in a woman of reproductive age (simple vs hemorrhagic)
Simple: <5cm just observe 5-7cm US annually >7 MRI/surg Hemorrhagic: >8cm FU ultrasound within a few months
75
What does it mean if a mass is hemorrhagic
Blood seen on US. Can't miss it, blood looks much different than serous fluid on US
76
US management of a mass seen on a post-menopausal woman
<7cm US annually. Consider getting a CA125 for these women
77
US management of a dermoid cyst
Remember these guys will not resolve spontaneous. US q6-12 months Cystectomy
78
US management of an endometrioma
Initially fu w/ US in 6-12wks After than US annually Still there? Get a cystectomy
79
Indicatinos for an ovarian cystectomy or oopherectomy
1) Symptomatic cysts 2) Persistent 5-10cm cysts (especially if symptomatic) 3) Ovarian torsion 4) Suspected malignancy
80
Treatment of ovarian cysts
1) Analgesia (NSAIDS work fine) 2) Hormonal OCPS for recurrent functional cysts 3) Surgery
81
What kind of cysts typically need surgery
Follicular, corpus luteal, very large or hemorrhagic cysts
82
Why do OCP's work so well for recurrent functional cysts
They work so well because they suppress ovulation, but sometimes even when you're on the pill your body still goes through the motions and you'll get a follicular cyst
83
Which muscle group is the primary support of the pelvic floor
Levator ani muscle complex | pubococcygeus puborectalis, iliococcygeus
84
What is pelvic organ prolapse (POP)
Herniation of pelvic organs to/beyond vaginal walls
85
What is Anterior compartment prolapse (cystocele)
Bladder prolapsing into the anterior vaginal wall
86
What is Posterior compartment prolapse (rectocele)
Rectum prolapsing into the posterior vaginal wall
87
What is Enterocele
Herniation of the intestines to or through the vaginal wall
88
What is apical compartment (uterine prolapse)
Cervix/uterus prolapsing into the lower vagina or beyond (dear god)
89
What is uterine procidentia
Herniation of all three compartments into the vagina (jesus)
90
What two prolapses like to happen together?
Enterocele and rectocele
91
When do we most commonly see an enterocele
This happens when we don't have a uterus/cervix. The intestines will just hang out around here and poke around when they're feeling it.
92
RF for prolapse
``` Parity (vag deliveries are rough) Adv age OBesity jumps your risk so much Hysterectomy (enterocele esp) Other things like chronic constipation, heavy lifting, CT Dx, Ehlers danlos ```
93
Three types of prolapse symptoms
Defecatory Urinary Sexual
94
Defecatory symptoms in a prolapse patient
Constipation (most common) Fecal urgency Fecal incontinence (during intercourse) Incomplete emptying
95
Urinary symptoms in a prolapse pt
Slow urine stream Sensation of incomplete emptying Overactive bladder (urgency, freq, incontinence)
96
Why do we get the overactive bladder symptoms in a prolapse patient
Because the urine that doesn't make it past the urethral kink will build up, and then overnight when the prolapse isn't protruding as much they'll have to pee like every half hour
97
Sexual symptoms in a prolapse pt
Avoidance/shame | +/- dyspareurnia
98
WU for a prolapse
All in the the PE. ``` External pelvix Internal exam Bimanual exam Rectovag exam Consider a neuromuscular exam? +/- urodynamic testing in women w/ incontinence symptoms ```
99
How to grade a prolapse
POP-O, POP stages 0-IV
100
Prolapse grading POP-O
Stage 0: No prolapse Stage I: Prolapse 1cm above hymenal plane Stage II: Prolapse descends to introitus Stage III: Prolapse >1cm past hymanal remnant, but does not cause complete vaginal vault eversion or complete uterine procidentia Stage IV: Complete vaginal vault ecersion or complete uterine pocidentia. AKA vagina and/or uterus is maximally prolapse with entire vaginal mucosa everted
101
Tx options for a prolapse patient
Symptomatic! (urinary vs bowel vs sexual) 1) Expectant 2) Conservative 3) Surgical
102
Two methods of conservative therapy
1) Pessary | 2) Pelvic floor PT.
103
Will PT make the prolapse go back in?
Nah, but it will stop it from getting any worse.
104
What is a pessary? Who are they intended for?
Silicone devices that plug the prolapse. Must be removed and cleaned reguarly. These are great for patients who don't want or can't get surgery
105
Surgical options for prolapse patients
1) Anterior wall repair (colporrhaphy) 2) Posterior wall repair (colporrhaphy) 3) If there's an apical defect, we've got sacral colpopexy and a hysterectomy.
106
What exactly is sacral colpopexy?
SUPER COOL SURGERY. Basically post hysterectomy you tie the posterior wall of the vagina off to some nails in the sacrum. Really keeps it taut
107
What exactly is colporrhaphy?
Pretty cool surg. Basically cut out the weakened vaginal tissue and then stitch together the stronger tissue surrounding it with fascia
108
Do prolapses cause pain?
Nah dude
109
Main concerns of a prolapse
Inability to empty bladder (inc risk of infection) and defecatory dysfunction
110
Do we have to tx a prolapse if asymptomatic and the patient doesn't care?
Nope!

CM III Exam III (8 decks)

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