GYN-Adnexal masses

Question 1

conditions that CA-125 can be elevated

Answer 1

fibroids, endometriosis, PID, ascites, other inflammatory diseases

50% of stage 1 ovarian cancer have normal CA125

Question 2

adnexal mass in teenager

Answer 2

asymptomatic functional cysts up to 10 cm can be managed expectantly with serial ultrasound imaging

Question 3

MC adnexal mass in pregnancy

Answer 3

mature cystic teratomas, paravorian cysts, and corpus luteum cysts

Question 4

malignancy percentage in pregnant patients with persistent masses

Answer 4

10%

Question 5

most common malignancies in reproductive age women

Answer 5

germ cell and sex cord stromal

Question 6

highest risk of torsion in pregnant patients

Answer 6

if mass is 6-8 cm and between 10-16 weeks when uterus starts to grow rapidly

Question 7

risk for ovarian cancer in general population

Answer 7

1 in 70

Question 8

when to refer to onc in older patient with adnexal mass

Answer 8

1. Ascites
2. Evidence of mets
3. Elevated score on formal risk assessment
4. Premenopausal patient with very elevated CA-125 (>200)
5. Postmenopausal patient with elevated CA-125 (>35)
6. Fix/nodular pelvic mass

Question 9

how to manage adnexal mass in older patient
<10 cm, < 5 cm, > 5cm,

Answer 9

1) if asymptomatic and less than 10 cm, repeat imaging in 4-6 months. See resolution in 2/3 of patients
-can observe asymptomatic simple cysts up to 10 cm even in menopausal patients (if nl CA125)
2) If <5 cm and normal CA 125 and multilocular or solid/cystic –> can repeat imaging and CA 125 in 4 weeks. If size or CA 125 increase, then surgery. if stable or decrease in size and CA125, repeat imaging in 3-6 months. If continues to be stable for 18-24 months, then you can stop
3) if >5 cm (5-10 cm), papillary, or with ascites, then need to refer to gyn onc for surgery

Question 10

Management of TOA

Answer 10

-IV antibiotics for at least 24 hours, resolution of fever for more than 24 hours and improvement in pain. Then complete 14 day course of doxy and flagyl
-surgery in menopausal woman with pelvic abscess bc of risk of underlying malignancy

Question 11

TOA and IUD

Answer 11

can leave IUD in place. If not improving in 48-72h with IV antibiotics, then remove it

Question 12

if TOA fails to improve with IV antibiotics

Answer 12

if fails to improve with IV antibiotics in 48-72 hours, then CT/US guided drainage or surgery
-transvaginal drainage and antibiotics has success rate of 90-93%
-approximately 25% of cases fail to improve with just IV antibiotics’
-abscess <10 cm treated with drainage had shorter hospital stay and less likely to require surgical intervention

Question 13

How to treat cervical ectopic pregnancy

Answer 13

single or multi dose methotrexate is treatment of choice
If fetal cardiac activity present, intra amniotic injection of KCL
DC carries risk of hemorrhage
UAE may be useful preop or to manage acute heavy bleeding

Question 14

How to manage c scar pregnancy

Answer 14

-medical management (intragestational MTX)
-minimally invasive techniques (wedge resection)
-surgical treatment
-UAE with DC
-gravid hysterectomy

Question 15

recurrence rate of c scar pregnancy

Answer 15

5-40%

Question 16

recurrence rate of ectopic with
1 prior, 2 prior
Tubal surgery
tubal ligation
ART
IUD

Answer 16

1 prior: 10%
2 prior: 25%
Tubal surgery: 20%
Tubal ligation: 50%
ART: 5%
IUD >20% with LNG, <20% with Cu

Question 17

if you have a SAB, how much should your HCG decrease by in 48

Answer 17

21-35%

Question 18

MOA for MTX

Answer 18

folate antagonist, binds to dihydrofolate reductase, interrupts synthesis of purine nucleotides and amino acids inhibiting DNA synthesis and repair and cell replication

Question 19

For PUL, if bHCG decreases by XXX after MVA, indicative of likely intrauterine process

Answer 19

50% in 12-24h

Question 20

absolute and relative contraindications to MTX

Answer 20

absolute: IUP, immunodeficiency, anemia/leukopenia/thrombocytopenia, allergy to MTX, active pulm dz, active peptic ulcer dz, hepatic dysfunction, renal dysfunction, breastfeed, c/f ruptured ectopic, hemodynamically unstable, inability to fu
relative: +FHT, high initial HCG (>5k), >4cm in size, refusal to accept blood transfusion

Question 21

2 dose MTX regimen and when to consider

Answer 21

consider if HCG >3000 or mass >2 cm.
50 mg/m2 body surface area on day 1 and day 4.
After 4 doses consider surgery
HCG should drop >15% between days 4 and 7 after treatment, >15% weekly after

Question 22

multi dose MTX regimen

Answer 22

1 mg/kg on days 1, 3, 5, 7, with leucovorin 0.1 mg/kg on days 2, 4, 6,8
recommended for cornual/cervical pregnancies when managed medically
check hCG on either odd days, after the day 1 administration (3, 5, 7). On whichever odd day, the hCG declined >15%, no further mtx administered. Weekly monitoring

Question 23

heterotopic pregnancy rate

Answer 23

spontaneous?: 1:30,000
IVF: 1.5/1000

Question 24

cyst aspiration recurrence rate

Answer 24

44% at 6 months for pre menopausal woman, 25% menopausal

Question 25

Torsion ovarian function

Answer 25

preserved in >90% of cases by 3 months

Question 26

tumor markers for
mucinous epithelial tumor
endodermal sinus tumor
choriocarcinoma and germ cell
granulosa cell tumor
dysgerminoma

Answer 26

mucinous: CEA
endodermal: AFP, hCG
chorio: bHCG, AFP, +/- LDH
granulosa: estrogen and inhibin
dysgerminoma: LDH, hCG

Question 27

adnexal mass is post menopausal patient workup

Answer 27

H&P
ultrasound
tumor markers
CT or MRI
laparoscopy or laparotomy
if suspicious for malignancy- refer to gyn onc

Question 28

indications for inpatient treatment of PID

Answer 28

pregnancy
failed outpatient management
severe disease
suspected abscess
unclear diagnosis
generalized peritonitis
temp >38.3
WBC >15k
inability to tolerate PO or fu

Question 29

risk and benefits of BSO

Answer 29

don’t do before 55-65 yo
increased risk of cardiovascular disease, nega impact on bone health, cognitive function and overall mortality
removal reduces risk of ovarian ca, put still possible from pelvic peritoneum
Also reduces risk of breast cancer (if removed premenopausal)