Gynae Flashcards by Sabrina Yeh

Cervical mass DDx

Cervical polyp or fibroid (including prolapsed uterine fibroid)

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Subtypes of cervical ca

SCC, adenocarcinoma (clear cell, endometroid, mucinous)

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Cervical ca risk factors

HPV 16/18, multiple sexual partners, smoking, young age at first intercourse, high parity, immunosuppression

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Cervical ca pathology

HPV integrates with host DNA, viral proteins E6 and E7 disrupt tumour suppressor proteins. LSIL (lower third atypia, 10% become HSIL), HSIL (lower 2/3rds or more, 10% become cancer)

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Cervical Ca staging

FIGO: 1 - cervix, 2a - outside cervix with no parametrial invasion (surgery), 2b - parametrial involvement (chemoradio), 3 - pelvic sidewall/hydronephrosis, 4 - bladder/rectum

2b is key differentiator

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Cervical ca screening in australia

Free 5 yearly screening swabs (looking for evidence of HPV) for for women 25-74

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What are the types of Mullerian duct anomalies?

1 - uterine agenesis (MRKH syndrome)
2 - unicornuate
3 - didelphys
4 - bicornuate
5 - septate/subseptate (most common 45%)
6 - arcuate
7 - DES

MRKH syndrome is a congenital condition characterized by the absence of the uterus and the upper two-thirds of the vagina.

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What are the complications of a septate uterus?

Infertility (requires septoplasty)

Septoplasty is a surgical procedure to correct a septate uterus, which can improve fertility outcomes.

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What are the associations of Mullerian duct anomalies?

Renal anomalies (renal agenesis, crossed fused ectopia, duplex)

These renal anomalies are often seen in conjunction with Mullerian duct anomalies due to their embryological origins.

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What are the MRI findings for fibroids (leiomyomas)?

High T1, low T2, variable enhancement. If degeneration, opposite signal

MRI is a useful imaging modality for characterizing fibroids and their degeneration can change imaging characteristics.

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What are the subtypes of fibroids (leiomyomas)?

Intrauterine:
* subserosal
* intramural
* submucosal
Extrauterine:
* cervical
* broad ligament

The location of fibroids can significantly affect symptoms and treatment options.

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What are the risk factors for Fibroid (leiomyoma)?

Age, family history

Risk factors can influence the likelihood of developing fibroids.

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What is the pathology of Fibroid (leiomyoma)?

Benign monoclonal tumours of smooth muscle cells and fibrous connective tissue

This describes the basic structural composition of fibroids.

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What are the types of degeneration for Fibroid (leiomyoma)?

Hyaline (most common)
Cystic
Myxoid
Red

These types indicate the various ways fibroids can change over time.

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What are the management options for Fibroid (leiomyoma)?

Myomectomy
Focal endometrial curettage
Hysterectomy
UAE (more effective for T2 hyper fibroids)
High intensity focused ultrasound

Management strategies depend on the severity and symptoms of fibroids.

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What are the complications associated with Fibroid (leiomyoma)?

Benign metastases (lung/peritoneal nodules, intravenous)
Infertility
IUGR in pregnancy due to growth
Sarcomatous transformation (<1%)
Torsion if pedunculated
Abruption if retroplacental

Complications can arise from the presence and growth of fibroids.

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What are the associations with Adenomyosis?

Endometriosis (20%)
Fibroids (50%)
Endometrial hyperplasia/polyps/cancer

These associations indicate co-occurring conditions with adenomyosis.

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What is the pathology of Adenomyosis?

Benign downgrowth proliferation of ectopic endometrial glands within the myometrial layer (presents as dysmenorrhoea/menorrhagia). >12mm junctional zone thickness is highly specific

This describes the abnormal growth patterns seen in adenomyosis.

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What are the types of Adenomyosis?

Diffuse (favours posterior wall)
Focal (adenomyoma)
Cystic

Different types of adenomyosis can affect treatment decisions.

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What is the differential diagnosis (Ddx) for AVM?

EMV (differentiate on DSA). If bHCG+ –> molar pregnancy or RPOC (centred at endometrium, not myometrium)

Differential diagnoses help in identifying the correct condition affecting the patient.

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What are the risk factors for AVM?

Multiple pregnancies
Miscarriage
Prior surgery (D&C, C-section, termination)

These factors can increase the likelihood of developing an arteriovenous malformation.

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What is the management for AVM?

O&G and IR referral (transcatheter arterial embolisation)

Management typically involves specialists in obstetrics and gynecology as well as interventional radiology.

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What are the differential diagnoses (Ddx) for endometrial cancer?

RPOC, endometritis, hyperplasia, polyp, submucosal fibroid, tamoxifen changes

RPOC refers to retained products of conception.

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What are the subtypes of endometrial cancer?

Type 1, Type 2

Type 1 is more common (80%) and associated with hyperestrogenism; Type 2 is less common (20%) and associated with endometrial atrophy.

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What is the normal endometrial thickness in premenopausal women?

2-16mm depending on cycle ## Footnote Thickness can vary during the menstrual cycle.

What is the normal endometrial thickness in postmenopausal women?

<5mm (if PVB) or <8-11mm (if no PVB) ## Footnote PVB refers to postmenopausal vaginal bleeding.

What are the stages of endometrial cancer according to FIGO?

1 - uterine body, 2 - cervical involvement, 3 - serosa/adnexal/vaginal/parametrial involvement or lymphadenopathy, 4 - bladder/rectum, ascites, distant mets ## Footnote FIGO stands for the International Federation of Gynecology and Obstetrics.

What is the pathology of a polyp?

Localized hyperplastic overgrowth of glands & stroma; pedunculated or sessile ## Footnote Pedunculated polyps are attached by a stalk, while sessile polyps are flat and attached directly.

What are the aetiologies of hydro/haematometrocolpos?

Imperforate hymen, vaginal stenosis/septum, lower vaginal atresia, cervical stenosis ## Footnote These conditions can obstruct the normal flow of menstrual blood.

What is the follow-up timeframe for a simple cyst if it is >5cm in premenopausal and >3cm in postmenopausal?

2-6 months for resolution or 6-12 months for growth rate assessment

What are the differential diagnoses for a haemorrhagic cyst?

* Ruptured ectopic (if bHCG positive) * Endometrioma * Cystic neoplasm

What is the management protocol for a haemorrhagic cyst that is >5cm in premenopausal or peri-menopausal?

Follow up US in 6-12 weeks; surgical evaluation if post-menopausal

What percentage of dermoid cysts can be malignant?

1-2% can transform into SCC

What is the recommended management for a dermoid cyst?

Short term follow up in 3 months to ensure stability

What are the possible complications of a dermoid cyst?

* Torsion (3-16%) * Rupture * 1% malignant transformation into SCC * Limbic encephalitis * Hyperthyroidism (for struma ovarii)

What happens to an endometrioma during pregnancy?

Decidualisation

Where are the common locations of endometriosis deposits?

* Ovaries * Uterosacral ligament * Bladder * Pouch of Douglas * Peritoneum * Rectum/GIT * Chest

What imaging modalities are best for the three types of endometriosis?

* Superficial: MRI, laparoscopy * Endometrioma: TV US, MRI * Deep: TA/TV US, MRI

What are the types of pathology associated with endometriosis?

* Metastatic (retrograde menstruation) * Metaplastic * Induction (from shed endometrium)

What is the management for endometriosis?

* Drugs to target hormonal regulation (GRH analogues, OCP) * Surgery (adhesiolysis, uterosacral ligament excision, hysterectomy, oophorectomy)

What is the management protocol for an endometrioma?

Follow up ultrasound yearly to ensure no malignant transformation (1% risk of ca)

What are the IOTA criteria for benign ovarian tumours?

* Unilocular cyst * Smooth multilocular <10cm * Solid components <7mm * Acoustic shadows * No vascularity

What are the IOTA criteria for malignant ovarian tumours?

* Irregular solid * Irregular multilocular-solid >10cm * >4 papillary structures * Ascites * High vascularity

What are the types of ovarian tumours?

* Epithelial (serous, mucinous, endometrioid, clear cell, Brenner, carcinosarcoma) * Germ cell (dysgerminoma, embryonal, choriocarcinoma, teratoma, yolk sac) * Sex cord/stromal (granulosa, fibroma-thecoma, Sertoli-Leydig) * Metastases

What are the differential diagnoses for solid ovarian tumours in pre-menopausal women?

* Dysgeminoma * Immature teratoma * Sertoli-Leydig * Juvenile granulosa cell tumour

What are the differential diagnoses for solid ovarian tumours in post-menopausal women?

* Brenner * Fibroma-thecoma * Adult granulosa cell tumour

Which ovarian tumours are typically bilateral?

* Endometriomas * Serous cystadenomas/cystadenocarcinomas * Metastases (including Krukenberg tumours) * Lymphoma * Endometroid * Dermoid

Which tumours are associated with Meigs syndrome?

* Fibroma (80-90%) * Thecoma * Fibrothecoma * Granulosa cell * Brenner

What are the genetic associations of ovarian cancer?

* BRCA1 * TP53 mutation * HNPCC

What is the management approach according to ORADS criteria for low-risk patients?

Specialist US/MRI, gynae referral

What is the management approach according to ORADS criteria for intermediate/high-risk patients?

Gynae-onc referral

What are the steps in the management of ovarian tumours?

* Correlate with serum tumour markers (CA125) * CT for staging (FIGO) * Refer to gynae-oncology * Likely need surgery + chemo

What is the FIGO staging for ovarian cancer?

* 1 - Ovaries * 2 - Pelvic extension * 3 - Peritoneal extension or retroperitoneal LN * 4 - Distant mets

What are the primary sites of Krukenberg tumour metastasis?

* Stomach (signet ring cells) * Colon * Breast * Lung * Contralateral ovary * Pancreas * Biliary tree

What is the differential diagnosis for multicystic ovarian morphology?

* PCOM (check for endometrial hyperplasia) * Theca lutein cysts in OHSS or molar pregnancy

What are the diagnostic criteria for polycystic morphology?

≥20 follicles per ovary and/or ≥10ml ovarian volume

What are the Rotterdam criteria for diagnosing polycystic ovary syndrome?

* Ovulatory dysfunction (oligomenorrhoea, anovulation) * Clinical/biochemical signs of hyperandrogenism (hirsutism, obesity, increased AMH) * Polycystic morphology on US

What is the classification of OHSS according to the Modified Golan criteria?

* 1 - Abdominal distension * 2 - Nausea and vomiting, diarrhoea * 3 - Ascites on imaging * 4 - Clinical ascites +/- pleural effusion * 5 - Hypovolaemia, abnormal FBC/EUC

What are the colour scores for ORADS

1 = no detectable flow 2 = flow present, challenging to see 3 = moderate flow 4 = robust flow, easily seen

How many ORADS categories

0 = incomplete 1 = normal 2 = almost certainly benign 3 = low risk malignancy 4 = intermediate risk malignancy 5 = high risk

How many sub types in ORADS 2

Simple cyst Classic benign cyst (includes hemorrhagic, dermoid, endometrioma, paraovarian, peritoneal inclusion, hydrosalpinx) Non simple unilocular cyst, smooth inner margin

Gynae Flashcards

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