Lecture 9: Benign Conditions of Uterus, Cervix, Ovary and FT's

Question 1

Most common congenital cervical anomalies are a result of what?

Answer 1

Malfusion of the paramesonephric ducts

Question 2

What is a uterus didelphysis?

Answer 2

2 separate uterine bodies w/ its own cervix, attached fallopian tube and vagina

Question 3

A small T-shaped endometrial cavity or cervical collar deformity have historically been seen w/ exposure to what?

Answer 3

DES

Question 4

What is the most common neoplasm of the uterus and what does it arise from?

Answer 4

• Uterine leiomyomas “fibroids”
• Benign tumors derived from local proliferation of smooth muscle cells of myometrium

Question 5

Uterine leiomyomas “fibroids” are generally asymptomatic, but if symptomatic, what sx’s are seen and this is the most common indication for what?

Answer 5

• Excessive uterine bleeding, pelvic pressure, pain and infertility
• Most common indication for hysterectomy

Question 6

What are 4 risk factors for developing uterine leiomyomas “fibroids?”

Answer 6

• ↑ age during reproductive years
• African American women have 2-3 fold ↑ risk
• Nulliparity
• Family hx

Question 7

What are the gross characteristics of uterine fibroids?

Answer 7

Spherical, well-circumscribed, white firm lesions w/ a whorled appearance of cut sections

Question 8

What is the most common subtype of uterine fibroids; arise where?

Answer 8

INTRAMURAL arising within myometrium

Question 9

What is the most common presenting sx of uterine leiomyomas “fibroids?”

Answer 9

Prolonged or heavy bleeding

Question 10

What are some of the signs of a uterine fibroid on bimanual exam; how is the degree of enlargement characterized?

Answer 10

• Enlarged, irregularly shaped uterus
• If palpated mass moves with the cervix it is suggestive of a fibroid uterus
• Degree of enlargement is described in “week size” used to estimate equivalent gestational size

Question 11

What is the typically the first theapeutic option for treatment of uterine leiomyomas?

Answer 11

Combination (estogen + progesterone) –> OCP’s and rings

Question 12

When are GnRH agonist such as Depo-Lupon used as therapy for uterine leiomyomas?

Answer 12

Used to ↓ fibroid size; usually used to alter route of surgery

Question 13

What is uterine artery embolization used for treatment of fibroids?

Answer 13

Microspheres/polyvinyl alcohol particles are introduced into the uterine a. and occlude the artery feeding the fibroid –> necrosis of the fibroid

Question 14

What may be seen on ultrasound with endometrial polyps; which type of imaging allows for better detection?

Answer 14

• Focal thickening of the endometrial stripe
• Saline hysterosonography and hysteroscopy allow for better detection

Question 15

How are endometrial polyps managed clinically?

Answer 15

Need to remove via hysteroscopy since endometrial hyperplasia and carcinoma may also present as polyps

Question 16

How do endocervical polyps differ from ectocervical polyps; which is most common?

Answer 16

• Endocervical = more common; beefy red in color; arise from endocervical canal
• Ectocervical = less common; pale in appearance

Question 17

Common symptoms of endometrial hyperplasia?

Answer 17

Intermenstrual, heavy or prolonged bleeding that is unexplained

Question 18

Which finding of the endometrium on ultrasound in a post-menopausal woman warrants biopsy?

Answer 18

Endometrial lining ≥4 mm

Question 19

What is the treatment for simple and complex endometrial hyperplasia without and with atypia?

Answer 19

• Without atypia treat w/ progestin and resample in 3 months
• With atypia is best treated with a hysterectomy

Question 20

Which functional cyst of the ovary is more likely to cause symptoms?

Answer 20

Hemorrhagic cysts

Question 21

Are theca-lutein cysts (bi-/unilateral) and what are distinguishing characteristics?

Answer 21

• Usually bilateral and can become large (>30 cm)
• May develop in pt’s w/ high serum hCG; regress when gonadotropin levels fall

Question 22

Functional ovarian cysts, luteomas of pregnancy, are caused by what?

Answer 22

Hyperplastic rxn of the ovarian theca cells; 2’ to prolonged hCG stimulation during pregnancy

Question 23

Malignant serous cystadenocarcinomas will often have what histologic finding?

Answer 23

Psammoma bodies

Question 24

What is the most common type of epithelial ovarian tumor?

Answer 24

Serous

Question 25

Which type of epithelial ovarian tumor can attain a huge size, sometime filling the entire pelvis and abdomen?

Answer 25

Mucinous cystadenoma

Question 26

What are signs/sx's associated with granulosa-theca cell ovarian tumors?

Answer 26

- **Feminizing signs** - **Precocious menarche** and **thelarche** - **Premenarchal uterine bleeding** during **infancy** and **childhood** - **Menorrhagia**, **endometrial hyperplasia** and **cancer** - **Breast tenderness**, fluid retention, and **postmenopausal bleeding**

Question 27

Sertoli-leydig ovarian tumors produce what sign/sx's?

Answer 27

- **Hirsutism** + temporal blindness + deepening of voice - **Clitoromegaly** - **Defemenizing** of the **female** body habitus ---\> **muscular build**

Question 28

What is the most common benign **solid** ovarian tumor?

Answer 28

**Fibroma** (sex cord-stromal tumor)

Question 29

On occasion, ovarian fibromas can be associated with what syndrome?

Answer 29

- **Meigs syndrome** - **Ascites** + **right pleural effusion (hydrothorax)** + ovarian **fibroma**

Question 30

What is the most common ovarain neoplasm found in women of **all ages**?

Answer 30

**Germ cell tumor --\> Cystic Teratoma**

Question 31

Rokintanksy's protuberance is seen with what type of ovarian tumor?

Answer 31

Cystic teratoma (germ cell tumor)

Question 32

Benign ovarian tumors are often asymptomatic, but can be painful in what situations?

Answer 32

- If tumor **twists** on its pedicle (**torsion**) - **Rupture** of the cyst --\> **pain + peritoneal inflammation**; can occur spontaneously, with trauma, during bimanual exam, or with intercourse

Question 33

Which is preferable for diagnosis of benign ovarian tumors, laparotomy or laparoscopy?

Answer 33

**Laparotomy** is **preferable** unless the mass can be removed **without** rupture

Question 34

Can a persistent ovarian neoplasm be assumed benign?

Answer 34

**No**, must be **proven** by **surgical exploration** and **pathologic exam**

Question 35

If surgery is warranted for ovarian neoplasm what 2 things must be done?

Answer 35

- Collect **pelvic washings** for **cytologic examination** - Obtain **frozen section** for **histologic diagnosis**

Question 36

How are benign epithelial ovarian tumors typically managed; what if the diagnosis is a mucinous type?

Answer 36

- Typically managed w/ **unilateral salpingo-oophorectomy** - If **mucinous**, perform an **appendectomy** 2' to possibe coexistence of an **appendiceal mucocele**

Question 37

What is appropriate management of epithelial ovarian neoplasm in young nulliparous patients vs. older women?

Answer 37

- **Young** = may perform a **cystectomy** for **ovarian preservation** - **Older** = total abdominal **hysterectomy** w/ **bilateral salpingo-oophrectomy** is appropriate

Question 38

What is appropriate management and steps for benign mature cystic teratomas "dermoid?"

Answer 38

- Can be tx w/ **ovarian cystectomy** - **Carefully** evaluate **other ovary** since they are **bilateral** in 15-20% of cases - **Copiously irrigate** **pelvis** to avoid chemical peritonitis

Question 39

What is hydrosalpinx vs. pyosalpinx?

Answer 39

- **Hydrosalpinx** = fluid filled FT's from **previous** infection - **Pyosalpinx** = purulent filld tube from **active** infection

Question 40

What is the primary risk factor for ovarian torsion?

Answer 40

**Ovarian mass ≥5 cm**

Question 41

What is the classic presentation for ovarian torsion?

Answer 41

- **ACUTE** onset of **unilateral pain** - **Nausea** and possibly **vomiting**

Question 42

How is diagnosis of ovarian torsion made?

Answer 42

- **US** is **first line imaging** study to **identify mass** - **Definitive dx** is made by **direct visualization**

Question 43

What is treatment for ovarian torsion; how does this change if ovary is necrotic or you suspect malignancy?

Answer 43

- **Detorsion** and **ovarian** conservation w/ an ovarian **cystectomy** - **Salpingo-oophorectomy** is performed if ovary is **necrotic** or you **suspect malignancy**