14: Upper GT disorders

Question 1

anatomic anomalies of the uterus are rare and result from problems in the fusion of ?
often associated with ?

Answer 1

the paramesonephric (müllerian) ducts

urinary tract anomalies (unilateral renal agenesis, pelvic or horseshoe kidneys, or irregularities in the collecting system) and inguinal hernias.

Question 2

symptoms of uterine anomalies

Answer 2

amenorrhea, dysmenorrhea, cyclic pelvic pain, infertility, recurrent pregnancy loss, and premature labor.

Question 3

uterine anomalies dx by

Answer 3

physical examination, pelvic ultrasound, CT, MRI, hysterosalpingogram, hysteroscopy, and laparoscopy.

Question 4

fibroids

Answer 4

benign, monoclonal, estrogen-sensitive, smooth muscle tumors of unclear etiology found in 50% of reproductive-age women

• submucosal (heavy bleeding), *intramural (most common), or subserosal and can grow to great size, especially during pregnancy
• when symptomatic, they can cause heavy or prolonged bleeding (most common), pressure, pain, and infertility (rare)
• dx by pelvic US

Question 5

fibroid incidence is 3-9x higher in what races?

other risk factors?

Answer 5

higher in black women compared to white, Asian, and Hispanic women

obese, nonsmoking, increased alcohol use, HTN, and perimenopausal women.

Question 6

fibroid treatment

Answer 6

• in most cases, none
• can be treated temporarily with Provera, danazol, or GnRH analogs to decrease estrogen and shrink the tumors, or myomectomy to resect the tumors when future fertility is desired
• treated definitively by hysterectomy in the case of severe pain, when large or multiple, when causing pressure symptoms, or when there is evidence of postmenopausal or rapid growth.

Question 7

endometrial hyperplasia is classified as simple or complex (without atypia) if ?

Answer 7

only architectural alterations (glandular crowding) exist

Question 8

endometrial hyperplasia is classified as atypical simple or atypical complex if ?

Answer 8

cytologic (cellular) atypia is also present along with architectural alterations (glandular crowding)

Question 9

endometrial hyperplasia is caused by ?

risk factors?

Answer 9

prolonged exposure to exogenous or endogenous estrogen in the absence of progesterone.
chronic anovulation, obesity, PCOS, granulosa-theca cell tumors, tamoxifen, nulliparity, late menopause, and unopposed estrogen use.
HTN, DM, Lynch II syndrome (HNPCC)-10x increase

Question 10

Risk of malignant transformation in endometrial hyperplasia

Answer 10

1% in simple hyperplasia, 3% in complex hyperplasia, 10% in atypical simple hyperplasia, and 30% in atypical complex hyperplasia
(“penny, nickel, dime, quarter”)

Question 11

endometrial hyperplasia is diagnosed with

if no atypia, how to treat?

Answer 11

EMB or D/C and if no atypia is present it is usually treated medically with progestin therapy for 3 to 6 months, followed by resampling of the endometrium.

Question 12

recommended treatment for atypical complex hyperplasia

Answer 12

hysterectomy, as risk progressing to endometrial cancer is 30%

Question 13

follicular cysts result from ?

how to manage?

Answer 13

unruptured follicles
-usually asymptomatic unless torsion occurs.
Management includes observation +/- OCPs to suppress future cyst formation, followed by repeat pelvic US

Question 14

Corpus luteum cysts result from ?
s/s?
management?

Answer 14

an enlarged and/or hemorrhagic corpus luteum

• may cause a missed period or dull LQ pain. When ruptured, these cysts can cause acute abdominal pain and intra-abdominal hemorrhage.
• should resolve spontaneously or may be suppressed with OCPs if recurrent.

Question 15

differential diagnosis for ovarian cysts

Answer 15

ectopic pregnancy, PID, torsed adnexa, tubo-ovarian abscess, endometriosis, fibroids, and ovarian neoplasms.

Question 16

Any palpable ovarian or adnexal mass in a premenarchal or postmenopausal patient is suggestive of ? and should be investigated with ?

Answer 16

ovarian neoplasm

exploratory laparoscopy or laparotomy

Question 17

Cysts that do not resolve spontaneously in ? require further evaluation and treatment with ?

Answer 17

60 to 90 days, track with serial pelvic US, CA-125 if risk for ovarian cancer (not dx)
cystectomy or oophorectomy (rarely) via laparoscopy or laparotomy.

Question 18

All reproductive structures arise from the müllerian system except the ? and the ?

Answer 18

ovaries (which arise from the genital ridge)

lower one-third of the vagina (which arises from the urogenital diaphragm)

Question 19

malfusion of paramesonephric ducts results in

Answer 19

septate uterus

Question 20

increased incidence of müllerian anomalies in women who were exposed in utero to?

Answer 20

diethylstilbestrol (DES) from 1940 to 1971
-synthetic nonsteroidal estrogen that was indicated for gonorrheal vaginitis, atrophic vaginitis, menopausal symptoms, postpartum lactation, miscarriage prevention, and for advanced prostate and breast cancer.

Question 21

uterine septa associated with ?

Answer 21

recurrent 1st trimester pregnancy loss (25%)

• lack adequate blood supply
• can be excised with operative hysteroscopy

Question 22

bicornuate uterus associated with ?

Answer 22

2nd trimester pregnancy loss, malpresentation, PTL/PTD, require C-section to avoid uterine rupture
-limited size of uterine horn

Question 23

Classification of Mullerian anomalies

Answer 23

Class I. Segmented müllerian agenesis or hypoplasia
Class II. Unicornuate uterus
Class III. Uterus didelphis
Class IV. Bicornuate uterus
Class V. Septate uterus
Class VI. Uterus with internal luminal changes

Question 24

most common indication for surgery for women in the US

Answer 24

fibroids

-1/3 of all hysterectomies

Question 25

leiomyomas vs adenomyosis

Answer 25

fibroids are surrounded by a pseudocapsule of compressed areolar tissue and smooth muscle cells (few blood/lymphatic vessels)
adenomyosis: more diffusely organized in the myometrium

Question 26

how do low dose OCPs affect fibroids?

Answer 26

protective against the development of new fibroids but may stimulate existing fibroids.
-exception: girls who start OCPs btw 13 and 16

Question 27

risk of fibroids decreases with

Answer 27

increasing parity, with oral contraception use, and injectable depot medroxyprogesterone acetate use.

Question 28

most common symptom of fibroids

Answer 28

submucosal fibroids impinging on the endometrial cavity lead to abnormal uterine bleeding: menorrhagia, postcoital spotting, metrorrhagia, menometrorrhagia
-can lead to chronic iron-deficiency anemia, dizziness, weakness, and fatigue.

Question 29

do fibroids cause pain?

Answer 29

pelvic pain is not usually a symptom
may have secondary dysmenorrhea or pressure-related symptoms: pelvic pressure, constipation, hydronephrosis, urinary retention, and venous stasis

Question 30

do fibroids cause infertility?

Answer 30

Not typically.
Submucosal fibroids can impact implantation, placentation, and ongoing pregnancy, resection can increase conception rates in infertile females

Question 31

if multiple, large (5-10cm) fibroids or located behind the placenta, may increase rates of

Answer 31

PTL/PTD, fetal malpresentation, dysfunctional labor, and Cesarean delivery.

Question 32

fibroids on physical exam

Answer 32

nontender irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions that feel firm or solid on palpation.

Question 33

how to diagnose fibroids

Answer 33

most common: pelvic US: show areas of hypoechogenicity

others: Hysterosalpingogram (HSG), saline infusion sonogram (sonohysterogram), and hysteroscopy
- MRI is especially helpful in distinguishing fibroids from adenomyosis

Question 34

medical management of uterine leiomyomas (fibroids)

GO PAN AM

Answer 34

G: GnRH agonists (nafarelin acetate, leuprolide acetate depot, and goserelin acetate)
O: OCPs
P: Progestins (medroxyprogesterone acetate, Mirena IUD, norethindrone acetate)
A: Antifibrinolytics (tranexamic acid)
N: NSAIDs
A: Androgenic steroids (danazol and gestrinone)
M: Mifepristone

Question 35

medical treatment of fibroids treat dysmenorrhea and abnormal bleeding but ? can shrink fibroids as well

Answer 35

GnRH agonists
-decrease circulating estrogen levels. Unfortunately, the tumors usually resume growth after the medications are discontinued.

Question 36

UAE goal

Answer 36

decrease the blood supply to the fibroid, thereby causing ischemic necrosis, degeneration, and reduction in fibroid size

• may compromise uterus/ovaries
• not good for large/pedunculated fibroids

Question 37

MRI-guided high-intensity ultrasound

Answer 37

uses MRI to locate individual fibroids that are then thermoablated with high-intensity ultrasound waves
-expensive and not widely available

Question 38

myomectomy

Answer 38

sx resection of 1+ fibroids from uterine wall

• good for preserving fertility
• hysteroscopically, laparoscopically with and without robotic assistance, or abdominally
• fibroids recur in more than 60% of patients in 5 years and adhesions frequently form that may further complicate pain and infertility

Question 39

indications for surgical intervention for fibroids

Answer 39

Abnormal uterine bleeding, causing anemia
Severe pelvic pain or secondary amenorrhea
Uterine size (>12 wk) obscuring evaluation of adnexa
Urinary frequency, retention, or hydronephrosis
Growth after menopause
Recurrent miscarriage or infertility
Rapid increase in size

Question 40

definitive tx for leiomyomas

Answer 40

hysterectomy

• vag/lap for small
• TAH for large/multiple

Question 41

Rapid growth of a fibroid tumor in postmenopausal women may be a sign of ? (extremely rare) or other ? and should be investigated immediately

Answer 41

leiomyosarcoma

pelvic neoplasia

Question 42

endometrial polyps

Answer 42

localized benign overgrowths of endometrial glands and stroma over a vascular core
-women 40-50, taking tamoxifen (^risk endometrial polyps, cysts, cancer)

Question 43

endometrial polyp s/s

Answer 43

abnormal vaginal bleeding: metrorrhagia, menorrhagia, menometrorrhagia, postcoital

Question 44

how to evaluated polyps

Answer 44

US, sonohysterogram, and hysteroscopy-also therapeutic

-if 45+ evaluate with EMB

Question 45

when/why to remove endometrial polyps

Answer 45

• remove in postmenopausal patients as they can mask bleeding from another sources such as endometrial hyperplasia (25%) or endometrial cancer (<1%)
• remove from premenopausal F if at risk of infertility, endometrial hyperplasia, and endometrial cancer

Question 46

endometrial hyperplasia is ?

Answer 46

abnormal proliferation of both the glandular and stromal elements of the endometrium. In its earliest stages, the stimulation results in changes to the organization of the glands. In its later, more severe forms, the stimulation results in atypical changes in the cells themselves
-can lead to endometrial carcinoma

Question 47

atypic includes these cytological changes

Answer 47

large nuclei with lost polarity, increased nuclear-to-cytoplasmic ratios, prominent nuclei, and irregular clumped chromatin

Question 48

Risk Factors for Endometrial Hyperplasia (Mnemonic: ENDOMETRIUM)

Answer 48

E: Excess exogenous estrogen use without progesterone
N: Nulliparity
D: Diabetes mellitus
O: Obesity
M: Menstrual irregularity
E: Elevated blood pressure
T: Tamoxifen use
R: Rectal cancer (personal history of hereditary nonpolyposis colorectal cancer)
I: Infertility history
U: Unopposed estrogen
M: Menopause late (> age 55)

Question 49

typical presentation of endometrial hyperplasia

Answer 49

long periods of oligomenorrhea or amenorrhea followed by irregular or excessive uterine bleeding.

• pelvic exam typically normal, uterus may be enlarged
• may show obesity, acanthuses, acne, hirsutism

Question 50

endometrial hyperplasia diagnosis

Answer 50

thickened endometrial stripe on US

-need tissue diagnosis: D/C, EMB is best

Question 51

when D/C (OR) over EMB (outpatient)?

Answer 51

insufficient tissue, patient discomfort, or cervical stenosis
-also if atypical complex hyperplasia on biopsy because approximately 30% of those patients will have a coexistent endometrial carcinoma

Question 52

Theca lutein cysts

Answer 52

are large bilateral cysts filled with clear, straw-colored fluid.
-result from stimulation by abnormally high β-hCG (e.g., from a molar pregnancy, choriocarcinoma, or ovulation induction therapy).

Question 53

Endometriomas

Answer 53

-from the growth of ectopic endometrial tissue within the ovary, aka “chocolate cysts,” -s/s of endometriosis such as pelvic pain, dysmenorrhea, dyspareunia, and infertility.

Question 54

s/s when an ovarian cyst results in a torsed adnexa

Answer 54

waxing and waning pain, and nausea and vomiting

Question 55

if reproductive age and cyst <7cm ?

Answer 55

observation w. f/u US, should resolve in 60-90 days, start on OCPs to prevent future cysts
-those that don’t resolve require valuation with cystectomy and (rarely) oophorectomy via laparoscopy or laparotomy.

Question 56

reproductive-age women with cysts larger than 7 cm or that persist or that are solid or complex on ultrasound

Answer 56

probably not just a functional cyst, follow closely with MRI or sx exploration

Question 57

an ovarian cyst greater than ? is concerning for ovarian torsion

Answer 57

4 cm