18. Benign Conditions of Uterus, Cervix and Ovary/FT Flashcards
What embryonic changes do we see in female development?
[Absence of Y chromosome] and [Mullerian-Inhibiting Substance] =>
- Fusion of the mullerian (paramesonephric) ducts
- Degeneration of the mesonephric ducts
Most common congenital cervical anomalies are a result of what?
Malfusion of the paramesonephric ducts, with varying degrees of septation (didelphys cervix and septate cervix)
Failure of the paramesonephric (Mullerian) ducts to fuse causes:
- Uterus didelphysis => 2 seperate uterus with their own cervix attached to a fallopian tubes and vagina.
- Bicornuate uterus
- Bicornuate uterus with a double cervix
2 causes of uterine and cervical anomalies.
- Most occur spontaneously
- Early maternal exposure to DES
Early maternal exposure to DES can cause uterine/cervical anomalies?
- Small T-shaped endometrial cavity
- Cervical collar deformity
What is the most common neoplasm of the uterus and what does it arise from?
Uterine leiomyomas “fibroids”
- Benign tumors (rarely malignant) derived from local proliferation of smooth muscle cells of myometrium
70% of women will have a _____ by 50YO.
Fibroids
Uterine leiomyomas “fibroids” are mostly asymptomatic, but if symptomatic, what sx’s are seen and this is the most common indication for what?
- Excessive [uterine bleeding, pelvic pressure, pain and infertility]
- Most common indication for hysterectomy
4 risk factors for developing uterine leiomyomas “fibroids”
- ↑ age during reproductive years
- African American W
- Nulliparity
- Family hx
When do fibroids typically enlarge?
- 40% enlarge during pregnancy bc growth is stimulated by estrogen
- Rarely form BEFORE menarche
- Rarely enlarge AFTER menopause
What are the gross characteristics of uterine fibroids?
- Gross: Spherical, well-circumscribed, white firm lesions
- Cut section: whorled
What is the most common subtype of uterine fibroids; arise where?
INTRAMURAL, arising within myometrium
Which type of uterine fibroid is more at risk of becoming a parasitic fibroid?
Subserosal (beneath serosal surface) fibroid = Loosely connected to uterus and rarely attaches to BS or bowel mesentary.
Which type of fibroid causes more prolonged or heavy bleeding?
Submucosal fibroid = located beneath endometrium and can become pedunculated and go through cervical os
What is the most common presenting sx of uterine leiomyomas “fibroids?”
Prolonged or heavy bleeding (mostly with submucosal or intramural fibroids), but 80% are asx
Which type of fibroid is most likely to cause infertility?
Submucosal fibroid
What are some of the signs of a uterine fibroid on bimanual exam; how is the degree of enlargement characterized?
- Enlarged, irregularly shaped uterus. If a palpated mass moves => FIBROID UTERUS
- Degree of enlargement is described in “week size” used to estimate equivalent gestational size
What is used to distinguihs [adnexal masses vs lateral leiomyomas]?
US
What is the typically the 1st line of therapy for uterine leiomyomas?
- Combination (estogen + progesterone) –> OCP’s and rings
When are GnRH agonist (Depo-Lupon) used to treat uterine leiomyomas?
Used to ↓ fibroid size to alter route of surgery
How is uterine artery embolization used to treatment fibroids?
Microspheres/polyvinyl alcohol particles are introduced into the uterine a. => thrombose & occlude the artery feeding the fibroid –> necrosis of the fibroid => shrink 40-60%
Performing a myomectomy (cut the fibroid out) to treat the fibroid will result in what 2 things?
- If enter endometrial cavity => all future bbs must be delivered by c-section
- Fibroids often grow back
What is a endometrial polyp?
- Soft friable protrusion into endometrial cavity.
What may be seen on ultrasound with endometrial polyps; which type of imaging allows for better detection?
- Focal thickening of the endometrial stripe
- Saline hysterosonography and hysteroscopy*** allow for better detection
How are endometrial polyps managed clinically?
Need to remove via hysteroscopy because they COULD be endometrial hyperplasia and carcinoma.
Most endometrial polyps are benign/malignant hyperplastic masses.
benign
What are Nabothian cysts?
- NL [yellow/blue mucus-filled cysts] on the cervix that occur due to squamous metaplasia, where a layer of superficial squamous epithelium entraps a layer of columnar cells beneath, which still makes and secretes mucus.
What are the most common benign growths on the cervix?
Ectocervical/endocervical polyps
How do endocervical polyps differ from ectocervical polyps; which is most common?
- Endocervical polyp= more common; beefy red in color; arise from endocervical canal
- Ectocervical polyp = less common; pale in appearance
Symptoms and clinical management of cervical polyps
-
Sx
- None
- Coital bleeding (bleeding after sex)
- Menorrhagia (heavy periods)
-
Management
- Remove in office bc rarely malignany
What is endometrial hyperplasia caused by?
Persistant unopposed estrogen
- PCOS and anovulation
- Granulosa theca cell tumors, which make estrogen
- Obesity
Endometrial hyperplasia is a precursor to __________.
Endometrial carcinoma
Common symptoms of endometrial hyperplasia?
- Intermenstrual bleeding
- Unexplained heavy or prolonged bleeding
Which finding of the US is indicative of endometrial hyperplasia and what is the next step?
- Endometrial lining > 4mm in a post-menopausal F.
- => do a biopsy
What are the 4 types of endometrial hyperplasia and what % progress to cancer?
- Simple hyperplasia W/O atypia (1%)
- Complex hyperplasia W/O atypia (3%)
- Simple hyperplasia WITH atypia (9%)
- Complex hyperplasia WITH atypia (27%)
What is the treatment for simple and complex endometrial hyperplasia with and without atypia?
- Without atypia => progestin and resample in 3 months
- With atypia => hysterectomy
In 46 XY, complete androgen insensitivity syndrome / testicular feminization, how do we treat?
Remove functioning gonads (testes) bc they have malignant potential.
What are the functional cysts of the ovaries?
- Follicular cyst
- Lutein cyst
- Hemorrhagic cyst
- Polycystic cyst
Which functional cyst of the ovary is more likely to cause symptoms?
Hemorrhagic cysts
Are theca-lutein cysts (bi-/unilateral) and what are distinguishing characteristics?
- Usually bilateral, large (>30 cm) cysts filled w straw-colored fluid due to excessive hCG and regress when levels fall.
When are theca-lutein cysts most common?
When hCG is high
- Pregnancy
- Choriocarcinoma or hydratiform molar pregnancy
- Undergoing ovulation induction
Functional ovarian cysts, pregnancy luteomas, are caused by what?
-
Pregnancy ovarian cysts (red/brown nodule) that form bc prolonged hCG causes hyperplastic rxn of the ovarian theca cells.
- Goes away spontaneously after PG.
PCOS (polycystic ovarian cysts) is can cause what 4 things?
- Anovulatory infertility
- Menstrual abnormalities (amenorrhea)
- Hyperandrogenism (hirtuism, acne, deep voice)
- Insulin resistance (T2DM)
What causes PCOS?
-
Multiple ovarian follicular cysts in enlarged ovary form due to hormone imbalance (increase LH; low FSH)
- LH => theca cells => androgen => 1. hirtuism (body hair); 2. goes to adipose tissue and is converted to estrone (estrogen)
- Estrone then feedbacks and decreases FSH from AP => - granulosa cells => decrease in estradiol
- => follicle does not mature => cystic degeneration of the follicle.
What is a complication of PCOS?
- Increase risk of endometrial hyperplasia => endometrial carcinoma (d/t high levels of estrone)
Classic presentation of a pt with PCOS
Obese young W with infertility, oligomenorrhea and hirtuism, with insulin resistance and may develop T2DM years later.
What are the most commons benign surface epithelial ovarian tumors?
- Serous tumors
- Mucinous tumors
- Brenners tumors
What are the most commons benign sex cord-stroma ovarian tumors?
- Fibromas
- Granulosa - theca cell tumors
- Sertoli-Leydic cell tumors
What are the most common benign germ-cell ovarian tumors?
- Cystic teratoma (dermoid)
What is the single most common benign ovarian neoplasm in a PREMENOPAUSAL female?
Cystic teratoma (dermoid) = germ cell tumor
What is the most common type of epithelial ovarian tumor?
Serous cystadenoma (75%), which are benign (70%), BL or malignant (20-25%)
Malignant serous cystadenocarcinomas will often have what histologic finding?
Psammoma bodies
Treatment of serous cystadenoma?
- Surgery depends on if you want to maintain fertility
- => cystectomy
- => oophorectomy
- => hyst with bilateral oopherectomy
Which type of epithelial ovarian tumor is multiloculated can attain a huge size, sometime filling the entire pelvis and abdomen?
Benign/maligant?
Mucinous cystadenoma (2nd most common epithelial tumor), 80% benign
Mucinous cystadenomas are associated with _________ and can rarely lead to _______.
- Mucocele of the appendix
- Pseudomyxoma peritonei = > benign implants are seeded onto surface of bowel and peritoneal => make alot of mucus
What is a Brenner tumor?
Small, smooth, solid ovarian neoplasm made up of fibrotic component that surrounds bladder-like transitional cells that is usually benign.
33% of Brenners tumors are associated with _______ epithelial elements.
Mucinous
IF the ultimate differentiation of cell types in the tumor are feminine, then the tumor is what?
Feminine =>
- Granulosa cell tumor
- Theca cell tumor
- or
- Granulosa- theca cell tumor
IF the ultimate differentiation of cell types in the tumor are masculine, then the tumor is what?
Sertoli-leydig tumor
Granulosa-theca cell ovarian tumors
- Occur when?
- Sx and signs
- Malignant potential
-
Any age => produce estrogen => femininzing signs
- B4 puberty => precocious puberty (menarche and thelarche = dev of boobs), premanarchal uterine bleeding
- Reproductive age => meorrhagia
- Postmenopause => endometrial hyperplasia/cancer and post-menopausal bleeding
- Low
Sertoli-leydig ovarian tumors
- Histo
- Sx and signs
- Malignant potential
- Sertoli cells make tubules and leydig cells make Reinke crystals
- Makes androgenic components
- Hirtuism/baldness/ deep voice
- Clitormegaly
- Defeminzing F body => muscular build
What is the most common benign solid ovarian tumor?
Fibroma (sex cord-stromal tumor)= benign tumor of fibroblasts but does NOT secrete sex steroids
Ovarian fibromas can be associated with what syndrome?
- Meigs syndrome: ascites => (flows into R pleural cavity)=> right pleural effusion (hydrothorax)
What is the most common ovarain neoplasm found in women of all ages?
Germ cell tumor –> Cystic Teratoma
What is a Cystic teratoma?
- -MC-
- -Unilateral/bilateral-
- -size-
- Benign cystic tumor made up of fetal tissue from all 3 embroyological layers, mainly ectodermal tissue
- 80% occur in reproductive years (30YO)
- Bilateral (10%)
- Slow growing, most < 10cm.
What is the appearance of the Cystic Teratoma?
What happens if it ruptures?
- Multicystic with hair, teeth, sebaceous material
- Ruptures => chemical peritonitis
Rokintanksy’s protuberance is seen with what type of ovarian tumor?
What is it^?
Rokintanksy’s protuberance = prominence at the junction of the [teratoma and NL ovarian tissue]. If found, can have malignant cells.
Cystic teratoma (germ cell tumor)
Benign ovarian tumors are often asymptomatic, but can be painful in what situations?
- 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
Which is preferable for diagnosis of benign ovarian tumors, laparotomy or laparoscopy?
Laparotomy, is preferable unless the mass can be removed without rupture bc laparoscopy can be used to distinguish between [uterine fibroids vs ovarian tumors vs hydrosalpinx]/
What can US help us with when diagnosing Benign ovarian tumors?
- Simple vs complex in nature
- ID Dermoid cyst: will look like a tooth-like calcification
What tumor marker is used to diagnose benign ovarian tumors and who is it best in?
CA 125 => post-menopausal W
Can a persistent ovarian neoplasm be assumed benign?
No, must be proven by surgical exploration and pathologic exam
If surgery is warranted for ovarian neoplasm, what 2 things must be done?
- Collect pelvic washings for cytologic examination
- Obtain frozen section for histologic diagnosis
How are benign epithelial ovarian tumors typically managed; what if the diagnosis is a mucinous type?
- Typically managed w/ unilateral salpingo-oophorectomy
- If mucinous, perform an appendectomy bc there may be a appendiceal mucocele
What is appropriate management of epithelial ovarian neoplasm in young nulliparous patients vs. older women?
- Young = may perform a cystectomy to preserve ovaries
- Older = total abdominal hysterectomy w/ bilateral salpingo-oophrectomy
What is appropriate management and steps for benign mature cystic teratomas “dermoid?”
- Can be tx w/ ovarian cystectomy
- Carefully evaluate other ovary since they are bilateral in 15-20% of case
- Irrigate pelvis to avoid chemical peritonitis
How are stromal cell tumors MC treated?
Unilateral salpingo-oophorectomy
What is hydrosalpinx vs. pyosalpinx?
- Hydrosalpinx = fluid filled FT’s from previous infection
- Pyosalpinx = purulent filld tube from active infection
What is more common in fallopian tubes: benign/malignant tumors.
Benign (infectious or inflamm)
Malignancy is rare
What is one of the most common gynecologic emergencies?
Ovarian torsion = rotation of ovary on ligaments, which can impede blood supply
What is the primary risk factor for ovarian torsion?
Ovarian mass ≥5 cm
What is the classic presentation for ovarian torsion?
- ACUTE onset of unilateral pain
- Nausea and possibly vomiting
How is diagnosis of ovarian torsion made?
- US = first line imaging study to identify mass
- Definitive dx is made by direct visualization
What is treatment for ovarian torsion; how does this change if ovary is necrotic or you suspect malignancy?
- Detorsion and ovarian cystectomy to preserve ovaries
- Salpingo-oophorectomy is performed if ovary is necroticor you suspect malignancy
