2- Vulvar and Ovarian Disease Flashcards
Postmenopausal pt presents with pruritis and pain (dysuria, dyspareunia). On PE you note “cellophane paper” plaques and fragility (purpura, erosions, fissures) that starts periclitorally and spreads to perineal skin. What are you concerned for?
Lichen sclerosus
What areas of the genitalia are spared with lichen sclerosus?
Keratinized/ hair bearing labia and mucus membranes
(vaginal, vestibule, rectal mucosa)
Elderly pt with untreated lichen sclerosus and hyperkeratotic lesions is at an increased risk for what?
Squamous cell carcinoma
What is used to confirm dx of lichen sclerosus?
Vulvar punch biopsy
What is the treatment for lichen sclerosus and what are the side effects?
Temovate (ultrapotent steroid ointment)
SEs: atrophy, dermatitis, rosacea
Pt presents with acute, unilateral labial swelling and c/o pain with intercourse, sitting, or walking. PE shows tender, fluctuant labial mass with surrounding erythema/ edema. What are you concerned for?
Bartholin cyst/ abscess
What is the treatment for bartholin cyst/ abscess?
I+D with Word catheter +/- culture/ abx
What pt edu should be provided if diagnosis of bartholin cyst/ abscess?
Sitz baths 2-3 days, no intercourse until cath removed
Although ultimately unknown, the pathophysiology of what vulvar disease might be a/w estrogen concentration (onset ~ menopause), pelvic floor dysfunction, psych factors, or neurologic sensitization (more sensitive to pain)?
Vulvodynia
Pt presents with vulvar discomfort described as burning and stabbing and reports pain with intercourse. PE shows pain limited to vestibule with q-tip palpation. What might you be concerned for?
Vulvodynia
In additional to q-tip palpation, what other physical exam should you perform for a pt with suspected vulvodynia and what are you checking for?
Single digit exam
Feel for spasm/ tenderness of pelvic floor musculature
What is the treatment for vulvodynia?
Topical vaginal estrogen with testosterone + pelvic floor PT +
Nortriptyline OR Gabapentin
What type of VIN is a/w HPV type 16 and 18, seen in younger women, and has RFs of smoking, IMC, and multiple sex partners?
VINU (usual type)
What type of VIN is unrelated to HPV, seen in older women (hx of lichen sclerosus), and involves only the lower 1/3 of the epithelium?
VIND (differentiated type)
How are VINU and VIND diagnosed?
Vulvar colposcopy
Pt presents with vulvar burning and itching (although most asx). You suspect VINU. If on vulvar colposcopy a lesion is noted, what additional mandatory work up is needed?
Colposcopy of cervix (a/w high grade CIN)
Although no treatment provides guaranteered cure for VINU (intractable vulvitis), what off-label medical/ topical therapies may be used?
5FU cream (Efudex), Interferon, Imiquimod cream
What is the standard of care for VINU?
Surgical tx (prevent progression to CA) = CO2 laser, local wide excision, vulvectomy)
*NO CO2 laser if suspected invasion*
What is the tx for VIND and how is it prevented?
Tx: surgical excision (prevent progression to CA)
Prevention: tx underlying condition
What follow up recommendations should be considered for pt with VIN?
Gardasil vaccine ≤ 45 yo (VINU)
Lifetime risk for recurrence
Vulvar colposcopy @ 6 mos, 12 mos, anually
Vulvar CA is most common in what populations?
Bimodal peak: 20-40 yo (VINU) and 60-70 yo (VIND)
How does vulvar CA typically present?
ASX (inspect vulva)
If sx: pruritus, vulvar bleeding/ pain
Pt presents with large, exophytic, cauliflower like lesions or small ulcerative lesions with surrounding hyperkeratosis on the vulva. What are you concerned for?
SCC
Pt presents with raised lesion with an ulcerated center and rolled borders on the vulva. What are you concerned for?
BCC
Pt presents with a raised, darkly pigmented lesion at the labia minora and clitoris. What are you concerned for?
Malignant melanoma
Staging for vulvar CA is based on FIGO. What is the primary treatment?
Complete surgical removal of tumor w/ inguinal node dissection + radiation therapy if lymph node spread
What must be present for an individual to develop VaIN (vaginal intraepithelial neoplasia)?
HPV
Majority of lesions a/w vaginal intraepithelial neoplasia are located in what part of the vagina?
Upper 1/3
How is VaIN (vaginal intraepithelial neoplasia) classified?
VaIN 1: benign viral proliferation
VaIN 2: intermediate risk
VaIN 3: true precursor to vaginal CA
How is VaIN (vaginal intraepithelial neoplasia) diagnosed?
Detection via pap smear (cytology), confirmed via colposcopy
What is the management for VaIN 1?
Observation (younger women) + cytology/ HPV/ colposcopy q 6 months
What is the mangement for VaIN 2/3?
Surgical intervention- vaginectomy = highest success rate, laser vaporization
Topical chemo/ 5FU- if other tx options not feasible
What is the most common type of vaginal CA?
SCC
Pt presents with leukorrhea, vaginal odor, and post-coital bleeding (although can be asx). Pap smear is abnormal and colposcopy shows acetowhite changes, punctation or mosaicism. What are you suspicious for?
Vaginal CA
Although occurence of vaginal CA is so rare there is no standardized tx, what is the most common management?
Vaginectomy + radiation
Pathophysiology including abn androgen/ estrogen metabolism, high T levels, insulin resistance, decreased adiponectin, and increased LH/ decreased FSH is suggestive of what condition?
PCOS
Pt presents with oligomenorrhea/ amenorrhea and states she is having difficulty getting pregnant. You note acne and hirsutism on PE. What are you concerned for?
PCOS
How is PCOS diagnosed using the Rotterdam/ NIH criteria?
Exclude: hyperprolactinemia, CAH, Cushing’s syndrome PLUS
2 of the 3: oligomenorrhea, clinical/ biochemical signs of hyperandrogenism, polycystic ovaries
US of pt shows “string of pearls” and no evidence of dominant follicle/ corpus luteum. What are you concerned for?
PCOS
(also may note presence of > 12 follicles (2-9mm each) in each ovary/ ovarian volume > 10mL)
Pt with suspected diagnosis of PCOS shows a total testosterone > 60 ng/dL (N = 40-60). What additional labs should be ordered? (6)
17-OH progesterone, DHEA-S, cortisol, prolactin, TSH, HCG
*Prolactin should be NORMAL in PCOS pts*
What is the treatment for PCOS? (4)
Weight loss
Metformin (if hyperinsulinemia) + Clomid (if infertility)
Low androgenic OCP’s
Provera (endometrial protection)
US of adnexal mass on premenopausal pt shows a thin walled <3cm mass or <1cm mass on postmenopausal pt. What is the likely dx?
Simple cyst (benign)
US of adnexal mass shows a thin walled hyperechoic nodule with distal acoustic shadowing. What is the likely dx?
Teratoma (benign)
US of adnexal mass shows a thin walled mass with network of linear or curvilinear pattern. What is the likely dx?
Hemorrhagic cyst (benign)
US of adnexal mass shows a thin walled mass with homogenous echos. What is the likely dx?
Endometrioma (benign)
US of adnexal mass shows thick septations > 2mm, solid component that appears nodular or papillary, and (+) blood flow. What is the likely dx?
Malignant mass
What type of ovarian cyst is the most common, ranges in diameter from 2-8cm, is non-malignant, regresses after 1-2 menstrual cycles, and results from either failure of the mature follicle to rupture or failure of the non-dominant follicles to undergo atresia?
Follicular
What type of ovarian cyst ranges in size from 3-11cm, resolves after 1-2 menstrual cycles and is the result of failure of the corpus luteum to resolve following ovulation?
Corpus luteum
What type of ovarian cyst is a/w elevated chorionic gonadotropin levels, is usually seen bilaterally, contains clear/ straw-colored fluid, and regresses spontaneously with tx of underlying disorder?
Theca lutein
What type of cyst represents ~ 1/2 of benign neoplasms, is seen in reproductive ago women, and is thought to have originated from germ cells/ layers?
Mature teratoma
(Ectodermal germ cell most common = hair, teeth)
Pt presents with pelvic pain, urinary frequency/ urgency, and back pain (although may be asx). On bimanual exam you note a pelvic mass. Transvaginal US shows a unilateral, complex, cyst and all tumor markers are within N limits. What are you concerned for?
Mature teratoma
What is the treatment for a mature teratoma?
Surgery
What type of ovarian cyst is lined with columnar epithelium, secretes a thick, gelatinous mucin, is thin-walled and ranges in size, and is common in women ages 30-50 yo?
Mucinous > serous cystadenoma
What is the treatment for a mucinous/ serous cystadenoma?
Surgical excision + ensure benign pathology
What is the 2nd common gynecologic CA, most common cause of gynecologic CA death in the US, and has the highest incidence among women ages 65-74?
Ovarian CA
Increased menses (nulliparity, early menarche, late menopause) place women at an increased risk for what?
Ovarian CA
What are the protective factors (risk reduction) of ovarian CA?
Decreased menses (elective sterilization, muliparity, breastfeeding, OC use)
What are the 4 main categories of ovarian CA?
Epithelial (arising from surface of ovary), germ cell (arising from internal ovary), sex cord/ stromal, mets from other location
Epithelial ovarian CA arising from the fallopian tube is a/w what?
High-grade serous papillary carcinoma (most common)
(others: endometrioid, clear cell, mucinous)
What type of ovarian CA more commonly occurs in women ages 20-30 yo, are usually unilateral, and only make up ~2-3% of all ovarian cancers?
Germ cell ovarian CA
What is the most common type of germ cell ovarian cancer?
Dysgerminoma
(others: yolk sac tumor, immature teratoma, embryonal carcinoma, choriocarcinoma)
What type of sex-cord stromal tumor is the most common and causes hyperestrogenism (precocious puberty, post-menopausal bleeding)?
Granulosa cell
What type of sex-cord stromal tumor is rare and causes hyperandrogenism?
Sertoli-stromal cell
PE of female pt shows ascites, inguinal lymphadenopathy and pelvic mass. You are concerned for ovarian CA. What is the 1st line imaging used for inital workup?
Transabdominal/ vaginal US
What type of ovarian CA are you concerned for if you note elevated CA-125 (tumor marker)?
Epithelial ovarian CA
What type of ovarian CA are you concerned for if you note elevated hCG, AFP, LDH (tumor markers)?
Germ cell tumor
What is the treatment for epithelial ovarian CA and germ cell ovarian CA?
Consult gyn-onc, surgical staging
Epithelial: chemo
Germ cell: removal of involved adnexa w/ preservation of contralateral adnexa/ uterus (if early dx)
