25. Disease Of The Uterus

Question 1

Disease of the uterus
include
non neoplastic and neoplastic

Answer 1

non neo
Abnormal uterine bleeding (AUB)
Dysfunctional uterine bleeding (DUB)
Anovulatory cycle

neoplastic
Endometriosis
Adenomyosis
Endometrial hyperplasia
Endometrial polyps
Endometrial carcinoma
Leiomyoma
Leiomyosarcomas

Question 2

Abnormal uterine bleeding (AUB)

Answer 2

Abnormal uterine bleeding (AUB)
Uterine bleeding which is different from normal menstrual bleeding in amount, duration, etc…

Question 3

Dysfunctional uterine bleeding (DUB)

Answer 3

AUB with out organic (structural) cause
Due to endocrine disturbance
Anovulatory cycle and luteal phase inadequacy are two important cause

Question 4

Anovulatory cycle

Answer 4

Occurs around menarche and menopause
Causes include – PCOS, anxiety, stress, malnutrition, hypothyroidism and hyperprolactinemia

Question 5

Luteal phase inadequacy

Answer 5

= Luteal phase defect
Ovulation occurs but corpus luteum not produce adequate amount of progesterone
Spotting and premature onset of menstrual bleeding are characteristics
Causes include – PCOS, anxiety, stress, malnutrition, hypothyroidism and hyperprolactinemia.

Question 6

Endometriosis

Answer 6

Functional endometrial gland and stroma out side endometrial lining of the uterus
6% - 10% of women
Mostly in the 3rd and 4th decades
3x increase in Endometrioid and Clear cell variant of ovarian cancer

Question 7

Pathogenesis
of endometriosis 4

Answer 7

Retrograde menstruation theory
Metaplasia of coelomic epithelium theory
Benign metastasis theory (lung or lymph nodes)
The extrauterine stem or progenitor theory (arises from stem cells derived from bone marrow)

Question 8

location of endometrial implant and appearance of nodulesof endometriosis

Answer 8

ovary
gun powder

Question 9

Clinical presentation
of endometriosis

Answer 9

Pelvic pain
Infertility (30 - 40% of infertile women has endometriosis)
Dyspareunia
Dysmenorrhea
Pain on defecation and urination
Hemoptysis

Question 9

Atypical endometriosis

Answer 9

1.7 - 4.4% of endometriotic lesions
Precursor lesion for endometriosis associated carcinomas
Cytologic atypia in the epithelial lining of the glands or gland crowding lined by atypical epithelium resembling endometrial atypical hyperplasia

Question 10

what mutation in atypical endometriosis

Answer 10

PTEN and AT-rich interactive domain-containing protein 1A (ARIDA1) mutations

Question 11

Adenomyosis
aka
define
due to

Answer 11

= Endometriosis interna
Island of endometrial gland and stroma deep in the myometrium
15 - 20% of hysterectomy specimen
Probably due to down ward growth of endometrium

Question 12

The endometrial tissue must be separated from the basalis by at least 2–3 mm

Question 13

Endometrial hyperplasia

Answer 13

Proliferation of the endometrial glands resulting in an increased gland to stroma ratio (>1 to 3:1)
Present with post menopausal bleeding
Diffuse thickening of endometrium

Question 14

causes of endo hyperplasia

Answer 14

obesity because aromatase testestrone to estradiol
menopause
pcos
functional granulosa cell tumor
estrogen replacement therapy

Question 15

Endometrial polyps
define
common in
present with
risk factor

Answer 15

Fingerlike masses project into the endometrial cavity
Common in perimenopause women
Presented with spotting or irregular bleeding
Tamoxifen is an important risk factor

Question 16

Endometrial carcinoma
define
epidemology
present with
types

Answer 16

The most common and the 2nd deadly malignant tumor of FGT
Primarily a disease of postmenopausal women, the peak incidence is in 6th to 7th decades of life and is uncommon below the age of 40 years
Present as with irregular or postmenopausal bleeding and leucorrhoea
Broadly divided in to Type I and Type II

Question 17

Type I (Endometrioid) carcinoma

Answer 17

~ 80% of cases
Associated with endometrial hyperplasia
30-80% have PTEN mutation
Associated with Lynch II syndrome (HNPCC) – breast ca + colon ca + endometrial ca

Question 18

lynch 2 syndrome

Answer 18

breast cancer
colon cancer
endometrial cancer

Question 19

Type II (serous) carcinoma

Answer 19

~ 15% of cases
Associated with endometrial atrophy
90% have P53 mutation
Serous carcinoma > clear cell and malignant mixed mullerian tumor
Has poor prognosis due to transtubal metastasis to peritoneal cavity
All are poorly differentiated (grade 3)

Question 20

Leiomyoma
aka
epidemology
define
often look

Answer 20

= fibroid, myoma
The most common neoplasm of FGT
Benign smooth muscle tumor of myometrium
Often they are multiple and are estrogen sensitive
20–30% of women older than 30 yr
More common in black women

Question 21

types based on location

Answer 21

serosal
subserosal
intramural
cervical

Question 22

clinical intramural –……………..and submucosal - ………………………..

Answer 22

menorrhagia
metrorrhagia

Question 23

Leiomyosarcomas

Answer 23

Malignant tumor of smooth muscle
Arises de novo
Often single
Peak incidence at 40 to 60 years of age

Question 24

Tumors and Cysts of fallopian tube

Answer 25

Adenomatoid tumor- Benign tumor of mesothelium, which occurs subserosally on the tube or sometimes in the mesosalpinx

Question 26

Paratubal cysts

Answer 26

The most common primary lesions of the fallopian tube. 0.1 to 2-cm translucent cysts filled with clear serous fluid

Question 27

Ovarian pathology

Answer 27

Non neoplastic – cysts (follicular cyst, luteal cyst, chocolate cyst and PCOS) Neoplastic – ovarian tumor

Question 28

Follicular cysts

Answer 28

Results from failure of ovulation due to hormonal dysfunction lined by inner granulosa cell layer and outer theca interna layer Size 3 – 8cm

Question 29

Corpus luteum cyst

Answer 29

Results from filing of corpus luteum by blood lined by luteinized granulosa cell Size 3 – 11cm

Question 30

Poly cystic ovarian syndrome (PCOS) charachteristic pathogenesis

Answer 30

Characterized by hirsutism, infertility, poly cystic ovaries, oligomenorrhea and/or anovulation. Associated with obesity, type 2 diabetes 6%-10% reproductive age women Hyperglycemia, LH/FSH >2 and increase androgen Etiology and pathogenesis is not completely understood high lh high androgen high estrone in adipose tissue feeback inhibition of fsh no estrogen to maintain follicle degeneratice follicle cyst

Question 31

= Ovarian tumor epidemology risk factors types

Answer 31

= Ovarian tumor The most common cause of death from FGT malignancy Risk factors include nulligravidity, ovarian dysgenesis, family history (BRCA1 and BRCA2 mutation) Peritoneal seeding (omental caking) Primary or secondary

Question 32

primary ovarian tumor types

Answer 32

epithelial germ cell tumor sex cord tumor

Question 33

Epithelial ovarian carcinoma

Answer 33

60 - 70 % of ovarian tumor and 90 % of malignant ovarian cancer Most of which have cystic component

Question 34

types of epithelial cell tumor mnemonic

Answer 34

serous tumor mucinous endometroid clear cell transitional some men eat cervic too

Question 35

Serous tumor

Answer 35

35% of ovarian tumor and 40% of malignant ovarian tumor Usually cystic and field by clear fluid 60% are clearly benign,15% are border line and 25% are clearly malignant. 65 % of borderline and clearly malignant are bilateral

Question 36

Mucinous tumor

Answer 36

20% of ovarian tumor and 10 % of ovarian malignant cancer Comparing to serous it tends to be larger, unilateral and multiloculated Cystic field by mucinous material and can be benign, borderline and malignant

Question 37

mucinous tumor associated with

Answer 37

Associated with pseudomyxoma peritonei (PMP) jelly belly

Question 38

Endometrioid tumor

Answer 38

5% of ovarian tumor and 15%-20% of ovarian malignant cancer 15%-30% has an accompanied endometrial carcinoma of uterus Malignant transformation of endometriosis Histologically resemble tumor of endometrium Borderline are uncommon

Question 39

Clear cell ovarian tumor

Answer 39

5% of ovarian tumor Looks like clear cell adenocarcinoma of the kidney

Question 40

Transitional cell carcinoma aka

Answer 40

= Brenner tumor 2% of ovarian tumor and 90% unilateral

Question 40

Germ cell tumor list

Answer 40

teratoma choriocarcinoma endodermal sinus carcinoma embryonal dysgerminoma

Question 41

Teratomas define type

Answer 41

Composed of tissue derived from the three germ layer (endoderm, mesoderm and ectoderm ) Divided in to three mature, immature and monodermal

Question 42

Mature teratomas

Answer 42

= Benign teratoma/dermoid cyst Majority are cystic Solid area called Rokitansky protuberance < 1% transform in to malignant cancer most commonly in to squamous cell carcinoma

Question 43

Immature teratomas

Answer 43

= Malignant teratoma Very rare Predominantly solid tumor composed of immature or embryonal tissue

Question 44

Monodermal teratoma types

Answer 44

= Specialized teratoma Struma ovarii: only thyroid tissue. May be functional and cause hyperthyroidism Carcinoid tumor: may produce serotonin (5-HT) and causes carcinoid syndrome

Question 45

Dysgerminoma epidemo high what

Answer 45

abnormal development of germ cells which give ride to the ova 2% of ovarian cancer and ~ 50% of malignant germ cell tumor 75% occurs in 2nd and 3rd decades Some occurs in gonadal dysgenesis All are malignant and radiosensitive LDH and ?PLAP may be elevated and 3-5% has elevated HCG

Question 46

Choriocarcinoma elevated what different from normal by

Answer 46

Gestational or non gestational (gonadal) Non gestational is more malignant and less responsive for chemotherapy than gestational one Metastases hematogenously Produce HCG Composed of cytotrophoblast and syncytiotrophoblast with no villi

Question 46

Yolk sac tumor what is elevated epidemology histologic features

Answer 46

= Endodermal sinus tumor. 2nd most common malignat tumor of germ cell origin Most commonly occurs in children Highly aggressive and grows rapidly Produce α- fetoprotein (AFP) The characteristic histologic feature is glomerulus like structure called Schiller-Duval body

Question 47

Embryonal carcinoma

Answer 47

Produce HCG and α-fetoprotein.

Question 48

Sex cord stromal tumor

Answer 48

granulosacell tumor theca cell tumor sertoli leydig

Question 49

Granulosa cell tumor causes histology

Answer 49

Most produce estrogen which causes precocious puberty in children and endometrial polyp/hyperplasia/carcinoma or cystic breast change in older adult Some produce androgen and cause virilization effect Histologically granulosa cell arrange them self as rosette called Call-Exner bodies

Question 50

Thecoma

Answer 50

Pure thecoma is almost always is benign Frequently in postmenopausal women. Produce estrogen and occasionally androgen

Question 51

Fibroma

Answer 51

Fibroma- benign tumor of fibroblast Hormonally inactive

Question 52

Meig's syndrome;

Answer 52

Meig's syndrome; ovarian fibroma + ascites + right side pleural effusion

Question 53

Sertoli - leydig cell tumor

Answer 53

Produce androgen and cause virilization Peak incidence in 2nd and 3rd decade

Question 54

Secondary ovarian tumor special name

Answer 54

Metastases to the ovaries 10% of ovarian tumor Usually both ovary are involved Primary sites include carcinomas of breast, genital tract, stomach, colon and appendix krukenberg

Question 55

Abdominal pregnancy

Answer 55

1ᵒ initial gestational sac implantation directly in the abdominal peritoneum. 2ᵒ after a tubal abortion or rupture. Placenta will not be removed at the time of baby delivery

Question 56

Lithopedion

Answer 56

(Greek lithos (stone) and paedion (child)), is an abdominal ectopic pregnancy in which the fetus dies but cannot be reabsorbed by the mother's body The dead fetus is retained in the abdominal cavity, forming a calcium shell around it

Question 57

vascular anastamose complications in monozygote twins

Answer 57

trap ttts

Question 58

TTTS

Answer 58

Twin-to-twin transfusion syndrome (TTTS) Unbalanced flow of blood from one twin (the donor) to its co-twin (the recipient) through one or more arteriovenous shunts If severe, it may result in the death of one or both fetuses polyhydramnios-oligohydramnios–syndrome—“poly-oli.”

Question 59

TRAP

Answer 59

This “used” arterial blood reaches the recipient twin through its umbilical arteries and preferentially goes to its iliac vessels. Thus, only the lower body is perfused, and disrupted growth and development of the upper body results. Failure of head growth is called acardius acephalus; a partially developed head with identifiable limbs is called acardius myelacephalus; and failure of any recognizable structure to form is acardius amorphous

Question 60

Placental Infections

Answer 60

Ascending infection - Commonest, always bacterial, Chorionamnionitis and “vasculitis” of the umbilical and fetal chorionic plate vessels. Results in PROM (vice versa) and preterm delivery. Hematogenous (transplacental) infection- TORCH group (toxoplasmosis and others [syphilis, tuberculosis, listeriosis], rubella, cytomegalovirus, herpes simplex. Chronic villitis

Question 61

Placenta Previa define risk contraindication in

Answer 61

Implantation of placenta in lower uterine segment Present as third trimester bleeding (APH) Risk factors include high order pregnancy, smoking, high altitude Don’t do vaginal (PV) exam unless you exclude placenta Previa in women with antepartum hemorrhage (APH)

Question 62

Placenta accreta spectrum define risk factors

Answer 62

Adhesion of placenta to myometrium due to partial or complete absence of decidua Risk factors include placenta Previa, uterine surgery and aggressive curettage Some time it can invade even penetrate the myometrium and known as placenta increta and placenta percreta respectively. Cause of retained placenta and PPH

Question 63

Placental Abruption

Answer 63

Separation of placenta before the birth of last fetus Related with hypertension and trauma

Question 64

Preeclampsia

Answer 64

=Toxemia 3% - 5% of pregnant women mainly in nulliparous Usually occurs in 3rd trimester Characterized by hypertension after 20wk of gestation, proteinuria and/or edema

Question 65

Eclampsia

Answer 65

Eclampsia = Preeclampsia + convulsions(seizer), due to cerebral artery by thrombus and delivery is mode of treatment

Question 66

what syndrome associated with preeclampsia

Answer 66

HELLP syndrome

Question 67

HELLP syndorme

Answer 67

Severe form of preeclampsia with hemolytic anemia , elevated liver enzyme and low platelets Delivery is the mode of treatment

Question 68

gestational trophoblastic diseases define include

Answer 68

a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception molar pregnancy, invasive mole, choriocarcinoma, ETT and PSTT

Question 69

Molar pregnancy define type

Answer 69

= Hydatidiform mole Result of faulty fertilization Classified in to complete and partial hydatidiform mole

Question 70

partial and complete mole difference

Answer 70

P57+ partial mole P57-complete genetic makeup partial 1 egg with 2 sperm complete 0 egg 2 sperm fetal tissue present partial absent complete villious edema some in partial most in complete trophoblastic proliferation focal proli. around hydropic villi in partial diffuse in complete risk

Question 71

Clinical presentation of molar pregnancy

Answer 71

Passage of grapes like vesicle Preeclampsia before 20 weeks of gestation Hyperthyroidism Big for date uterus

Question 72

why hyperthyroidism

Answer 72

high levels of hcg can stimulate thyroid gland hCG-α is identical to the α-subunit of LH, FSH, and TSH.

Question 73

Invasive mole

Answer 73

Mole which invade even penetrate the uterine wall Locally destructive and some time embolize to other site

Question 74

Invasive mole , choriocarcinoma and PSTT are collectively known as

Answer 74

GTN neoplasia

Question 75

Choriocarcinoma

Answer 75

Malignant proliferation of cytotrophoblast and syncytiotrophoblast 50% follow molar pregnancy, 25% follow abortion and 25% follow normal pregnancy Histologically lacks villi The most common sites of metastasis are the lungs (50%) and vagina (30% to 40%)

Question 76

Placental site trophoblastic tumor (PSTT) define hormone ? risk

Answer 76

Arises from implantation site intermediate trophoblasts Monitored by human placental lactogen (HPL) > 50% follow normal pregnancy Resistance for chemotherapy and hysterectomy is the mode of treatment

Question 77

HPL induces

Answer 77

HPL induce peripheral insulin resistance

Question 78

Epithelioid trophoblastic tumor(ETT)

Answer 78

Derived from chorionic intermediate trophoblasts