4. Gynaecology p61-72 (Uterus and Vagina)

Question 1

Uterus - changes during life (6)

Answer 1

Neonate
- Uterus is larger than expected for baby (maternal/placental hormones are still working)
- Cervic is often larger than the fundus
Pre-puberty
- Shape of uterus changes, becoming more tube like, cervix and uterus are same size.
Puberty
- Shape changes again, now looking more adult like (pear shape, fundus larger than uterus)
- Uterus starts to have a visible endometrium, phases vary during cycle

Question 2

Ovaries - changes during life (2)

Answer 2

Infants tend to have large ovaries (1cc), then decreases and remains just under 1cc until age 6.
Ovaries then gradually increase to normal adult size as puberty approaches and occurs.

Question 3

Turner syndrome (3)

Answer 3

45XO.
Often get aortic coarctation and horseshoe kidneys.
Pre-puberty uterus and streaky ovaries.

Question 4

Embryology (8)

Answer 4

Mullerian ducts make the uterus, fallopian tubes and upper 2/3 of vagina.
Urogenital sinus makes bottom 1/3 of vagina (and prostate in males).
Wolfian ducts become male parts (Vas deferens, seminal vesicles, epididymis), and should completely regress in female embryology.
The uterus is made from the same embryological origin material as the kidneys, so right and left halves fuse together at some point to make it. The central cavity is then formed by cleaving from bottom to top.

Question 5

3 main ways for embroylogy to fail (3)

Answer 5

Failure to form.
Failure to fuse.
Failure to cleave.

Question 6

Failure to form (4)

Answer 6

No embryological material one one side means no kidney or half of uterus (unicornate uterus) on one side.
Unilateral kidney is associated with Unicornate uterus.
Failure to form can be Mullerian agenesis or Unicornate uterus

Question 7

Mullerian agenesis (5)

Answer 7

Mayer-Rokitansky-Kuster-Hauser syndrome.
- Vaginal atresia
- Absent or rudimentary uterus (unicornate or bicornate)
- Normal overies.
Kidneys have issues (agenesis, ectopia) in half of cases

Question 8

Unicornate uterus (4)

Answer 8

4 subtypes (+/- rudimentary horn, +/- endometrial tissue).
Endometrial tissue in non-communicating horn will cause pelvic pain.
Endometrial tissue in a rudimentary horn (communicating or not) will increase risk of miscarriage and uterine rupture.
40% will have renal issue (usually agenesis) ipsilateral to the rudimentary horn.

Question 9

Failure to fuse (2)

Answer 9

Spectrum of mostly not fused (basically separate, uterus didelphys) or mostly fused except top (Bicornus, looks like a heart).
Both get vaginal septa (didelphis more than biconus, because it’s the more severe anomaly)

Question 10

Uterus Didelphis (4)

Answer 10

Complete uterine duplication (2 cervices, 2 uteri, 2 upper 1/3 of vagina).
Vaginal septum present in 75%.
Usually asymptomatic unless they have vaginal obstruction.

Question 11

Bicornus (4)

Answer 11

either 1 cervix (Unicollis) or 2 (bicollis).
Separation of uterus by deep myometrial cleft, looking heart shaped.
Vaginal septum is seen around 25%, less than didelphys.
Increased risk of foetal loss, less of an issue compared to septae.

Question 12

T-shaped (2)

Answer 12

DES related anomaly.
DES was a synthetic oestrogen given to prevent miscarriage in the 1940s. Daughters of such patients ended up with vaginal clear cell carcinoma and uterine anomalies, classsically T shaped uterus

Question 13

Failure to cleave (2)

Answer 13

Failure to create the cavity within the central uterus.
Classic example is Septate uterus, where a septum remains between the 2 uterine cavities.

Question 14

Septate uterus (5)

Answer 14

2 endometrial canals separated by fibrous or muscular septum.
Fibrous vs muscular can be determined by MRI, changes surgical management.
Increased risk of infertility and recurrent spontaneous abortion.
Septum has poor blood supply, and if there’s implantation on it, it will fail early.
Resecting the septum improves outcomes.

Question 15

Arcuate uterus (3)

Answer 15

Mild, smooth concavity of the uterine fundus (instead of normal, straight or convex).
Normal variant rather than malformation.
NOT associated with infertility or obstetric complications.

Question 16

Bicornuate vs Septate (6)

Answer 16

Bicornuate:
- heart shaped (fundal contour is less than 5mm above tubal ostia)
- No significant infertility issues
- Resection of the septum results in poor outcomes
Septate
- Fundal contour is normal, more than 5mm above tubal ostia
- Infertility issues - implantation fails on septim due to poor blood supply.
- Resection of the septum can help

Question 17

Hysterosalpingogram (HSG) (5)

Answer 17

Cannulation of cervix and injection of contrast under fluoro.
Done to evaluate cavity of the uterus and patency of fallopian tubes.
Performed on days 7-10 of menstrual cycle.
Contraindications: PID, active bleeding, pregnancy, contrast allergy.
Bicornate vs Septate is difficult to appreciate on HSG, needs MRI or 3D US to evaluate the outer fundal contour

Question 18

Salpingitis Isthmica Nodosa (4)

Answer 18

Nodular scarring of the fallopian tubes.
Usually involves proximal 2/3 of tube.
Unknown aetiology, likely post inflammatory/infection.
Strongly associated with infertility and ectopic pregnancy.

Question 19

Uterine AVM (4)

Answer 19

Congenital or acquired, acquired more commonly.
Can cause fatal haemorrhage.
Caused by
- Previous D&C, therapeutic abortion, C-section or multiple pregnancies.
Doppler US shows serpiginous and/or tubular anechoic structures within the myometrium with high velocity flow.

Question 20

Intrauterine adhesions (4)

Answer 20

aka Ashermans
Scarring in uterus, due to injury (prior D&C, surgery, pregnancy or infection (classically TB))
HSG: non-filing of uterus or multiple, irregular linear filing defects (lacunar pattern), with inability to appropriately distend the endometrium.
MRI: T2 dark bands
Causes infertility

Question 21

Endometritis (5)

Answer 21

In the spectrum of PID.
Often 2-5 days post delivery, especially in prolonged laour or premature rupture.
Fluid and thickened endometrial cavity.
Can have gas in the cavity (not specific in post partum women).
Can progress to pyometrium, seen as expansion with pus.

Question 22

Fibroids (uterine leiomyoma) (5)

Answer 22

Most common uterine mass.
Benign smooth muscle tumours, most common in women African ancestry.
Most common in reproductive age women.
Due to relationship with oestrogen, they grow rapidly during pregnancy, and involute in menopause.
Location is either intramural (most common), submucosal (least common) or subserosal.

Question 23

Fibroids - typical appearance (5)

Answer 23

Can look like anything, but usually hypoechoic on US, with preipheral blood flow and shadowing in a Venetian Blind pattern.
CT: peripheral calcifications (popcorn).
MRI: T1 dark to intermediate, T2 dark, variable enhancement.
Higher T2 Fibroids respond better to IR treatment.
Lipoleiomyoma is a fat containing subtype.

Question 24

Fibroid degeneration (4)

Answer 24

4 types, all have lack of enhancement (fibroids normally enhance avidly):
Hyaline
- Most common, fibroid outgrows it’s blood supply, end up with accumulation of proteinaceous tissue.
- T2 dark, no Gd enhancement.
Red (Carneous)
- Occurs during pregnancy. Cause of venous thrombosis.
- Peripheral rim of T1 brightness. T2 varies
Myxoid
- Uncommon, T1 dark, T2 bright and minimal gradual enhancementt
Cystic
- Uncommon

Question 25

Uterine leiomyosarcoma (3)

Answer 25

Risk of malignant transformation is low (0.1%).
Look like fibroid, but rapidly enlarging.
Areas of necrosis often seen.

Question 26

Adenomyosis (4)

Answer 26

Endometrial tissue migrated into myometrium.
Seen in multiparous women of reproductive age, especially with Hx of uterine procedures (C-section, D&C).
Several types, but usually generalised and favouring large portions of the uterus, especially posterior wall, but sparing cervix.
Classically causes marked enlargement of uterus, with preserved overall contour.

Question 27

Adenomyosis - imaging (4)

Answer 27

US is less specific: heterogenous uterus (hyperechoic adenomyosis with hypoechoic muscular hypertrophy), or just posterior wall enlargement.
MRI is better test: thickening of junctional zone of uterus >12mm (normal <5mm).
Thickening can be focal or diffuse.
Small high T2 signal regions corresponding to regions of cystic change.

Question 28

Thickened endometrium (6)

Answer 28

Stripe is measured without including any fluid in the canal.
Focal or generalised thickening in post menopausal women >5mm needs biopsy.
Premenopausal: up to 20mm can be normal.
Oestrogen secreting tumours - Granulosa Cell tumours of the ovary thicken the endometrium.
HNPCC have 30-50x increased risk of endometrial cancer.

Question 29

Tamoxifen changes (5)

Answer 29

Tamoxifen is a SERM (acts like oestrogen in the pelvus, blocks it in the breast).
Used for breast cancer, but increases risk of endometrial Ca.
Causes subendometrial cysts and endometrial polyps (30%).
Normal postmenopausal endometrial tissue should be <4mm, but on tamoxifen <8mm is normal.
>8mm needs biopsy.

Question 30

Endometrial fluid (2)

Answer 30

Common in premenopausal women.
In postmenopausal women, it means either cervical stenosis or obstructing mass (usually cervical stenosis)

Question 31

Cervical cancer (3)

Answer 31

Usually squamous cell, related to HPV (90%).
Stage IIa or below treated surgically.
Stage IIb (parametrial invasion) or involvement of the lower 1/3 of vagina needs chemo/radiation.

Question 32

Parametrial invasion (3)

Answer 32

The parametrium is a fibrous band that separates the supravaginal cervix from the bladder.
It extends between the layers of the broad ligament.
The uterine artery runs inside the parametrium, hence the need for chemo once invaded.

Question 33

Solid vaginal masses (2)

Answer 33

Can be secondary (cervical or uterine carcinoma protruding into vagina) or Primary (clear cell adenocarcinoma or Rhabdomyosarcoma)

Question 34

Leiomyoma

Answer 34

Rare in the vagina, but can occur. Mostly in the anterior wall.

Question 35

Squamous cell carcinoma (2)

Answer 35

Most common cancer of vagina (85%).
Associated with HPV, just like cervix.

Question 36

Clear cell adenocarcinoma (2)

Answer 36

Seen in women who’s mothers took DES.
T-shaped uterus.

Question 37

Mets (2)

Answer 37

Met to the vagina in anterior wall upper 1/3 is usually upper genital tract.
Met to vagina in posterior wall lower 1/3 is usually from GI tract

Question 38

Gartner duct cysts (3)

Answer 38

Due to incomplete regression of the wolffian ducts.
Classically located along the anterior lateral wall of the upper vagina.
If located at the level of the urethra, can cause mass effect on the urethra and symptoms.

Question 39

Vaginal rhabdomyosarcoma (5)

Answer 39

The most common tumour of the vagina in kids.
Bimodal age distribution (ages 2-6 and 14-18).
Usually come off the anterior wall near the cervix.
Can occur in the uterus, but typically invades it secondarily.
Think of this if solid T2 bright enhancing mass in the vagina/lower uterus in child.

Question 40

Nabothian cysts (2)

Answer 40

Usually on the cervix. Common.
Result of inflammation causing epithelium plugging of mucous glands

Question 41

Skene gland cysts (2)

Answer 41

Cysts in these periurethral glands can cause recurrent UTIs and urethral obstruction.

Question 42

Bartholin cysts (3)

Answer 42

Due to obstruction of the Bartholin glands (mucin secreting glands from the urogenital sinus).
Found below the pubic symphysis (helps distinguish from Gartner duct)