40: Gynecology Flashcards

Question

Which gynecologic diagnosis is under hormonal influence and can cause recurrent abortions, infertility, and bleeding?

Answer 1

Uterine fibroids (leiomyoma)

Answer 2

* Ovarian cancer: **Clear cell** subtype * Endometrial cancer: **Serous** and **papillary** subtypes [Wikipedia: Clear cell ovarian tumors are part of the surface epithelial-stromal tumor group of ovarian cancers, accounting for 6% of these cancers. Clear cell tumors are also associated with the pancreas and salivary glands.]

Answer 3

* \<40 year old with anovulation: **Clomiphene citrate** * \<40 year old with leiomyoma: **GnRH agonists** (leuprolide) * \>40 year old: **Biopsy** to rule out cancer [UpToDate: Abnormal uterine bleeding (AUB) is a common gynecologic problem and may cause anemia and impair quality of life. Prolonged bleeding that is not cyclical is often caused by ovulatory dysfunction (AUB-O). In contrast, heavy menstrual bleeding (HMB) is cyclical and often associated with structural uterine disorders. AUB treatment choices should take the following factors into consideration: etiology; severity of bleeding (eg, anemia, interference with daily activities); associated symptoms and issues (eg, dysmenorrhea/pelvic pain, infertility); contraceptive needs and plans for future pregnancy; medical comorbidities; risk of venous or arterial thrombosis; and patient preferences regarding, as well as access to, medical versus surgical and short-term versus long-term therapy. The goal of initial therapy is to control the bleeding, treat anemia (if present), and restore quality of life. Initial therapy is typically pharmacologic. Once the initial treatment goals have been accomplished, some women are satisfied with continuing chronic medical therapy, while others desire a treatment that requires less maintenance or is definitive. For most women with HMB, we suggest estrogen-progestin contraceptives rather than other medications as first-line therapy (Grade 2C). Oral or injectable progestin-only medications are also reasonable as first-line management. The levonorgestrel-releasing (20 mcg/day) intrauterine device (LNg20 IUD; Mirena) is the most effective medical treatment of HMB. However, due to logistical/financial issues, it is often appropriate to begin therapy with estrogen-progestin regimens or oral/injectable progestin therapy. Tranexamic acid or nonsteroidal antiinflammatory drugs are useful for patients with HMB who have contraindications to or would prefer to avoid hormonal agents. Expectant management is reasonable for women who are not anemic and do not desire treatment. For women with AUB-O, estrogen-progestin formulations, oral progestin therapy, or the LNg20 are first-line treatment options, as these approaches reduce bleeding and decrease the risk of endometrial hyperplasia or cancer. We suggest the LNg20 rather than endometrial ablation (Grade 2C). Endometrial ablation is a reasonable choice in women who do not desire future pregnancy and wish to avoid using or changing an intrauterine device. Hysterectomy is a reasonable option in women who do not desire future pregnancy, who desire definitive therapy, and who are aware of the risk of perioperative complications Estrogen-progestins contraceptives are contraindicated in women with risk factors for venous or arterial thrombosis (eg, history of venous thromboembolism, known thrombogenic mutations, ≥35 years-old and smoking ≥15 cigarettes/day). Progestins may be appropriate for some women with such risk factors, but medical consultation may be required. For women at an increased risk of venous or arterial thrombosis treated for AUB with progestins, we suggest the LNg20 rather than depot medroxyprogesterone acetate (DMPA) or high-dose oral progestins (Grade 2C).]

Answer 4

1. Gestational sac: Seen with beta-HCG of 1,500 2. Fetal pole: Seen with beta-HCG of 6,000 [UpToDate: Human chorionic gonadotropin — Detection of human chorionic gonadotropin (hCG) in blood or urine is the basis of all pregnancy tests. HCG is secreted into the maternal circulation after implantation, which occurs 6 to 12 days after ovulation. This is the earliest that hCG can be detected with an ultrasensitive test. Late implantation has been associated with an increased risk of pregnancy loss. The hCG concentration doubles every 29 to 53 hours during the first 30 days after implantation of a viable, intrauterine pregnancy; a slower rise is suggestive of an abnormal pregnancy (eg, ectopic, early embryonic death). In a study of women with normal menstrual cycles who were attempting to conceive, the median hCG concentration on the first day of expected but missed menses was 239 milli-int. units/mL in serum and 49 milli-int. units/mL in a spot urine, but there was a wide range among individuals. The range of hCG values was narrower in a study of over 4400 women who conceived by IVF, underwent embryo transfer two to three days after egg retrieval, and had at least one viable embryo at 8 weeks of gestation: the median hCG concentration on day 12 after embryo transfer was 118 milli-int. units/mL (interquartile range 98). The concentration of hCG peaks at 8 to 10 weeks of gestation, averaging 60,000 to 90,000 milli-int. units/mL at that time, but again the range of normal is quite wide (5000 to 150,000 milli-int. units/mL or more); thus, hCG levels are not useful for estimating gestational age, except in the first one to three weeks post-conception. In the next 10 weeks, hCG levels decline, reaching a median concentration of about 12,000 milli-int. units/mL at 20 weeks, again with a wide range of normal: 2000 to 50,000 milli-int. units/mL or more. HCG concentration stays relatively constant from about the 20th week until term.]

Answer 5

* Main risk factor: Multiple sexual partners * Two most common causes: Chlamydia (most common), gonorrhea * Diagnostic characteristics: Cervical motion tenderness, cervical cultures, positive gram stain * Treatment: Ceftriaxone (for gonorrhea) and doxycycline (for chlamydia) [UpToDate: PID is a polymicrobial infection, which generally requires broad coverage, particularly among those with severe disease requiring hospitalization. Acute PID is an ascending infection **caused by** cervical microorganisms (including C. trachomatis and N. gonorrhoeae), as well as the vaginal microflora, including anaerobic organisms, enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella vaginalis, which is associated bacterial vaginosis. Bacterial vaginosis results in complex alterations of the normal vaginal flora, which may alter host defense mechanisms in the cervicovaginal environment. Mycoplasma genitalium is recognized as a cause of urethritis in men, but its role in pelvic inflammatory disease is less well-defined. The presumptive clinical **diagnosis** of PID is made in sexually active young women, especially women at high risk for sexually transmitted infections (STIs), who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam. The sensitivity of this clinical diagnosis is only 65% to 90%, but because of the potential for serious reproductive sequelae if PID treatment is delayed or not given, this presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID. Even patients with minimal or subtle findings should be treated since the potential consequences of withholding therapy are great. In general, adding more diagnostic criteria increases the specificity, but decreases the sensitivity of the diagnosis. The following additional findings can be used to support the clinical diagnosis of PID: * Oral temperature \>101°F (\>38.3°C) * Abnormal cervical or vaginal mucopurulent discharge or cervical friability * Presence of abundant numbers of white blood cells (WBCs) on saline microscopy of vaginal secretions (eg, \>15 to 20 WBCs per hpf or more WBCs than epithelial cells) * Documentation of cervical infection with N. gonorrhoeae or C. trachomatis For outpatient **therapy** of mild or moderate PID, we suggest ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) (Grade 2B). We suggest the addition of metronidazole (500 mg orally twice a day for 14 days) for those with a history of gynecological instrumentation in the preceding two to three weeks.]

Answer 6

* Estrogen secreting tumor causing precocious puberty: **Granulosa-theca tumor** * Androgen secreting tumor causing masculinization: **Sertoli-Leydig tumor** * Thyroid tissue: **Struma ovarii** * Elevated beta-HCG: **Choriocarcinoma** [Other ovarian tumor types include: teratoma, mucinous, serous, and papillary tumors.]

Answer 7

Oral contraceptives [UpToDate: Our approach to treating endometriosis-related pain treatment is based on the severity of symptoms. Other causes of pelvic pain are excluded prior to treatment. For women with mild to moderate pain, we suggest nonsteroidal anti-inflammatory drugs (NSAIDs) and continuous hormonal contraceptives rather than either agent alone (Grade 2C). These therapies are low-risk, have few side effects, are low-cost, and are generally well-tolerated compared with other medical therapies. Women who wish to conceive can use the NSAID alone. Women with adequate symptom improvement continue the hormonal therapy/NSAID regimen until pregnancy is desired or the average age of menopause is reached. Women whose symptoms do not improve continue NSAID treatment and are offered an alternate hormonal combination (eg, change to a different estrogen-progestin contraceptive or norethindrone acetate). For women with severe symptoms, symptoms that do not respond to the above therapies, or recurrent symptoms, we suggest a trial of gonadotropin-releasing hormone (GnRH) agonist with add-back hormonal therapy rather than surgical resection (Grade 2C). GnRH agonist treatment has demonstrated efficacy without the risks or negative impact on ovarian reserve of surgery. Women who continue to have refractory symptoms despite GnRH agonist treatment are offered medical therapy with an aromatase inhibitor. Women whose pain does not respond to the above treatments are offered laparoscopy for confirmation of the diagnosis and surgical resection.]

Answer 8

* Stage I: Total abdominal hysterectomy and BSO or XRT * Stage II: Total abdominal hysterectomy and BSO or XRT * Stage III: Total abdominal hysterectomy and BSO **and** XRT * Stage IV: Total abdominal hysterectomy and BSO **and** XRT [UpToDate: We recommend total extrafascial hysterectomy with bilateral salpingo-oophorectomy performed either via laparotomy or laparoscopy for staging and initial management of endometrial carcinoma (Grade 1B). Women with apparent stage IA grade 1 endometrial carcinoma who wish to preserve fertility can opt to avoid TAH-BSO and undergo progestin therapy, but the optimum surveillance of these women is not known and they are at risk for recurrent and synchronous disease. Thus, we recommend that these women undergo TAH-BSO after completion of childbearing, even in cases with demonstrated tumor regression (Grade 1C). We suggest surgical cytoreduction for women with pelvic or intra-abdominal disease (Grade 2C). The status of both the pelvic and paraaortic lymph nodes should be assessed intraoperatively in all patients. Given the importance of identification of nodal metastases to staging and treatment decisions, this assessment should be performed by experienced surgeons, such as gynecological oncologists. Lymph node dissection provides the most comprehensive and precise evaluation of patients with apparent stage I endometrial carcinoma (Grade 2B). It is reasonable not to remove lymph nodes in those who do not have individual patient or tumor characteristics (eg, serous, clear cell, or high-grade histology; myometrial invasion \>50%; or a large tumor) associated with a high risk of nodal metastases. Women with endometrial carcinoma who do not undergo at least sampling of pelvic and paraaortic lymph nodes at the time of surgery are incompletely surgically staged. For women with endometrial carcinoma who are undergoing lymph node evaluation, we suggest pelvic and extended paraaortic lymph node dissection rather than nodal sampling alone (Grade 2C). For women with stage II endometrial carcinoma, we suggest performing a simple hysterectomy (extrafascial class I) with lymphadenectomy rather than radical hysterectomy (Grade 2C). The exceptions to this are women with gross cervical involvement in whom performing a simple hysterectomy would cut through the tumor (all gross disease should be removed) and/or those in whom it is uncertain whether the primary is cervical or uterine.]

Answer 9

Syndrome: **Meig's syndrome** Treatment: **Excision of tumor** cures syndrome [UpToDate: The association of ovarian fibroma with ascites and/or pleural effusion is termed Meigs' syndrome. Fluid accumulation is probably related to substances like vascular endothelial growth factor (VEGF) that raise capillary permeability. Removal of the neoplasm results in elimination of ascites and pleural effusion. Several cases of Meigs' syndrome have been reported in association with elevated serum CA 125 levels. Thus, neither ascites or pleural effusion, nor an elevated CA 125 is necessarily indicative of an advanced epithelial ovarian carcinoma in a woman with a pelvic mass. Pseudo-Meigs' syndrome (a clinical syndrome of pleural effusion, ascites, and an ovarian mass that is not a fibroma or fibroma-like mass/tumor) has been reported from a number of sources, such as leiomyomas, struma ovarii, mucinous cystadenoma, teratoma, and malignancies that are metastatic to the ovary (particularly colorectal cancer). Ovarian fibromas associated with basal cell cancers are called nevoid basal cell carcinoma syndrome or Gorlin syndrome. Other associated findings include odontogenic keratocysts, brain neoplasms, and mesenteric cysts. Gorlin syndrome is inherited as an autosomal dominant trait with high degree of penetrance (97%), but variable expressivity. Whether the inherited germline abnormality responsible for Gorlin syndrome (a mutation in the patched or PTCH1 gene on chromosome 9) is related to the development of ovarian fibromas as well is unclear.]

Answer 10

* 1st trimester bleeding, closed os, positive sac on U/S, and no heart beat: **Missed abortion** * 1st trimester bleeding, positive heartbeat: **Threatened abortion** * Tissue protrudes through os: **Incomplete abortion**

Answer 11

* Stage of ovarian cancer with bilateral ovary involvement: **Stage Ib** * Most common initial site of regional spread: **Other ovary** * Role of debulking: **Can be effective at helping chemo and XRT** (including omentectomy) * Treatment: **Total abdominal hysterectomy** and **bilateral oophorectomy** for all stages [Treatment includes pelvic and para-aortic lymph node dissection, omentectomy, 4 quadrant washes, and chemotherapy (Cisplatin and Paclitaxel).]