40: Gynecology Flashcards
What are the 4 contraindications to estrogen therapy?
- Endometrial cancer
- Thromboembolic disease
- Undiagnosed vaginal bleeding
- Breast cancer
What is Mittelschmerz?
Pain that can be confused with appendicitis that is caused by rupture of a graafian follicle
[It occurs 14 days after the 1st day of menses.]
[Wikipedia: Mittelschmerz is a medical term for “ovulation pain” or “midcycle pain”. About 20% of women experience mittelschmerz, some every cycle, some intermittently. Hormonal forms of contraception can be taken to prevent ovulation—and therefore ovulatory pain—but otherwise there is no known prevention.]
[UpToDate: This ovulatory event causes recurrent midcycle pain in females with regular ovulatory cycles. This pain is caused by normal follicular enlargement just prior to ovulation or to normal follicular bleeding at ovulation. The pain is typically mild and unilateral; it occurs midway between menstrual periods and lasts for a few hours to a couple of days.]
What are the following characteristics of endometriosus?
- Three most common symptoms
- Most common site
- Three most common symptoms: Dysmenorrhea (painful menstruation), dyspareunia (pain with intercourse), infertility
- Most common site: Ovaries
[It can involve the rectum and cause bleeding during menses -> endoscopy shows a blue mass.]
What should be done if an incidental ovarian mass is discovered at the time of laparotomy for another procedure?
- Biopsy the mass
- 4 quadrant wash
- Biopsy omentum
- Look for metastasis and biopsy if present
[Do not perform an oophorectomy.]
Which sexually transmitted infections are associated with the below characteristics?
- Vesicles
- Condylomata
- Painless chancre
- Diplococci
- Positive dark-field microscopy
- Vesicles: HSV
- Condylomata: HPV
- Painless chancre: Syphilis
- Diplococci: Gonococcus
- Positive dark-field microscopy: Syphilis
At what gestational age can most pregnancies be seen on ultrasound?
6 weeks
[UpToDate:When cardiac activity is present, the fetal heart can usually be heard by 12 weeks of gestation using a Doppler instrument. Transvaginal ultrasound can identify fetal cardiac motion as early as 5.5.]
What are the 4 ligaments of the uterus?
- Round ligament
- Broad ligament
- Suspensory (Infundibulopelvic) ligament
- Cardinal ligament
[UpToDate: Uterosacral and cardinal ligament complex — The uterosacral/cardinal ligament complex suspends the uterus and upper vagina in its normal orientation. It serves to maintain vaginal length and keep the vaginal axis nearly horizontal in a standing woman so that it can be supported by the levator plate. Loss of this support contributes to prolapse of the uterus and/or vaginal apex. The cardinal ligaments are condensations of connective tissue that are several centimeters in width and run from the cervix and upper vagina to the pelvic sidewall. The uterine vessels run for much of their course within the cardinal ligaments. The uterosacral ligaments are bands of connective tissue that are fused with the cardinal ligaments at their point of insertion in the cervix. The uterosacral ligaments pass posteriorly and inferiorly to attach to the ischial spine and sacrum.
Round ligaments — The round ligaments are extensions of the uterine musculature. They begin at the uterine fundus anterior and inferior to the fallopian tubes, travel retroperitoneally through the layers of the broad ligament, then enter the inguinal canal, and terminate in the labia majora. The male homolog of the round ligaments is the gubernaculum testis.
Broad ligament — The broad ligament covers the lateral uterine corpus and upper cervix. The boundaries of the broad ligament are: superiorly, the round ligaments; posteriorly, the infundibulopelvic ligaments; and inferiorly, the cardinal and uterosacral ligaments. It consists of anterior and posterior leaves that separate to enclose viscera and blood vessels. Structures within the broad ligament are considered retroperitoneal. Dissection between these leaves is necessary to provide exposure of these structures. Various portions of the broad ligament are named for nearby structures, ie, the mesosalpinx (located near the fallopian tubes) and the mesovarium (located near the ovary). The broad ligament is composed of visceral and parietal peritoneum that contains smooth muscle and connective tissue.
Endopelvic fascia — The pelvic viscera are covered by endopelvic fascia, a connective tissue layer that provides support to the pelvic organs, yet allows for their mobility to permit storage of urine and stool, coitus, parturition, and defecation.
Ovary — The ovaries are suspended lateral and/or posterior to the uterus, depending upon the position of the patient. The supporting structures of the ovaries include the utero-ovarian ligament that attaches the ovary to the uterus; the infundibulopelvic ligament (also referred to as the suspensory ligament of the ovary), through which the ovarian vessels travel, that attaches the ovary to the pelvic sidewall; and the broad ligament, which condenses to form the mesovarium. It is also attached to the broad ligament through the mesovarium.]
What is the extent that endometrial cancer has spread in each stage of the disease?
- Stage I
- Stage II
- Stage III
- Stage IV
- Stage I: Endometrium
- Stage II: Cervix
- Stage III: Vagina, peritoneum, and ovary
- Stage IV: Bladder and rectum
What are the risk factors for vulvar cancer as it pertains to the below factors?
- Age (young or old)
- Parity (nulliparous or multiparous)
- Weight (thin or obese)
- Age: Elderly
- Parity: Nulliparous
- Weight: Obese
[Usually occus unilaterally.]
[UpToDate: The age-adjusted incidence of vulvar cancer in the United States was 2.5 per 100,000 women, based upon 1997 to 2004 data from a national cancer database. Vulvar carcinoma is encountered most frequently in postmenopausal women. The mean age at diagnosis is 65, but may be falling. This was illustrated in a study of 78 women diagnosed with vulvar cancer between 1979 and 1993 in which the average age at presentation dropped from 69 to 55 during this interval. Within the United States, almost 4900 cases are diagnosed each year, with over 1000 of those women expected to succumb to their disease.
Risk factors for vulvar cancer include cigarette smoking, vulvar dystrophy (eg, lichen sclerosus), vulvar or cervical intraepithelial neoplasia, human papillomavirus (HPV) infection, immunodeficiency syndromes, a prior history of cervical cancer, and northern European ancestry.
Two independent pathways of vulvar carcinogenesis are felt to currently exist, the first related to mucosal HPV infection and the second related to chronic inflammatory (vulvar dystrophy) or autoimmune processes. HPV has been shown to be responsible for 60% of vulvar cancers. Specifically, HPV 16 and 33 are the predominant subtypes accounting for 55.5% of all HPV-related vulvar cancers.
The increasing incidence of HPV-related vulvar intraepithelial neoplasia among young women may account for the fall in mean age of diagnosis of vulvar cancer discussed above. HPV DNA is found more commonly in vulvar cancers of young women who smoke as compared with older nonsmokers. Early detection and treatment of vulvar intraepithelial neoplasia may prevent the development of cancer. This may explain why the incidence of invasive vulvar cancer has remained stable even though the incidence of vulvar intraepithelial neoplasia has increased.]
What are the various treatments of cervical cancer depending on stage?
- Microscopic disease without basement membrane invasion: Cone biopsy (conization sufficient to remove disease)
- Stage I and Stage IIa: Total abdominal hysterectomy (TAH)
- Stage IIb to Stage IV: XRT
[UpToDate: Women are defined as having early-stage cervical cancer if their cancer was diagnosed on microscopic examination (stage IA) or they have a clinically visible lesion confined to the cervix measuring less than 4 cm (stage IB1).
For women with early-stage cervical cancer, we suggest a modified radical hysterectomy with pelvic lymphadenectomy rather than primary chemoradiation (Grade 2C). We reserve primary radiation therapy (RT) for women who are not candidates for primary surgery due to medical comorbidities or poor functional status.
For women with microinvasive disease (stage IA1) who have no evidence of intermediate- or high-risk features, we suggest conization or extrafascial hysterectomy rather than radical hysterectomy (Grade 2C).
For women of reproductive age who wish to preserve their fertility and have a lesion size ≤2 cm and no lymph node metastases, uterus-preserving surgery is a reasonable treatment option.
For women with early-stage cervical cancer with intermediate-risk features (ie, lymphovascular invasion, cervical stromal invasion, or tumor is ≥4 cm), we suggest adjuvant RT rather than chemoradiation (Grade 2C).
For women with early-stage cervical cancer with high-risk features (ie, positive surgical margins, pathologically involved pelvic nodes, or positive involvement of the parametria), we recommend adjuvant chemoradiation rather than RT alone (Grade 1A). We suggest adjuvant RT be administered with single-agent cisplatin rather than the combination of cisplatin plus 5-FU (Grade 2C).
Stage is the most important prognostic factor, followed by nodal status. Outcomes are worse for women with involved pelvic or paraaortic nodes.
Hormone replacement therapy appears to be a safe treatment option for women with cervical cancer who report bothersome symptoms following treatment.]
Which uterine ligaments are characterized by each of the below?
- Allows anteversion of the uterus
- Contains uterine vessels
- Contains ovarian artery, nerve, and vein
- Holds cervix and vagina
- Allows anteversion of the uterus: Round ligament
- Contains uterine vessels: Broad ligament
- Contains ovarian artery, nerve, and vein: Infundibular ligament
- Holds cervix and vagina: Cardinal ligament
[UpToDate: Uterosacral and cardinal ligament complex — The uterosacral/cardinal ligament complex suspends the uterus and upper vagina in its normal orientation. It serves to maintain vaginal length and keep the vaginal axis nearly horizontal in a standing woman so that it can be supported by the levator plate. Loss of this support contributes to prolapse of the uterus and/or vaginal apex. The cardinal ligaments are condensations of connective tissue that are several centimeters in width and run from the cervix and upper vagina to the pelvic sidewall. The uterine vessels run for much of their course within the cardinal ligaments. The uterosacral ligaments are bands of connective tissue that are fused with the cardinal ligaments at their point of insertion in the cervix. The uterosacral ligaments pass posteriorly and inferiorly to attach to the ischial spine and sacrum.
Round ligaments — The round ligaments are extensions of the uterine musculature. They begin at the uterine fundus anterior and inferior to the fallopian tubes, travel retroperitoneally through the layers of the broad ligament, then enter the inguinal canal, and terminate in the labia majora. The male homolog of the round ligaments is the gubernaculum testis.
Broad ligament — The broad ligament covers the lateral uterine corpus and upper cervix. The boundaries of the broad ligament are: superiorly, the round ligaments; posteriorly, the infundibulopelvic ligaments; and inferiorly, the cardinal and uterosacral ligaments. It consists of anterior and posterior leaves that separate to enclose viscera and blood vessels. Structures within the broad ligament are considered retroperitoneal. Dissection between these leaves is necessary to provide exposure of these structures. Various portions of the broad ligament are named for nearby structures, ie, the mesosalpinx (located near the fallopian tubes) and the mesovarium (located near the ovary). The broad ligament is composed of visceral and parietal peritoneum that contains smooth muscle and connective tissue.
Endopelvic fascia — The pelvic viscera are covered by endopelvic fascia, a connective tissue layer that provides support to the pelvic organs, yet allows for their mobility to permit storage of urine and stool, coitus, parturition, and defecation.
Ovary — The ovaries are suspended lateral and/or posterior to the uterus, depending upon the position of the patient. The supporting structures of the ovaries include the utero-ovarian ligament that attaches the ovary to the uterus; the infundibulopelvic ligament (also referred to as the suspensory ligament of the ovary), through which the ovarian vessels travel, that attaches the ovary to the pelvic sidewall; and the broad ligament, which condenses to form the mesovarium. It is also attached to the broad ligament through the mesovarium.]
Vaginal bleeding in a postmenopausal patient is what until proven otherwise?
Endometrial cancer
[Uterine polyps have a very low (0.1%) chance of malignancy.]
What are the 3 main risk factors for ectopic pregnancy?
- Previous tubal manipulation
- Pelvic inflammatory disease
- Previous ectopic pregnancy
Which 4 characteristics of an ovarian cyst are contraindications for surveillance alone?
- Septations
- Increased vascular flow
- Solid components
- Papillary projections
[Cysts with any of the above characteristics should be removed with intraoperative frozen section. If cancer is present on frozen section, a total abdominal hysterectomy should be performed (this may need to be tailored to the patient’s wishes if premenopausal and wanting children). If none of the above characteristics are present, the patient is a candidate for a repeat ultrasound in 1 year.]
How is the risk of ovarian cancer affected by the following?
- OCP use
- Nulliparity
- Late menopause
- Bilateral tubal ligation
- Early menarche
- OCP use: Decreased risk
- Nulliparity: Increased risk
- Late menopause: Increased risk
- Bilateral tubal ligation: Decreased risk
- Early menarche: Increased risk
What are 5 risk factors for endometrial cancer?
- Nulliparity
- Late 1st pregnancy
- Obesity
- Tamoxifen
- Unopposed estrogen
[UpToDate: Endometrioid histology tumors (type I) comprise 80% of endometrial carcinomas, as noted above. This section will describe risk factors for these tumors. Risk factors for type II endometrial carcinomas (serous and clear cell) are discussed in detail separately.
Endometrioid endometrial carcinoma is estrogen-responsive, and the main risk factor for this disease is long-term exposure to excess endogenous or exogenous estrogen without adequate opposition by a progestin. Other risk factors include obesity, nulliparity, diabetes mellitus, and hypertension.]
What is the extent that cervical cancer has spread in each stage of the disease?
- Stage I
- Stage II
- Stage III
- Stage IV
- Stage I: Cervix
- Stage II: Upper 2/3 of vagina
- Stage III: Pelvis, side wall, lower 1/3 of vagina
- Stage IV: Bladder and rectum
What is the extent that ovarian cancer has spread in each stage of the disease?
- Stage I
- Stage II
- Stage III
- Stage IV
- Stage I: One or both ovaries only
- Stage II: Limited to pelvis
- Stage III: Spread throughout abdomen
- Stage IV: Distant metastasis
What is the treatment for endometriosus?
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.]
What is the treatment for each stage of endometrial cancer?
- Stage I
- Stage II
- Stage III
- Stage IV
- 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.]
