Benign Conditions of the Uterus, Cervix, Ovary, and Fallopian Tubes Flashcards
the absence of a Y chromosome and absence of the mullerian inhibiting substance leads to the development of what?
the paramesonephric system with the regression of the mesonephric system
when do the paramesonephric ducts arise?
at 6 weeks gestational and by 9 weeks they fuse in midline to form the uterovaginal primordium
Failure of the paramesonephric duct to fuse can lead to:
1.
2.
3.
- uterus didelphysis: 2 separate uterine bodies with its own cervix, attached fallopian tube, and vagina
- Bicornuate uterus with a rudimentary horn
- bicornuate uterus with or without double cervices
Incomplete dissolution of the midline fusion of the paramesonephric ducts leads to:
septate uterus
failure of formation of mullerian ducts can lead to:
unicornate uterus
what is the most common congenital cervical anomalies the result of?
malfusion of the paramesonephric ducts with varying degrees of separation
- didelyphs cervix
- septate cervix
If not spontaneous, what could cause uterine and cervical anomalies?
early maternal exposure to drugs: DES
which can cause small T-shaped endometrial cavity or cervical collar deformity
What are uterine leiomyomas “fibroids”?
benign tumors derived from localized proliferation of smooth muscle cells of the myometrium
what is the most common neoplasm of the uterus?
uterine leiomyomas “fibroids”
what can symptomatic fibroids cause?
excessive uterine bleeding, pelvic pressure, pelvic pain and infertility
what is the most common indication for hysterectomy?
symptomatic fibroids
What are the risk factors for developing fibroids?
increasing age during reproductive years
african american women have a 2-3 fold increase risk
nulliparity
family history
what is the pathogenesis of fibroids?
factors that initiate leiomyomas are unknown
rarely form before menarche or enlarge after menopause: estrogen stimulates the proliferation of smooth muscle cells
what are the characteristics of fibroids?
usually spherical, well circumscribed, white firm lesions with a whorled appearance on cut sections
may degenerate and cause pain
-during pregnancy 5-10% of women with fibroids undergo a painful red or carneous degeneration caused by bleeding into the tumor
may calcify especially in postmenopausal patients
what are the different locations of fibroids?
- *subserosal**
- fibroid beneath the uterine serosal surface
- *intramural**
- fibroid arises within the myometrium ***most common
- *submucosal**
- fibroid beneath the endometrium
- prolonged or heavy menstrual bleeding is common
- *cervical intraligamentous**
-arise between the broad ligaments
women with leiomyoma symptoms may complain of what?
pelvic or lower back pain
pelvic pressure or fullness
severe pain is not common
frequency of urination if fibroid is pressing on bladder
prolonged or heavy bleeding (***most common presenting symptom and mainly associated with submucosal or intramural fibroids which distort the endometrium
increased incidence of infertility (more common with submucosal fibroids)
what are the signs of leiomyomas?
on bimanual examination: can reveal an enlarged, irregularly shaped uterus
if palpated mass moves with the cervix it is suggestive of a fibroid uterus
the degree of enlargement is described in “week size” used to estimate equivalent gestational size
Ultrasound: is often performed and can help distinguish between adnexal masses and lateral leiomyomas
how do you treat leiomyomas? medically
- Combination (estrogen + progesterone): oral contraceptive pills, rings; this is usually first therapeutic option
- progesterone-only therapies: Depo-provera, mirena intrauterine system
- Gonadotropin releasing hormones (GnRH agonist): Depo-Lupron
How do you treat leiomyomas surgically?
myomectomy, endometrial ablation, uterine artery embolization, and hysterectomy (the definitive therapy)
What is important to note about myomectomy?
if endometrial cavity is entered, then future deliveries must be by c-section
often the fibroids will grow back
what are endometrial polyps?
they form from the endometrium to create soft friable protrusion into the endometrial cavity
can cause menorrhagia, spontaneous, or post menopausal bleeding
what might US reveal in a patient with endometrial polyps?
focal thickening of the endometrial stripe
why is it important to remove endometrial polyps with hysteroscopy?
because endometrial hyperplasia and carcinoma may also present as polyps
what are nabothian cervical cysts?
appear opaque with a yellowish or bluish hue
vary in size 3mm to 3 cm
results from squamous metaplasia in which a layer of superficial squamous epithelial cells entrap a layer of columnar cells beneath it’s surface
columnar cells continue to secrete mucus and a mucus retention cyst is formed
what are the most common benign growths on the cervix?
ectocervical and endocervical polyps
what are the symptoms of cervical polyps?
how do endocervical polyps differ from ectocervical polyps?
symptoms: none, coital bleeding or menorrhagia
endocervical polyps: more common, beefy red in color, arise from endocervical canal
ectocervical polyps: less common, pale in appearance
what is endometrial hyperplasia?
represents an overabundant growth of the endometrial lining usually as a result of persistent unopposed estrogen
in what cases might endometrial hyperplasia be seen?
PCOS and anovulation
granulosa theca cell tumors
obesity
exogenous estrogens
tamoxifen
what is endometrial hyperplasia a precursor to?
endometrial cancer
what are the different classifications of endometrial hyperplasia?
simple hyperplasia without atypia
complex hyperplasia without atypia
simple hyperplasia with atypia
complex hyperplasia with atypia
what are the symptoms of endometrial hyperplasia?
intermenstrual, heavy or prolonged bleeding that is unexplained
how do you make the diagnosis of endometrial hyperplasia?
sample the endometrium
ultrasound reveals endometrial lining greater than or equal to 4 mm in a postmenopausal female: need to sample the endometrium
how do you treat endometrial hyperplasia?
simple and complex hyperplasia without atypia: treat with progestin and resample in 3 months
simple and complex hyperplasia with atypia: best treated with a hysterectomy
what is adnexa
when something involves the ovaries, fallopian tubes, upper portion of the broad ligament, and mesosalpinx
what is required for normal ovarian development?
two X chromosomes
What is the karyotype for Turner syndrome?
What is it associated with?
45XO
associated with abnormal gonad development: small rudimentary streaked ovaries; develop secondary sexual characteristics but enter menopause shortly after
What is the karyotype for complete androgen insensitivity syndrome (aka testicular feminization)?
What is this syndrome?
46XY
lack androgen receptors, phenotypically female, gonads (functioning testes) need to remove after puberty because of malignant potential
How could DES affect the fallopian tubes?
may lead to shortened, distorted or clubbed tubes
what are the 4 types of functional cysts?
follicular cysts
corpus luteum cysts
hemorrhagic cysts
polycystic ovaries
what are follicular cysts?
lined by one or more layers of granulosa cells
develops when an ovarian follicle fails to rupture
is clinically significant if it gets large enough to cause pain
when does a corpus luteum cyst develop?
if the corpus luteum becomes cystic, larger than 3 cm, and failes to regress normally after 14 days
which functional cyst is more likely to cause symptoms?
hemorrhagic cysts
what is a hemorrhagic cyst caused by?
hemorrhage in the corpus luteum cyst 2-3 days after ovulation
what is a theca-lutein cyst?
what patients might they develop in?
usually bilateral and can become large
may develop in patients:
with high serum levels of hCG
*characteristically they regress when gonadotropin levels fall
what is luteoma of pregnancy?
it is caused by a hyperplastic reaction of the ovarian theca cells secondary to prolonged hCG stimulation during pregnancy
appear as reddish-brown nodules
surgical resection is not indicated- they usually regress spontaneously postpartum
what is a polycystic ovarian cyst associated with?
What does it produce/lead to?
chronic anovulation, hyperandrogenism and insulin resistance
produces enlarged ovaries: with multiple small follicles that are inactive and are arrested in the mid antral stage
how do you make the diagnosis of a functional ovarian cyst?
bimanual exam reveals an enlarged, mobile, unilateral cyst
or
ultrasound
How can the benign neoplastic ovarian tumors be divided?
which type is the most common
by cell type of origin
the epithelial ovarian neoplasms are the most common: serous, mucinous, brenner tumors
what are the different types of benign neoplastic ovarian tumors?
epithelial, sex-cord stroma, and germ cell
what are the 3 different sex-cord stroma ovarian neoplasms?
fibromas, granulosa-theca cells, sertoli-leydig cell tumors
what is an example of a germ cell tumor?
benign cystic teratoma (dermoid)
what is the single most common benign ovarian neoplasm in a premenopausal females?
benign cystic teratoma (dermoid)
epithelial ovarian neoplasms are thought to derive from what?
the mesothelial cells lining the peritoneal cavity and also the lining from the surface of the ovary
what do mucinous ovarian tumors cytologically resemble?
the endocervical epithelium
what do serous ovarian tumors resemble?
the lining of the fallopian tubes
what is the most common epithelial ovarian tumor?
serous cystadenoma
what is the treatment for serous cystadenomas?
surgical (cystectomy vs. oophorectomy vs. hyst with bilateral oophorectomy)
what is the histologic appearance of serous cystadenoma?
psammoma bodies
these are more common in malignant serous cystadenocarcinomas
what is the second most common ovarian epithelial tumor?
mucinous cystadenoma
what is a mucinous cystadenoma associated with?
a mucocele of the appendix
what could a mucinous cystadenoma (rarely) lead to?
pseudomyxoma peritonei: condition in which numerous benign implants are seeded onto the surface of the bowel and other peritoneal surfaces producing large quantities of mucus
what is a brenner tumor?
an epithelial ovarian neoplasm
small smooth solid ovarian neoplasm
usually benign with a large fibrotic component that encases epithelioid cells that resemble transitional cells of the bladder
if the ultimate differentiation of cell types occurring in the sex-cord stromal ovarian tumor is feminine then the tumor is feminine and becomes what?
a granulosa or theca cell tumor or often a mixed granulosa-theca cell tumor
if the ultimate differentiation of cell types occurring in the sex-cord stromal tumor is masculine then the tumor becomes what?
a sertoli leydig tumor
