Benign Conditions of the Uterus, Cervix, Ovary & Fallopian Tubes Flashcards
What comes from the paramesonephric (Mullerian) ducts?
Absence of which “inhibiting substance” leads to the development of the paramesonephric system with regression of mesonephric system?
Upper vagina, cervix, uterus and fallopian tubes.
Absence of the Mullerian inhibiting substance and absence of Y chromosome.
What causes uterus didelphysis? What is it?
Failure of the paramesonephric duct to fuse. It results in 2 separate uterine bodies with its own cervix, fallopian tubes and vagina.
What causes a septate uterus?
Incomplete dissolution of the midline fusion of the paramesonephric ducts.
What causes unicornate uterus?
Failure of formation of the Mullerian ducts
What is Mullerian agenesis AKA?
What is it?
Meyer-Rokitansky-Kuster-Hauser syndrome
The complete lack of development of the paramesonephric system - absence of uterus and most of vagina.
The most common congenital cervical anomalies are the result of what?
Malfusion of the paramesonephric ducts with varying degrees of separation.
- didelphys cervix
- septate cervix
Most of the time, how do uterine and cervical anomalies occur?
What drug is implicated in some anomalies?
They occur spontaneously.
Early maternal exposure to DES: small T-shaped endometrial cavity, cervical collar deformity
Most common neoplasm of the uterus:
What age is most common?
What is the most common presentation?
It is the most common indication for what procedure?
What happens to them during pregnancy? What might happen in post-menopausal women?
What are some risk factors?
Fibroids: benign tumors from localized SM cells of the myometrium.
> 70% of women have them by 5th decade. Rarely form before menarch or enlarge after menopause.
Most are asymptomatic. Symptomatic fibroids can cause bleeding, pelvic pain and infertility.
Hysterectomy
40% will enlarge in pregnancy. May calcify in post-menopausal women.
Increasing age during reproductive years, AA 2-3x risk, nulliparity, FH
Subserosal fibroids
Intramural fibroids
Submucosal fibroids
Subserosal fibroids: fibroid beneath the uterine serosal surface. May rarely attach to blood supply of the omentum or bowel mesentery and lose uterine connection to become parasitic.
Intramural fibroids: fibroid arises in the myometrium. **Most common.
Submucosal fibroids: fibroid beneath the endometrium. Can become pedunculated and protrude through the cervical os. Prolonged or heavy menses is common.
What are signs of Leiomyoma on bimanual exam?
How is US helpful?
Bimanual exam: can reveal enlarged, irregularly shaped uterus. If the palpated mass moves with the cervix, it is suggestive of fibroid uterus. Degree of enlargement is described in “week size” to estimate equivalent gestational size.
US: it may help distinguish between adnexal masses and lateral leiomyomas.
What is the medical treatment options for Leiomyomas? (3)
Combination therapy (estrogen + progesterone)
- oral contraceptive pills, rings
- usually first option used**
Progesterone-only
-Depo-provera, Mirena intrauterine system
Gonadotropin releasing hormones (GnRH agonists)
- Depo-Lupron
- used as a surgical alternative
What is the definitive surgical treatment of fibroids?
What are 3 other surgical options?
Hysterectomy
Myomectomy: submucosal fibroids. Can be done laparoscopically or robotically.
Endometrial ablation: may cause decreased menstrual flow.
Uterine artery embolization: causes fibroid necrosis and 40-60% shrinkage.
What are some complications of myomectomy? (3)
If the endometrial cavity is entered, future deliveries must be via C-section.
Oftentimes the fibroids will grow back - 25% of patients will need subsequent operations.
If there is inadequate uterine tissue remaining post-myomectomy, a hysterectomy may be indicated.
What is an endometrial polyp?
What are symptoms?
What might be revealed on US? What are better diagnositics? (2)
Are the usually benign or malignant? What is the treatment generally?
Polyps in the endometrium that are soft, friable and protrude into the endometrial cavity.
Menorrhagia, spontaneous or post-menopausal bleeding.
US may reveal focal thickening of the endometrial stripe.
-Saline hysterosonography and hysterography are better.
Most are benign; however, they need to be removed via hysteroscopy since endometrial hyperplasia and carcinoma may also present as polyps.
What is a nabothian cyst?
What do they look like?
What causes it?
A normal finding on the cervix.
Opaque with yellowish or bluish hue. Approx. 3 mm to 3 cm.
Squamous metaplasia in which a layer of superficial squamous epithelial cells entrap a layer of columnar cells beneath, which continue to produce mucus, leading to a cyst.
Where do cervical polyps occur? What are features of each?
Endocervical polyps
- more common
- beefy red in color
- arise in endocervical canal
Ectocervical polyps
- less common
- pale in appearance
What are the symptoms of cervical polyps (endo- and ecto-)?
What is the treatment?
None (common), coital bleeding or menorrhagia.
Removed in office - rarely malignant (<1/1000 will become sarcomas).
What is the major cause of endometrial hyperplasia?
Which underlying processes are associated? (4)
What is it a precursor to?
Persistent unopposed estrogen.
PCOS and anovulatory cycle
Granulosa tumors - estrogen producing tumors
Obesity (peripheral conversion)
Tamoxifen
Precursor to endometrial cancer.
What are the 4 WHO classifications of endometrial hyperplasia? Which is most likely to progress to cancer?
Simple hyperplasia w/o atypia
Complex hyperplasia w/o atypia
Simple hyperplasia w/ atypia
Complex hyperplasia w/ atypia - 27% progress to cancer
What are the symptoms of endometrial hyperplasia?
What is needed to diagnose?
What is the treatment if there is atypia vs. if there is no atypia?
intermenstrual, heavy or prolonged bleeding that is otherwise unexplained.
Endometrial sample. US revelaing >4 mm in post-menopausal women.
Simple and complex with atypia - hysterectomy
Simple and complex w/o atypia - progestin and resample in 3 mo.
What are the 2 congenital abnormalities of the ovaries?
Turner syndrome - 45XO
Complete androgen insensitivity syndrome/testicular feminization (46XY) - lack of androgen receptors, phenotypically female but have functioning testes and need to be removed after puberty due to malignant transformation
What is the classification of a theca-lutein cyst?
What is the size of them and laterality?
They may develop in patients with: (3)
When do they go away?
Functional ovarian cyst
Large (>30 cm) and BL
Patients with high hCG
- pregnancy
- choriocarcinoma or molar pregnancy
- patients undergoing ovulation induction (gonadotropins or clomid)
Regress when gonadotropins (hCG) fall
What is the classification of a luteoma of pregnancy?
What causes it?
What is the appearance?
What is the treatment?
Functional ovarian cyst
Hyperplastic reaction of the ovarian theca cells (secondary to prolonged hCG stimulation during pregnancy)
Reddish-brown nodules
They will regress after delivery - no surgery needed
What is the classification of polycystic ovarian cyst?
What causes it?
What is the classic feature?
What hormones are elevated? (3)
What hormone is low?
Functional ovarian cyst
Chronic anovulation, hyperandrogenism and insulin resistance
Enlarged ovaries - multiple small follicles that are inactive and arrested in mid antral stage
LH, androgens (androstenedione and testosterone), estrogen
Low FSH
Follicular, corpus luteum, polycystic and hemorrhagic cysts are all classified as what kind of cysts?
Functional cysts
What is a follicular cyst made of?
When does it develop?
When does it become clinically significant?
It is lined by 1 or more layers of granulosa cells
Develops when an ovarian follicle fails to rupture
If it becomes large enough to cause pain
What causes a corpus luteum cyst to develop?
If the corpus luteum becomes cystic, larger than 3 cm and fails to regress normally after 14 days
Which ovarian cyst is most likely to cause symptoms?
What is the cause of this cyst?
Hemorrhagic cysts
Hemorrhage in the corpus luteum cyst 2-3 days after ovulation
Generally, follicular ovarian cysts have which clinical features? (4)
Asymptomatic
Less than 8 cm in size
Usually regress during subsequent cycle
Can become large and undergo torsion
How can functional ovarian cysts be diagnosed? (2)
Bimanual exam revealing enlarged, multiple, unilateral cysts
US
What is the management of functional ovarian cysts if:
Asymptomatic and premenopausal
Symptomatic and premenopausal (what must be r/o?)
Asymptomatic and premenopausal: place on OCPs (suppress hCG and prevent future cyst development) and repeat US
Symptomatic and premenopausal: must r/o ectopic pregnancy, torion, tubo-ovarian abscess
How are benign neoplastic ovarian tumors classified? (3)
By cell type of origin.
Epithelial: most common - serous, mucinous, Brenner tumors
Sex-cord stromal: fibromas, granulosa-theca cell, Sertoli-Leydig cell tumors
Germ cell: teratoma (dermoid) - most common benign neoplasm of pre-menopausal women
Endometrioid ovarian tumors resemble:
Serous ovarian tumors resemble:
Endometrioid ovarian tumors resemble the endometrium
Serous ovarian tumors resemble the lining of the fallopian tubes
Most common epithelial ovarian tumor (75%) is…
How many become malignant?
What is the treatment?
What is the classic histological finding?
Serous cystadenoma
20-25% become malignant
Surgically removed - operation depends on desire to remain fertile
Psammoma bodies - more common in malignant type
What is unique about mucinous cystadenomas?
How many become malignant?
What is it associated with?
They can become massive and invade the pelvis/abdomen
15% malignant (85% benign)
Mucocele apendicitis - Pseudomyxoma peritonei
Brenner tumors are benign or malignant?
What do they look like?
33% of cases are associated with…
Usually benign, rarely malignant
Large fibrotic component that encases epithelioid cells resembling transitional cells of the bladder
33% associated with mucinous epithelial elements
If the sex-cord stromal tumor differentiates feminine, then the tumor becomes…
If the sex-cord stromal tumor differentiates masculine, then the tumor becomes…
Feminine - Granulosa or theca cell tumor or mixed
Masculine - Sertoli-Leydig tumor
What is the classification of granulosa-theca cell tumors?
When do they occur?
What do they produce?
What is the malignant potential?
What signs/symptoms are common?
Sex cord-stromal tumors
May occur at any age
Produce estrogen
Low malignant potential
Feminizing signs and symptoms
- precocious menarch and thelarche
- premenarchal bleeding
- menorrhagia, hyperplasia, endometrial CA
- breast tendernes, post-menopausal bleeding, etc.
What is the classification of Sertoli-Leydig tumors?
What do they produce?
What is the malignant potential?
What signs/symptoms are common?
Sex cord-stromal tumor
Androgenic components
Low malignant potential
Virilization
- hirsutism
- baldness
- deepening of voice
- clitoromegaly
- defeminization of female body
What is the most common solid ovarian tumor?
What is unique about it in terms of sex-cord stromal tumors?
What is the unique association with these tumors?
Fibroma
They do NOT secrete any hormones
Meigs syndrome - ascites, right pleural effusion and ovarian fibroma
Germ cell tumors may occur at what age? What age is most common?
Can occur at any age, but they make up 60% of ovarian neoplasm in infants and children
Most common ovarian neoplasm =
How big are they? How many are BL?
If they rupture, what is a complication?
Cystic teratoma = dermoid cyst
Slow growing and < 10 cm (10-15% are BL)
Rupture may cause chemical peritonitis
What is Rokintansky’s protuberance?
Solid prominence located at junction of teratoma and normal ovarian tissue
When is CA 125 helpful? Why?
Helpful to follow ovarian tumors in post-menopausal women. It is not a very sensitive test, so it is not used as much in younger women.
4 ways to help diagnose ovarian tumors
Abdominal/Bimanual pelvic exam
US
Tumor markers - CA 125
Laparoscopy/Laparotomy
Never assume what in a patient with an ovarian tumor?
If surgery is warranted, what should be done before? (2)
Defnitive Tx depends on:
Don’t assume it is benign - work it up (exploration or pathology)
Collect pelvic washing for cytologic exam
Obtain frozen section for histological dx
Pt. age and desire for future pregnancies
How are epithelial ovarian neoplasms typically managed?
What if mucinous cystadenoma is dx?
What about in young nulliparous patients (they want to preserve fertility)?
What about in an older woman?
Usually with UL salpingo-oophorectomy
Mucinous cystadenoma - appendectomy also
Young - cystectomy to preserve ovaries
Old - total hysterectomy w/ BL salpingo-oophorectomy
How are stromal tumors usually managed?
UL salpingo-oophorectomy when future pregnancies are a consideration
How are fibromas managed?
May remove ovary or fibroma removal if fertility is desired
What is the management of germ cell tumors (teratomas)?
Ovarian cystectomy, but evaluate other ovary as some teratomas are BL.
*copiously irrigate pelvis to avoid chemical peritonitis
What causes most benign lesions of the fallopian tubes?
Infection or inflammatory processes
Hydrosalpinx - fluid-filled tubes from prior infection
Pyosalpinx - purulent-filled tube from active infection
What is an ovarian torsion?
What is the primary risk factor for ovarian torsion?
What is an adnexal torsion?
Complete or partial rotation of the ovary on its ligamentous support, which often impedes blood supply.
Major risk factor = ovarian mass > 5 cm
Adnexal torsion is twisting of ovary and fallopian tube.
Ovarian torsion
Presentation
Dx
Tx
Presentation: acute onset of UL pain, possible N/V
Dx: US is first-line, then direct visualization
Tx: detorsion and ovarian conservation with ovarian cystectomy is first-line. If ovary is necrotic/malignant, then a salpingo-oophorectomy is done.
