Benign Conditions of the Uterus, Cervix, Ovary, and Fallopian Tubes Flashcards
What leads to the development of the paramesonephric system and regression of the mesonephric system?
- Absence of a Y chromosome
- Absence of the mullerian inhibiting system
What is the timeline for paramesonephric system development?
- Arise at 6 weeks
- Fuse in the midline to form the uteroveaginal primordium at 9 weeks
What can failure to fuse of the paramesonephric duct lead to?
- Uterus didelphys
- Bicornuate uterus with rudimentary horn
- Bicornuate uterus with or without double cervices
What is uterus didelphysis?
- 2 separate uterine bodies with its own complex, attached fallopian tube and vagina
What can incomplete dissolution of the midline fusion of the paramesonephric ducts lead to?
- Septate uterus
What can failure of formation of mullerian ducts lead to?
- Unicornuate uterus
What is mullerian agenesis?
- Complete lack of development of the paramesonephric system
- Absence of the uterus and most of vagina
What are the most common congenital cervical anomalies of the cervix?
- Result in malfusion of the paramesonephric ducts with varying degrees of separation
- Didelphys cervix
- Septate cervix
How do uterine and cervical anomalies occur?
- Majority of the time, these occur spontaneously
- Could be caused by early maternal exposure to drugs (DES)
What are uterine leiomyomas?
- Benign tumors derived from localized proliferation of smooth muscle cells of the myometrium
- Most common neoplasm of the uterus
- > 70% of women will have leiomyomas by fifth decade
- Rarely malingnant
How do leiomyomas present?
- Most are asymptomatic
- Symptomatic fibroids cause: excessive uterine bleeding, pelvic pressure, pelvic pain, and infertility
What is the most common indication for a hysterectomy?
- Symptomatic fibroids
What are some risk factors for developing fibroids?
- Increasing age during reproductive years
- African American women have a 2-3 fold increase in risk
- Nulliparity
- Family history
What are some characteristics of uterine leiomyomas (fibroids)?
- Usually spherical, well circumscribed, white firm lesions with a whorled appearance on cut sections
- May degenerate and cause pain
- May calcify in postmenopausal patients
Where is a subserosal fibroid located?
- Beneath the uterine serosal surface
- Can rarely attach to the blood supply of the omentum or bowel mesentery and lose uterine connection thus becoming a parasitic fibroid
Where is an intramural fibroid located?
- Fibroid arises in the myometrium
- Most common
Where is a submucosal fibroid located?
- Beneath the endometrium
- Can be pedunculated and come through the cervical os
- Prolonged or heavy menstrual bleeding is common
Where is a cervical intraligamentous fibroid located?
- Arise between the broad ligaments
What are some symptoms of leiomyomas?
- 80% are asymptomatic
- Pelvic or low back pain
- Pelvic pressure or fullness
- Severe pain is not common
- Frequency of urination
- Prolonged or heavy menstrual bleeding (most common presenting system)
- Increased incidence of infertility
What are some signs of leiomyomas on PE?
- Bimanual examination
- Enlarged, irregularly shaped uterus
- If palpated mass moves with the cervix it is suggestive of a fibroid uterus
- Degree of enlargement is described in “week size” used to estimate equivalent gestational size
What could be on the differential for leiomyomas?
- Ovarian neoplasms
- Tubo-ovarian inflammatory mass
- Pelvic kidney
- Bowel mass
- Colon cancer
What are some medical treatments for leiomyomas?
- Combination (estrogen and progesterone): OCPs or rings
- Progesterone-only therapies: Depo-provera, mirena intrauterine system
- GnRH agonist: Depo-Lupron (can decrease fibroid size by 40% in 3 months and usually used instead of surgery)
What are some surgical treatments for leiomyomas?
- Myomectomy: hysteroscopic myomectomy or laparoscopic myomectomy
- Endometrial ablation
- Uterine artery embolization (artery feeding fibroid is occluded)
- Hysterectomy
What are some caveats to a myomectomy?
- If endometrial cavity is entered, future deliveries must be C section
- Often fibroids will grow back (25% of patients will need subsequent surgery)
- If after a myomectomy there is inadequate uterine tissue, a hysterectomy may be warrented
What are endometrial polyps?
- Form from the endometrium to create soft friable protrusion into the endometrial cavity
- May evade in office endometrial sampling
- Most are benign hyperplastic masses (need to remove due to endometrial hyperplasia and carcinoma also presenting as polyps)
What can endometrial polyps cause?
- Menorrhagia
- Spontaneous or post menopausal bleeding
What will ultrasound show for endometrial polyps?
- Focal thickening of the endometrial stripe
- Saling hysterosonography and hysteroscopy allow for better detection
What is a nabothian cervical cyst?
- A normal variant
- Appear opaque with a yellowish or bluish hue
What does a nabothian cervical cyst result from?
- Squamous metaplasia in which a layer of superficial squamous epithelial cells entrap a layer of columnar cells beneath its surface
- Columnar cells continue to secrete mucus and a mucus retention cyst is formed
What is a cervical polyp? Symptoms?
- Ectocervical and endocervical polyps are the most common benign growths on the cervix
- Can be removed in office
- Symptoms: non, coital bleeding or menorrhagia
What do endocervical polyps look like?
- More common
- Beefy red in color
- Arise from the endocervical canal
What do ectocervical polyps look like?
- Less common
- Pale in appearance
What is endometrial hyperplasia?
- Represents an overabundance growth of endometrial lining usually as a result of persistent unopposed estrogen
- Precursor to endometrial cancer
What are some causes of endometrial hyperplasia?
- PCOS and anovulation
- Granulosa theca cell tumors
- Obesity (second to peripheral conversion of androgens to estrogens)
- Exogenous estrogens without progesterone
- Tamoxifen
What are some symptoms of endometrial hyperplasia?
- Intermenstrual, heavy or prolonged bleeding that is unexplained
How is the diagnosis for endometrial hyperplasia made?
- Sample the endometrium in office
- U/S reveals endometrial lining ≥4 mm in a postmenopausal femal
What is the treatment for endometrial hyperplasia?
- Simple and complex hyperplasia WITHOUT atypia: treat with progestin and resample in 3 months
- SImple and complex hyperplasia WITH atypia: treat with a hysterectomy
What is adnexa?
- Includes the ovaries, fallopian tubes, upper portion of the broad ligament, and mesosalpinx
What is needed for normal ovarian development?
- Two X chromosomes
What is seen in Turner syndrome?
- Abnormal gonad development
- Small rudimentary streaked ovaries
- Develop secondary sexual characteristics but enter menopause shortly after
What is seen in complete androgen insensitivity syndrome/testicular feminization?
- Lack of androgen receptors
- Phenotypically female
- Gonads (functioning testes) need to be removed after puberty because of malignant potential
What are some functional cysts of the ovary?
- Follicular
- Lutein cyst
- Hemorrhagic cyst
- Polycystic ovaries
What are some benign neoplastic cysts of the ovary?
- Epithelial: serous cystadenoma and mucinous cystadenoma
- Sex cord stromal: Fibromas, granulosa theca cell, and sertoli leydig
- Germ cell: Mature cystic teratoma/dermoid
What is a follicular cyst?
- Lined by one or more layers of granulosa cells
- Develops when an ovarian follicle fails to rupture
- Is clinically significant when it is large enough to cause pain
What is a corpus luteum cyst?
- May develop if the corpus luteum becomes cystic, larger than 3 cm and fails to regress normally after 14 days
What is a hemorrhagic cyst?
- More likely to cause symptoms
- Caused by hemorrhage in the corpus luteum cyst 2-3 days after ovulation
What is polycystic ovaries?
- Enlarged ovaries with multiple simple follicles
Who is most affected by a theca-lutein cyst?
- Patients with high serum levels of hCG (pregnancy, choriocarcinoma or hydatidiform mole, or undergoing ovulation induction)
What is a theca-lutein cyst?
- Usually bilateral and can become large
- Often regress when hCG levels fall
What causes a luteoma of pregnancy?
- Hyperplastic reaction of the ovarian theca cells
- Secondary to prolonged hCG stimulation during pregnancy
How do a luteoma of pregnancy present?
- Reddish-brown nodules
What is a polycystic ovarian cyst?
- Associated with chronic anovulation, hyperandrogenism, and insulin release
- Produces enlarged ovaries with multiple small follicles that are inactive and arrested in the mid antral stage
What happens hormonally with polycystic ovarian cysts?
- Increased LH levels promote androgen secretion from the ovarian theca cells, leading to elevated levels of ovarian derived androstenedione and testosterone
What does peripheral conversion of androgens do in polycystic ovarian cysts?
- Leads to elevated estrogen levels that then suppress FSH from the pituitary gland
What are some clinical features of polycystic ovarian cysts?
- Usually asymptomatic and simple in nature
- Generally less than 8 mm in size
- Usually regress during subsequent cycle
- Can become large and undergo torsion
How is diagnosis made for polycystic ovarian cysts?
- Bimanual exam reveals an enlarged, mobile, unilateral cyst
- U/S
What is the management of polycystic ovarian cysts?
- Depends on patient
- If asymptomatic and premenopausal, can be placed on OCPs to suppress gonadotropin levels and prevent development of other cysts and repeat U/S
- If symptomatic and premenopausal, need to rule out ectopic pregnancy, torsion, tuboovarian abscess
Where do epithelial ovarian neoplasms come from?
- From the mesothelial cells lining the peritoneal cavity and also lining from the surface of the ovary
What do the different types of epithelial ovarian neoplasms resemble?
- Mucinous ovarian tumors cytologically resemble the endocervical epithelium
- Endometrioid ovarian tumors resemble the endometrium
- Serous ovarian tumors resemble the lining of the fallopian tubes
What are serous cystadenomas?
- Most common epithelial ovarian tumors
- 10% are bilateral
- 70% are benign
- 5-10% are borderline
- 20-25% are malignant
What is the treatment for serous cystadenomas?
- Surgical depending on desire to maintain fertility
What is seen histologically for serous cystadenomas?
- Psammoma bodies (more common in malignant tumors)
What is a mucinous cystadenoma?
- Can attain a huge size filling the entire pelvis and abdomen
- Second most common epithelial tumor
- 10% are bilateral
- 85% are benign
- 15% are malignant
What is a mucinous cystadenoma associated with?
- A mucocele of the appendix
- Rarely leads to pseudomyxoma peritonei
What is pseudomyxoma peritonei?
- Condition where numerous benign implants are seeded onto the surface of the bowel and other peritoneal structures producing large quantities of mucus
What is a brenner tumor?
- Small smooth solid ovarian neoplasm
- Usually benign and rarely malignant
- 33% of tumors associated with mucinous epithelial elements
What are sex cord stromal ovarian neoplasms?
- Derived from the sex cords stroma of the developing gonad
How are sex cord stromal ovarian neoplasms differentiated?
- If patient is feminine, then the tumor is feminine and is either a granulosa or theca cell tumor
- If patient is masculine, then the tumor is masculine and is a sertoli leydig tumor
What is a granulosa theca cell tumor?
- Can occur at any age
- Produce estrogenic components
- Low malignant potential
What does a granulosa theca cell tumor promote?
- Precocious menarche and thelarche
- Premenarcheal uterine bleeding during infancy and childhood
- Menorrhagia, endometrial hyperplasia, and endometrial cancer
- Breast tenderness, fluid retention, and postmenopausal bleeding
What is a sertoli leydig tumor?
- Less frequent than granulosa theca cell tumor
- Produce androgenic components
- Low malignant potential
What does a sertoli leydig tumor promote?
- Hirsutism
- Temporal baldness
- Deepening of the voice
- Ciltoromegaly
- Defeminizing of the female body habitus to a muscular build
What is a fibroma?
- Forms a solid, encapsulated, smooth surfaced tumor made up of interlacing bundles of fibrocytes
- Most common benign SOLID ovarian tumor
- Does not secrete sex steroid
What is occasionally associated with fibromas?
- Ascites secondary to transudation of fluid from the ovarian tissue
What is meigs syndrome?
- Ascites and right pleural effusion in association with an ovarian fibroma
- Flow of ascitic fluid through the transdiaphragmatic lymphatics into the right pleural cavity leads to Meigs’ syndrome
What is a cystic teratoma?
- Most common ovarian neoplasm found in women of all ages is the benign cystic teratoma
- 80% occur during reproductive years (median age is 30)
- 10-15% are bilateral
- Slow growing tumors, most <10 cm in size
What do dermoids (cystic teratomas) contain?
- Differentiated tissue from all three embryonic germ layers
- Composed primarily of ectodermal tissue (skin, sweat glands, hair follicles)
What is the characteristic macroscopic appearance of a cystic teratoma?
- Multicystic mass
- Hair, teeth, mixed into sebaceous thick material
- Rokintanksy’s protuberance
What is the Rokintanksy’s protuberance?
- Solid prominence located at the junction between the teratoma and normal ovarian tissue
What does rupture of a cystic teratoma lead to?
- Chemical peritonitis
How are benign ovarian tumors diagnosed?
- Abdominal and bimanual pelvic exam
- U/S (looking for complex vs simple or for a dermoid cyst)
- Tumor markers like CA 125
- Laparoscopy
What should be done if surgery is warranted for ovarian neoplasms?
- Collect pelvic washings for cytologic examination
- Obtain a frozen section for histologic diagnosis
How are epithelial benign ovarian tumors managed?
- Unilateral salpingo-oophorectomy
- If it is a mucinous cystadenoma –> perform an appendectomy due to possible mucocele
What is the difference in management of a benign ovarian tumor in young vs older women?
- Younger women: may perform cystectomy for ovarian preservation
- Older women: total abdominal hysterectomy with bilateral salpingo-oophorectomy
What is the management for a stromal cell tumor?
- Unilateral salpingo-oophorectomy when future pregnancies are a consideration
What is the management for a fibroma?
- Even with Meigs’ syndrome, almost always benign
- Remove ovary or treat by resection of the ovary in a young woman who desires future family
What is the management of a cystic teratoma?
- Ovarian cystectomy
- Carefully evaluate other ovary since bilateral is a change
- Rare recurrence after surgery
- Copiously irrigated pelvis to prevent chemical peritonitis
What are most benign conditions of the fallopian tubes?
- Infectious or inflammatory
- Hydrosalpinx –> fluid filled tubes from previous infection
- Pyosalpinx –> fluid filled tubes from active infection
What is ovarian torsion?
- Complete or partial rotation of the ovary on its ligamentous supports resulting in impedance of blood supply
- Most common gynecologic emergency
What are the two types of ovarian torsion?
- Adnexal torsion: ovary and fallopian tube both twist
- Isolated torsion of just fallopian tube
What is a primary risk for an ovarian torsion?
- Ovarian mass ≥ 5 cm
What is a classical presentation of an ovarian torsion?
- Acute onset of unilateral pain
- Nausea and possibly vomiting
How is an ovarian torsion diagnosed?
- U/S if first line
- Definitive diagnosis is made by direct visualization
What is the treatment of ovarian torsion?
- Detorsion and ovarian conservation with an ovarian cystectomy
- Salpingo-oophorectomy done if ovary is necrotic or malignancy is suspected
