Benign conditions of the Uterus, Ovary and Fallopian Tubes Flashcards
uterus and cervix- development
- upper vagina, cervix, uterus, fallopian tubes formed from mullerian (paramesonephric) ducts
- no Y chrom- no mullerian inhibiting substance- leads to development of paramesonephric system and regression of mesonephric system
- paramesonephric ducts arise at 6 wks- at 9 wks they fuse in midline and form uterovaginal primordium
- septum resolves later- leads to a single cervix and uterus
failure of paramesonephric ducts to fuse can lead to
- uterus didelphysis- 2 separate uterine bodes with its own cervix, fallopian tube, and vagina
- bicornuate uterus w/ or w/o dbl cervix
incomplete dissolution of midline fusion of paramesonephric ducts leads to
-septate uterus
mullerian agenesis (MRKH syndrome)
- complete lack of development of paramesonephric system
- absence of uterus and most of vagina
congenital anomalies of cervix
result of malfusion of paramesonephric ducts
- Didelphys cervix
- Septate cervix
uterine and cervical anomalies- due to?
- spontaneous (mostly)
- DES- small T-shaped endometrial cavity; cervical collar deformity
Uterine leiomyomas
(fibroids)
- benign tumors- smooth m cells of myometrium
- most common neoplasm of uterus!!!
- 70% of women have them by 50
- most asx
- if sx- uterine bleeding, pelvic pressure/pain, infertility- most common indication for hysterectomy
Fibroids- risk factors
- inc age during reprod yrs
- Af Am- 2-3X
- nulliparity
- FH
Fibroids- pathogenesis
- unknown factors
- rarely form b/f menarche or enlarge after menopause- estrogen stim prolif of smooth m cells
- 40% enlarge during pregnancy
Fibroids- characteristics
- spherical, well circumscribed, white firm lesions w/ whirled appearance
- may degenerate and cause pain- during pregnancy, 10% undergo a painful red degeneration caused by bleeding into the tumor
- may calcify in postmenopausal pts
Fibroids- types
- subserosal
- intramural- most common
- submucosal- heavy menstrual bleeding is common
- cervical
- intraligamentous
fibroids- sx’s
- 80% are asx
- pelvic pain/pressure
- severe pain is not common (unless red degeneration/acute infarction)
- freq of urination
- prolonged/heavy bleeding- most common sx!!
- infertility
fibroids- signs
- bimanual exam- enlarged, irregularly shaped uterus; palpated mass moves with cervix
- US- distinguish b/w adnexal masses and leiomyomas
fibroids- diff dx
- ovarian neoplasms
- tubo-ovarian infl mass
- pelvic kidney
- bowel mass
- colon cancer
fibroids- medical tx
- combo (estrogen, progesterone)- 1st option
- progesterone-only
- GnRH agonist- Depo-Lupron (dec fibroid size)
fibroids- surgical tx
- myomectomy
- endometrial ablation (to dec menstrual flow)
- uterine a embolization (occlude the a feeding the fibroid)
- hysterectomy -definitive tx
Myomectomy
- fibroids will often grow back
- if endometrial cavity is entered, future delivers must be c-section
- if an adequate amt of uterine tissue remains after- hysterectomy is warranted
Endometrial polyps
- form from the endometrium- create soft friable protrusion into endometrial cavity
- menorrhagia, spontaneous, or post menopausal bleeding
- US- focal thickening of endometrial stripe- saline hysterosonography and hysteroscopy for better detection
- most are benign hyperplastic masses- need to remove with hysteroscopy- endometrial hyperplasia and carcinoma may also present as polyps
Nabothian cervical cyst
- appear opaque with a yellowish/bluish hue
- result from squamous metaplasia- a layer of superficial squamous epit cells entrap a layer of columnar cells- columnar cells continue to secrete mucus
Cervical polyp
- most common benign growths on the cervix
- sx- none, coital bleeding, menorrhagia
- remove in office- rarely malignant
- endocervical- more common, beefy red
- ectocervical- less common, pale
endometrial hyperplasia
- result of persistent unopposed estrogen- PCOS/anovulation, granulosa theca cell tumors, obesity, exogenous estrogens, tamoxifen
- precursor to endometrial cancer!!
endometrial hyperplasia- classification
- simple w/o atypia- 1% progress to cancer
- complex w/o atypia- 3%
- simple with atypia- 9%
- complex with atypia- 27%
endometrial hyperplasia- sx, dx, tx
- intermenstrual, heavy/prolonged bleeding
- dx- sample endometrium; US reveals endometrial lining > 4 mm in postmenopausal female
- tx- simple and complex W/O atypia- progestin, resample in 3 months
- simple and complex WITH atypia- hysterectomy
congenital anomalies of ovaries
uncommon
- 2 X chrom are required for normal ovary development
- Turner syndrome (45X)- small streaked ovaries
- AIS/Testicular feminization (46XY)- phenotypically F, lack androgen Rs
congenital anomalies of fallopian tubes
rare
-DES- shortened, distorted tubes
Benign conditions of ovary
- functional cyst
- benign neoplastic cyst- epit, sex-cord stromal, germ cell
- malignant cysts
Functional cysts
- follicular cysts- ovarian follicle fails to rupture
- corpus luteum cysts
- hemorrhagic cysts- hemorrhage into corpus luteum cyst 2-3 days after ovulation
- polycystic ovaries
Functional cyst- Theca-lutein cyst
- b/l, large
- in pts with high HCG- pregnancy, choriocarcinoma, hydatidiform molar pregnancy, ovulation induction
- regress when gonadotropin levels fall
Functional cyst- luteoma of pregnancy
- hyperplastic rxn of ovarian theca cells- secondary to prolonged HCG stim
- reddish-brown nodules
- regress spontaneously postpartum
Functional cyst- polycystic ovarian cyst
- chronic anovulation, hyperandrogenism, insulin R
- enlarged ovaries- mult small follicles
- inc LH levels promote androgen secretion from ovarian theca cells- elevated androgens
- peripheral conversion of androgen to estrogen- suppress FSH from pit gland
Functional ovarian cyst- clinical, dx, management
- asx, usually regress during subsequent cycle, can become large and undergo torsion
- dx- bimanual exam (enlarged, mobile cyst), US
- tx- if asx, place on OCP’s; rule out ectopic pregnancy, torsion, tubo ovarian abscess
Benign neoplastic ovarian tumors
- epit- serous, mucinous, brenner
- sex-cord stroma- fibroma, granulosa-theca, sertoli-leydig cell
- germ cell- teratoma (dermoid)- most common benign ovarian neoplasm in premenopausal women!!!
Serous Cystadenoma
- most common epit ovarian tumor (75%)
- 10% b/l, 25% malignant
- tx- surgical
- histo- psammoma bodies
Mucinous cystadenoma
- second most common epit tumor (20%)
- 85% benign
- assoc with mucocele of appendix
- can lead to pseudomyxoma peritonei
Brenner tumor
- small smooth solid
- usually benign with a large fibrotic component that encases epithelioid cells that resemble transitional cells of bladder
Sex Cord stromal ovarian neoplasms
- if feminine- granulosa or theca cell tumor
- if masculine diff- sertoli leydig cell tumor
Granulosa-theca cell tumor
- produces estrogen
- feminizing signs, sx’s
Sertoli-Leydig tumor
- produce androgens
- virilizing effects
fibroma
- solid, encapsulated, smooth-surfaced tumor- bundles of fibrocytes
- most common benign SOLID ovarian tumor
- doesnt secrete sex steroids
- Meigs syndrome- ascites, right pleural effusion (hydrothorax)
Germ cell tumors
- 60% of ovarian neoplasms in infants/children
- cystic teratoma
Benign cystic teratoma
(dermoid cyst)
- most common ovarian neoplasm!!!
- median age- 30 yo
- diff tissue from all 2 embryonic germ layers
benign ovarian tumors- clinical features
- asx
- enlarge very slowly
- mild pain
- can be painful- if torsion; rupture of cyst
benign ovarian tumors- dx
- abd and bimanual pelvic exam
- US
- tumor markers- CA 125
- laparoscopy
epit benign ovarian tumors- management
- unilateral salpingo-oophorectomy
- if mucinous cystadenoma- appendectomy
- if young pts- cystectomy for ovarian preservation
sex-cord stromal tumors- management
-unilateral salpingo-oopherectomy
germ cell tumors (Benign cystic teratoma)- management
- ovarian cystectomy
- evaluate other ovary- b/l 20%
fallopian tubes- benign conditions
- hydrosalpinx- from infection
- pyosalpinx- from infection
primary risk factor for ovarian torsion
-ovarian mass > 5 cm
ovarian torsion- classic presentation
-acute onset of unilateral pain, N/V
-dx- US!!
-definitive dx- direct visualization
tx- detorsion and ovarian cystectomy
