Benign Disorders of the Upper Genital Tract

Question 1

Lower one third of the vagina derives from what embryonic structure?

Answer 1

Urogenital diaphragm

Question 2

Ovaries derive from what embryonic structure?

Answer 2

Genital ridge

Question 3

Upper vagina, cervix, uterus, and fallopian tubes derive from what embryonic structure?

Answer 3

Fusion of the paremesonephric (Mullerian) ducts.

Question 4

Most common anatomic anomaly of the uterus?

Answer 4

Septate uterus - from malfusion of the paremesonephric (Mullerian) ducts.

Question 5

Cause for increase in mullerian anomalies in the female population? Classic presentation of this anomaly?

Answer 5

DES exposure in utero. T-shaped uterus.

Question 6

Most common complication of having a uterine septum?

Answer 6

First trimester pregnancy loss (25%) - Decreased ability to perfuse the placenta.

Question 7

Common complications of having a uni/bicornuate uterus (3)?

Answer 7

Second trimester pregnancy loss, malpresentation, and preterm labor and delivery - Decreased size of the uterine horn

Question 8

What tests can distinguish between unicornuate and bicornuate uteri?

Answer 8

MRI or laparoscopy.

Question 9

What is the most common indication for surgery for women in the US? Symptoms?

Answer 9

Uterine leiomyomas (fibroids). Can cause pelvic pain, urinary frequency, constipation, abnormal uterine bleeding, and secondary dysmenorrhea.

Question 10

Are fibroids polyclonal or monoclonal?

Answer 10

Monoclonal - from from propagation of a single muscle cell.

Question 11

What increases the growth rate of fibroids? What decreases the growth rate of fibroids?

Answer 11

ESTROGEN and progesterone (endogenous and exogenous). Menopause - decreased estrogen.

Question 12

Three classes of uterine fibroids?
Most common type?
Type that causes the heaviest bleeding?
Type that causes the most pain?

Answer 12

Submucosal, intramural, and suberosal.
Intramural.
Submucosal.
Pedunculated subserosal.

Question 13

How to distinguish between fibroids and adenomyosis? Most helpful test?

Answer 13

Fibroids are encapsulated in pseudocapsule.

MRI.

Question 14

Which race of women are more likely to develop fibroids (as well as at a younger age with more severe fibroids, bleeding, and anemia)

Answer 14

Black women! 50% will get them by 40, only 30% of the general population will get them by 40.

Question 15

Most common symptom of fibroid? Second most common symptom?

Answer 15

Asymptomatic.

Abnormal uterine bleeding - Menorrhagia, metorrhagia, postcoital spotting, and menometorrhagia.

Question 16

Most common means of diagnosing fibroids?

Best diagnostic test for submucosal fibroid?

Answer 16

Pelvic ultrasound.

Sonohysterography.

Question 17

How frequently should a woman with actively growing fibroids be assessed?

Answer 17

Every 6 months.

Question 18

Role of GNRH agonists (Lupron) in treatment of fibroids?

Answer 18

Decrease size, stops bleeding, and increases hermatocrit.

Question 19

What is the definitive treatment for uterine fibroids?

Issue with myomectomy?

Answer 19

Hysterectomy.

50% recurrence.

Question 20

Indications for surgery for fibroids (7)?

Answer 20

Bleeding causing anemia.
Pelvic pain.
Urinary symptoms.
Growth after menopause.
Recurrent miscarriage/infertility.
Rapid increase in size. 
Large uterine size (>12 weeks)

Question 21

Cause of endometrial polyps?
Which age groups are most effected?
Most common symptoms?
Best diagnostic tests?

Answer 21

Overgrowths of endometrial glands and stroma.
40-50 year old women (especially on tamoxifen).
Metrorrhagia, menorrhagia, and menometrorrhagia.
Ultrasound and sonohysteogram.

Question 22

Why is it important to remove symptomatic endometrial polyps?

Answer 22

They mask bleeding from another source (endometrial hyperplasia or cancer).

Question 23

DDX of Abnormal bleeding (7)?

Answer 23

Adenomyosis, endometrial polyps, endometrial hyperplasia, endometrial cancer, dysfunctional uterine bleeding, ectopic pregnancy, and Uterine Fibroids.

Question 24

What causes endometrial hyperplasia?

Answer 24

Unopposed estrogen!
Exogenous - Hormone replacement therapy
Endogenous - Conversion of androgens to estrogens by aromatase in adipocyte cells.

Question 25

Classifications and progression from Simple Endometrial Hyperplasia to Endometrial Cancer (4).

Answer 25

Simple Hyperplasia - 1% risk of progressing to cancer.
Complex Hyperplasia - 3% risk of progressing to cancer.
Atypical Simple Hyperplasia - 8% risk of progressing to cancer.
Atypical Complex Hyperplasia - 29% risk of progressing to cancer.

Question 26

Treatment of Endometrial Atypical Complex Hyperplasia? Treatment in younger patients?

Answer 26

Hysterectomy - high risk of concurrent or incipient cancer.

Endometrial cuettage, progestin managment, and weight loss to maintain opportunity for pregnancy.

Question 27

Physical exam findings for Endometrial hyperplasia?

Diagnostic test?

Answer 27

Typically none - might see symtpoms of chronic annovulation like obesity, acanthosis, acne, or hirsutism.
Endometrial biopsies.

Question 28

Treatment of Endometrial Simple/Complex Hyperplasia?

Answer 28

Progestin therapy! Depo, Mirena, Provera…just give them progesterone.

Question 29

75% of ovarian cysts in reproductive age women are functional ovarian cysts, what are the three types of functional cysts?
Common risk factor?

Answer 29

Follicular - Most common, can cause torsion if large but mostly spontaneously resolve.
Corpus Luteum - Cause delay in menstration, pain, and signs of hemoperitoneum.
Theca Lutein - Large bilateral cysts from abnormally high bHCG.
SMOKING doubles the risk of developing functional cyst.

Question 30

Classic presentation of torsed adnexa from an ovarian cyst?

Answer 30

Waking and waning pain and nausea.

Question 31

Diagnostic test for functional ovarian cysts?

Answer 31

Pelvic ultrasound - most will spontaneously resolve in 60-90 days.

Question 32

Treatment of an 8 year old girl with a cystic adnexal mass >2cm?

Answer 32

It’s most likely a neoplasm - Exploratory Laparotomy.

Question 33

Treatment of a 30 year old woman with a cystic adnexal mass <8 cm?
What about a non resolving mass greater than 8cm?

Answer 33

Observation and ultrasound - put on OCP to suprress ovulation and formation of future cysts.
Ex lap or laparoscopy.

Question 34

Treatment of a 60 year old woman with a palpable cystic adnexal mass?

Answer 34

It’s most likely a neoplasm - Exploratory Laparotomy or laparoscopy.