Benign genital tract disorders Flashcards
Diagnosis of benign epithelial disorders of vulva/vagina?
CLINICALLY.
Lichen sclerosis
Thinning of the vulvar skin. Sx: asymptomatic or can have pruritis/dyspareunia
An inflammatory dermatosis
Postmenopauseal women
3-4% inc risk of vulvar skin cancer
Lichen planus
Papular or erosive lesions of the vulva that may also involve vagina. Pruritis–>severe erosions.
Purple papules with white striae on vulva
Complication of vaginal adhesions with erosive vaginitis
50s or 60s
3-4% inc risk of vulvar skin cancer
Lichen simplex chronicus
“itch that rashes”; chronic pruritis
THICKENED skin because of the scratching
When should you biopsy the lesion?
If there is ulceration, unifocal lesion, uncertain suspicion of lichen sclerosis, unidentifiable lesions, unresponsive to treatment.
Treatment?
Hygeine, loose clothes, unscented soaps.
Topical steroid like clobetasol for LS, LP, or SEVERE LSC
MC tumor found on the vulva?
Epidermal inclusion cysts. Formed by occlusion of hair follicle.
Sebaceous cyst
When duct of sebaceous gland is blocked. Often multiple and asymptomatic
Hiradenitis suppurativa
Skin disease that affects the apocrine sweat glands
Where is skene’s gland?
Next to the urethral meatus
Where are Bartholin’s glands?
4 and 8 o’clock
How do you treat a Bartholin’s gland cyst? Recurrent ones?
What should you do in one that appears in a woman over 40?
Word catheter placement (balloon left in place for 4-6 wks then serially reduced in size while the cyst/tract re-epithelialize)
Marsupialization- incision, removal, cyst wall sutured to vaginal mucosa to prevent reformation.
Over 40- biopsy it to r/o rare possibility of Bartholin’s gland carcinoma.
What is a Gartner duct cyst? Usually found where?
Presenting sx?
Rx?
Remnant of the mesonephric ducts of the Wolffian system.
Anterolateral vagina.
Usually ASYMPTOMATIC but could have dyspareunia or difficulty inserting a tampon
Excision (use vasopressin bc they tend to bleed a lot)
Rx of urethral caruncles or urethral prolapse? Who?
None req.
Postmenopauseal women due to vulvovaginal atrophy.
DES exposure #1 risk?
Cervical insufficiency in pregnancy.
Clear cell adenocarcinoma of cervix and vagina in only 0.1% of exposed!!!!! Women under 20
What is a nabothian cyst?
Dilated retention cyst of the cervix. Caused by intermittent blockage of an endocervical gland.
Usually asymptomatic.
Look like dots on cervix.
Rx of cervical polyp that is asymptomatic?
Remove it anyway bc it could mask something BAD, like cancer, fibroids, adenomyosis, etc.
Symptoms of cervical polyp
Intermenstrual or postcoital spotting
Can cervix have fibroids?
Yes, either arising from it OR prolapsing into it from the endometrial cavity
What complications can a cervical fibroid have in pregnancy?
Poor dilation, malpresentation, obstruction of the birth canal, hemorrhage (think stretching out during dilation and bam.)
What can lead to cervical stenosis?
Infection, atrophy, scarring, idiopathic
Neoplasm, polyp, fibroid.
Sx of cervical stenosis?
ASYMPTOMATIC and doesn’t affect menstruation or fertility
Rx of cervical stenosis?
IF there are sx, gently dilate cervix. Can leave a catheter in for a few days.
How does labial fusion come about?
Excess androgen exposure or enzymatic deficiency. MC from CAH 21-a-hydroxylase deficiency.
Rx of benign cystic and solid skin tumors?
Don’t treat unless symptomatic or infected. Incision/drainage OR excision.
Lower 1/3 of vagina arises from __
urogenital diaphragm
Ovaries arise from ___
Genital ridge
Everything else arises from ____
Mullerian system
MC congenital mullerian abnormality?
How is this usually discovered?
Septate uterus
25% of these patients have first trimester pregnancy loss (bc it’s collagenous and can’t support placentation)
Which abnormality for 1st trimester pregnancy loss? 2nd?
Uterine septa
Bicornuate or unicornuate uterus (also assoc with preterm labor)
How do you differentiate between uterine septa vs. bicornuate uterus?
COULD appear identical on hysteroscopy
MRI or laparoscopy to evaluate the uterine fundus
Also can look for renal anomalies in any Mullerian disorder
What can a woman with bicornuate uterus expect wrt pregnancy?
Possible to carry fetus to term. Risk of preterm labor.
If having trouble, surgical unification procedure can help with fertility.
Are fibroids responsive to anything?
Yes, grow in response to both estrogen and progesterone, so they get bigger in pregnancy and shrink in menopause.
How are fibroids distinguished from adenomyosis?
Fibroids have a pseudocapsule, uterus gets bigger non-uniformly from them.
MRI is the best for differentiating.
Leiomyoma epidemiology?
More than 80% of AA women will develop them by age 50. Younger, bigger fibroid, heavier bleeding, more #, more severe anemia.
Lifetime risk in whites is 70.
50% of reproductive age women
Risk factors of leiomyoma
AA heritage, nonsmoking, early menarche, nulliparity, perimenopause, alcohol use, htn.
Low dose OCPs can INHIBIT NEW fibroids but may STIMULATE existing ones.
How often are leimyomas asymptomatic?
What is most common symptom?
50-65%
Abnormal uterine bleeding (due to SUBMUCOSAL fibroids impinging on the endometrium).
Medical treatment for fibroids that is non hormonal?
NSAIDs (decreases prostaglandin levels which are ouch), anti-fibrinolytics eg. tranexamic acid
What medical rx can decrease fibroid size?
GnRH agonists (nafarelin acetate, leuprolide acetate, goserelin acetate)
Surgical option for fibroids?
Uterine artery embolization (not for women who desire future pregnancy; not for large or pedunculated fibroids).
Myomectomy
Hysterectomy is the definitive rx.
Main disadvantage of myomectomy?
Fibroids recur in >60% of patients in 5 years.
Indications for surgery for leiomyomas?
Anemia, severe pain or secondary amenorrhea, uterine size >12 wks, urinary sx like hydronephrosis/freq/retention, growth after menopause, recurrent miscarriage or infertility, rapid inc in size
Endometrial polyps risk of malignancy?
Malignant or premalignant in 1-2% of premenopausal, 5% of postmenopausal
Progression of endometrial hyperplasia to endometrial cancer?
Risk factors?
Independent risk factors?
10x lifetime inc risk?
Penny-nickel-dime-quarter
Simple w/out atypia
Complex w/out atypic
Simple w/ atypia
Complex w/ atypia
UNOPPOSED ESTROGEN (oligmenorrhea, obesity form peripheral conversion of androgens to estrogens)
Independent are DIABETES AND HTN.
Lynch syndrome
Diagnosis of endometrial hyperplasia
EMB
Rx of simple and complex hyperplasia w/out atypic?
Progestin (Depo, medroxyprogesterone oral, Mirena ring)
Rx of endometrium with atypia?
D&C or hysterectomy
If younger and desiring pregnancy, LOSE WEIGHT and repeat EMB in 3 months.
What are the functional ovarian cysts?
Follicular cysts and corpus luteum cysts
How do follicular cysts arise?
After the follicle fails to rupture during the follicular phase. Most resolve by 60-90 days.
Asymptomatic/unilateral
Corpus luteum cyst?
Corpus luteum fails to regress after 14 days then becomes enlarged or hemorrhagic.
MAY CAUSE A MISSED PERIOD OR DULL LOWER QUADRANT PAIN.
What are theca lutein cysts?
Ovarian large bilateral cysts filled with clear straw-colored fluid.
How do theca lutein cysts arise?
By abnormally high beta-HCG (eg. ovulation induction therapy, molar pregnancy)
What kind of cyst with an endometrioma?
Chocolate cyst
Complication of a large ovarian cyst?
Rupture
Torsed adnexa with waxing/waning pain/nausea/vomiting
Diagnosis of ovarian cyst?
Pelvic u/s and f/u with serial u/s to see if it resolves like they normally do.
General rule of palpable ovaries in premenarchal or postmenopausal female?
What do you do?
OVARIAN NEOPLASM MORE LIKELY
Ex-lap or laparotomy
Patient of reproductive age with cyst. Cutoff size for getting observation and f/u u/s?
7 cm
What is the size when cyst is at risk of torsion?
4cm
Best treatment to prevent formation of FUTURE cysts?
OCPs b/c they suppress ovulation
Mirena is progesterone-containing IUD and only PARTIALLY INHIBITS cyst formation…`
