Benign Upper Genital Tract Disorders

Question 1

Upper structures formed from fusion of ______ ducts. Lower 1/3 vagina from ____.

Answer 1

Upper structures formed from fusion of paramesonephric = mullerian ducts. Lower 1⁄3 vagina from UG sinus

Question 2

Congenital anomalies: septate uterus

Answer 2

Often a/w inguinal hernias & urinary tract anomalies (get imaging to eval!)

Question 3

Bicornate or septate uteri complications:

Answer 3

2nd trim pregnancy loss, malpresentation, PTL, etc.

Generally will require no treatment unless symptomatic

Question 4

Uterine leiomyomas = fibroids

Answer 4

Estrogen responsive monoclonal smooth muscle proliferation surrounded by pseudocapsule

Question 5

Fibroid demographics

Answer 5

Common in women of childbearing age → can enlarge in pregnancy → regress in menopause
More common in AA pts for unknown reasons

Question 6

Increased risk for fibroids:

Answer 6

Multip, nonsmoking, hypertensive, perimenopausal women

Question 7

Protection for fibroids:

Answer 7

OCPs protective

Question 8

Fibroids: when to treat

Answer 8

Only require treatment if bleeding / sx / problems with fertility
Submucosal bleed, take out under hysteroscopy. Intramural = most common, subserosal too - remove these via myomectomy.

Question 9

Fibroids: diagnosis

Answer 9

Dx with pelvic ultrasound.

MRI if need to distinguish from adenomyosis.

Question 10

Fibroid: treatment

Answer 10

Medical therapy: Provera, Lupron (decrease estrogen) - remember GnRH agonists can cause more bleeding initially.
Lupron usually used to shrink size / stop bleeding before surgery (fibroids will go back to previous size very quickly)

IR: can do uterine artery embolization

Surgical: myomectomy if fertility desired, but more morbid / recur. Hysterectomy definitive.

Question 11

Endometrial polyps:

Answer 11

Benign overgrowths
Common in women 40-50 y/o
Benign, but can mask bleeding from other sources.

Question 12

Endometrial polyp presentation:

Answer 12

Bleeding between periods (metrorrhagia, also meno / menometro)

Question 13

Endometrial polyp diagnosis:

Answer 13

U/S & sonohystogram.

If > 35, need endometrial biopsy if bleedin

Question 14

Endometrial hyperplasia:

Answer 14

Common cause of abnormal uterine bleeding

2/2 unopposed estrogen exposure (anovulatory cycles, etc) → can progress to carcinoma

Question 15

Risk factors for endometrial hyperplasia:

Answer 15

Obesity, nullips, late menopause, early menarche, exogenous estrogen w/o progesterone, PCOS, chronic anovulation, estrogen producing tumors (granulosa-theca cell), tamoxifen. Also HTN / DM

Question 16

Presentation of endometrial hyperplasia

Answer 16

P/w oligomenorrhea / amenorrhea, then excessive / irregular bleeding.

Question 17

Uterine bleeding in postmenopausal women:

Answer 17

Endometrial hyperplasia / cancer until proven otherwise!

Question 18

Endometrial hyperplasia classification:

Answer 18

Simple hyperplasia
Complex hyperplasia
Atypical simple hyperplasia
Atypical complex hyperplasia

If atypia, often have coexistent endometrial cancer!

Question 19

Diagnosis of endometrial hyperplasia

Answer 19

Need tissue dx: endometrial bx is first line; can do D&C if needed afterwards / bx not possible.

Question 20

Management of endometrial hyperplasia:

Answer 20

If just hyperplasia (simple / complex / SAH / CAH), can treat with progestin therapy (Provera to induce withdrawal bleed, or Mirena, etc) x 3 mo, then repeat endometrial bx to see regression

If CAH, often treat with hysterectomy (high risk coexistent endometrial cancer or developing it later).

Can follow closely if fertility preservation important, however.

Question 21

Ovarian cysts: functional

Answer 21

Normal functioning cysts

Question 22

Ovarian cysts: follicular

Answer 22

Most common. 
From failure of follicle to rupture. 
3-8cm. 
Asx, unilateral but can be tender. 
Higher risk of torsion if greater than 4-5 cm. Resolve in 60-90d

Question 23

Corpus luteum cyst

Answer 23

When corpus luteum fails to regress after 14d, or enlarges, or becomes hemorrhagic.
Can delay menses / cause unilateral lower quadrant pain.
Can rupture → hemoperitoneum.
Feel more firm on exam.

Question 24

Theca lutein cysts

Answer 24

Large, bilateral cysts, clear, straw-colored fluid.

From stimulation by abnormally high B-hCG (molar pregnancy, choriocarcinoma, ovarian induction therapy)

Question 25

Ovarian cyst warning signs

Answer 25

Ovarian torsion: classically waxing / waning pain & nausea. Concern if > 4cm

If premenarchal or postmenopausal, think neoplasm & do ex-lap

If persist > 60 days, are solid or complex on U/S, or larger than 8 cm in reproductive woman, think neoplasm → diagnostic laparoscopy or laparotomy.

Question 26

Ovarian cyst management

Answer 26

Follow up with pelvic ultrasounds serially to check for cyst resolution;
CA-125 if concerned for cancer
Start patients on oral contraceptives during observation period (to prevent future cysts)
Cystectomy / evaluation via laparoscopy / laparotomy if no resolution in 60-90d

Question 27

Simple endometrial hyperplasia

Answer 27

Proliferation of both stromal / glandular elements

Question 28

Complex endometrial hyperplasia

Answer 28

Glands proliferating, no cytologic atypia

Question 29

Atypical simple hyperplasia

Answer 29

Cellular atypia, mitotic figures too

Question 30

Atypical complex hyperplasia

Answer 30

Most severe form, atypia + proliferating glands, 29% risk progression to carcinoma