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Clin Med 3 - Exam 3 (Women's Health) > Benign Uterine and Ovarian Disease > Flashcards

Benign Uterine and Ovarian Disease Flashcards

1
Q

what are Leiomyomas aka Fibroids?

A

Benign tumors arising from smooth muscle cells of the myometrium (muscle layer of the uterus)

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2
Q

what is the MOST COMMON pelvic tumor in women?

A

Leiomyomas (Fibroids)

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3
Q

who are Fibroids MOST COMMON in?

A

black women

  • present younger and grow faster
  • also higher rate of hysterectomy d/t fibroids
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4
Q

Pathophysiology of Fibroids?

A
  • Benign tumors
  • Resemble normal tissue
  • Feel firm and smooth
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5
Q

Fibroids are classified by what?

A

their location of occurrence

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6
Q

Locations of Fibroids?

A 
Intramural myoma (M/C)
-located completely in the muscle layer

Subserosal Myoma (M/C)

Submucosal Myoma

Cervical Myoma

Pedunculated (Stemmed)
-subserosal or submucosal

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7
Q

what are the most common signs and symptoms of Fibroids?

A

MOST ARE ASYMPTOMATIC

Heavy or prolonged menstrual bleeding (increased clots, dysmenorrhea) -> M/C

Pelvic Pressure and Pain

Anemia (b/c of heavy bleeding)

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8
Q

Physical exam findings of Fibroids?

A

Enlarged uterus, irregular uterus, +/- tender uterus

these are found on bimanual exam

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9
Q

Dx of Fibroids?

A

Bimanual exam, but to confirm -> TRANSVAGINAL U/S

can do MRI if pt going to surgery

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10
Q

when do you treat pts with Fibroids?

A

only if they are symptomatic

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11
Q

growth of fibroids related to what?

A

to estrogen production

FIBROIDS REGRESS AFTER MENOPAUSE

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12
Q

Fibroids regress after?

A

Menopause d/t decreased estrogen

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13
Q

Fibroid tx options?

A

Watchful waiting (most don’t need tx)

Meds

Surgery (Mainstay of tx)

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14
Q

Medical tx for Fibroids?

A

NSAIDs for dysmenorrhea

OCPs (diminish estrogen, so diminish fibroid size)

Levonorgestrel IUD (diminish estrogen)

Leuprolide (Leupron) - GnRH agonist

Danazol (androgen that increases progesterone)

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15
Q

How does Leuprolide (Leupron) treat Fibroids?

A

Leuprolide is a GnRH agonist

  • puts pt into menopause
  • 3-6 month max use
  • goal is to decrease fibroid size pre-op

get menopause type sx’s (amenorrhea, hot flashes, osteoporosis)

once stop Leuprolide, fibroid and menorrhagia continue

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16
Q

what is the goal of using Leuprolide for tx of Fibroids?

A

goal is to decrease fibroid size pre-op

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17
Q

what are the indications for surgery to treat Fibroids?

A

abnormal uterine bleeding, bulk related sx’s, infertility, recurrent miscarriages

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18
Q

Surgical options for tx of Fibroids?

A

Hysterectomy, Myomectomy (easiest option), endometrial ablation, Uterine artery embolization, Magnetic resonance guided focused U/S surgery (not often done b/c expensive)

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19
Q

why do Myomectomy to treat for Fibroids?

A

b/c removing the muscle around the fibroid

done when want to preserve fertility, instead of doing a hysterectomy

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20
Q

what is Adenomyosis?

A

Ectopic endometrial tissue w/in the myometrium
-the tissue that’s supposed to be in the endometrium grows backwards into the myometrium and starts to hypertrophy and hyperplasia occurs

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21
Q

what’s the uterus like in Adenomyosis?

A

Diffusely enlarged uterus (“Globular”) -> “Boggy Uterus”

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22
Q

Buzz word for Adenomyosis?

A

Boggy Uterus

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23
Q

does the tissue in Adenomyosis look like normal tissue?

A

tissue in Adenomyosis not well differentiated from surrounding tissue -> difficult to excise

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24
Q

what is Adenomyoma?

A

when ectopic is confined to a discrete area

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25
Q

what do Adenomyomas resemble?

A

fibroids -> only way to tell what it is, is by bx

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26
Q

how do you definitively dx Adenomyosis?

A

via histology (bx) s/p hysterectomy

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27
Q

at what age does Adenomyosis commonly present?

A

age 40-50

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28
Q

Adenomyosis can coexist with what?

A

endometriosis and fibroids

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29
Q

Adenomyosis more common among what females?

A

parous females, esp with hx of C-section or hx of D&C

-d/t scar tissue that forms when have these procedures done

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30
Q

M/C symptoms of Adenomyosis?

A

Heavy Menstrual Bleeding and dysmenorrhea

also chronic pelvic pain

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31
Q

imaging for Adenomyosis?

A

Transvaginal US and MRI (but MRI expensive)

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32
Q

Key words for US findings of Adenomyosis?

A

“Asymmetric thickening of the myometrium”

“Linear striations” -> stretched tissue

“Loss of clear endomyometrial border”

“Increased myometrial heterogeneity”

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33
Q

what is the only effective tx for Adenomyosis?

A

Hysterectomy

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34
Q

other tx of Adenomyosis besides Hysterectomy, but not FDA approved for Adenomyosis?

A

OCPs/IUD -> treats bleeding and pain

GnRH analogs (Lupron) and Aromatase Inhibitors (anastrozole, Letrozole)

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35
Q

what is Endometriosis?

A

presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity

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36
Q

what does the ectopic tissue in Endometriosis respond to?

A

to cyclical hormonal fluctuations similar to intrauterine endometrium
-including release of prostaglandins leading to inflammatory process and scarring of ectopic areas

-they grow and bleed in response to the ovarian hormones

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37
Q

Endometriosis is a disease dependent on what? what leads to resolution of its sx’s?

A

it’s an estrogen dependent disease

menopause leads to resolution of sx’s

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38
Q

when should you consider Endometriosis?

A

when NSAIDs are ineffective in treating the woman’s menstrual/pelvic pain

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39
Q

what is the biggest risk factor of Endometriosis? other risk factors?

A

Nulliparity (never given birth) - M/C

others:
- fam hx, early menarche, short cycles, long duration of menstrual flow, heavy bleeding

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40
Q

what is the most common site for Endometriosis to occur in? other sites?

A

Ovaries - M/C

other sites:
-posterior cut-de-sac, broad ligament/uterosacral ligament, rectosigmoid colon, bladder

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41
Q

classic triad of sx’s in Endometriosis?

A

cyclic premenstrual pelvic pain, dysmenorrhea, dyspareunia (painful intercourse)

CAN BE ASYMPTOMATIC

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42
Q

are the physical exam findings specific for Endometriosis? what are some?

A

no, non-specific

lateral displacement of the cervix

  • Localized tenderness in the posterior cul-de-sac (Pouch of Douglas)
  • Palpable tender nodule in the posterior cul-de-sac (Endometrioma)
  • Pain with movement of the uterus
  • Severe abdominal pain (ruptured endometrioma)
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43
Q

what is the most common complication of Endometriosis? others?

A

Endometrioma - “Chocolate Cyst”
-M/C on ovaries

other complications: adhesion formation, infertility

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44
Q

dx tool of Endometriosis? what do you see?

A

Laparoscopy w/bx - Definitive dx

see classic blue black or powder burned appearance

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45
Q

dx aides of Endometriosis?

A

Pelvic US

-helps r/o other pathology and identify findings suggestive of endometriosis

46
Q

do most pts with Endometriosis respond to medical tx? how many have a return of sx’s after 5 years of med management?

A

95% response to medical management

50% will have return of symptoms after 5 years of medical management

47
Q

Medical tx for Endometriosis?

A

***Combined (Estrogen/Progestin) OCP or Progestin only OCP

GnRH analogues - Lupron (restricted to 6 months and risk of osteoporosis and menopause adrs)

Danazol (Adrogenic Steroid)

48
Q

GnRH analogues (Lupron) for tx of Endometriosis are restricted to how long of use and what are their risks?

A

restricted to 6 months and risk of osteoporosis and menopause adrs

49
Q

what surgical tx of Endometriosis is considered definitive therapy?

A

Hysterectomy with BSO

50
Q

what is the staging of Endometriosis how is it helpful and used for what?

A

Point system given to lesions and adhesions in pelvic organs

may help to determine prognosis

used to monitor response to therapy

51
Q

what is Endometriosis Stage 1?

A

Minimal

Only superficial lesions and possibly a few filmy adhesions (a little bit of scar tissue, nothing bad)

52
Q

what is Endometriosis Stage 2?

A

Mild

Superficial and deep lesions present in the cul-de-sac, no adhesions

53
Q

what is Endometriosis Stage 3?

A

Moderate

Multiple implants + endometriomas on one or both ovaries

54
Q

what is Endometriosis Stage 4?

A

Severe

Multiple implants (superficial and invasive) + large endometriomas and extensive adhesions (adhesions are what cause problems in pts)

55
Q

when are ovarian cysts most prevalent?

A

during infancy, adolescence, and childbearing years

56
Q

what is the most common ovarian cyst?

A

functional ovarian cysts

57
Q

what does “functional” mean in functional ovarian cysts?

A

Functional means they will grow and change along with the menstrual cycle

58
Q

what are the types of ovarian cysts? (HINT: 4)

A

follicular, corpus luteal cyst, theca lutein cyst, endometrioma

59
Q

what are simple cysts?

A

simple fluid, thin wall

E.g. follicular, luteal, serous cystadenoma

60
Q

what are complex cysts?

A

Debris, blood, varied wall thickness, septations, hemorrhagic

61
Q

follicular cysts (how do they occur? unilateral or bilateral? when do they resolve? what do they look like on U/S?)

A

Rupture of mature follicle doesn’t occur

Unilateral

Resolve spontaneously 2-3 months

On U/S, follicular cysts present as simple uniocular, anechoic cysts with a thin, smooth wall
-Anechoic means black on U/S and nothing fibrous in it

62
Q

corpus luteal cysts

A

Occurs after ovulation

Can be Vascular (b/c ovulation has just occurred)

Simple or Complex
-Increased likelihood of hemorrhagic cyst

Unilateral (b/c ovulating from one at a time)

63
Q

what do corpus luteal cysts look like on Doppler?

A

Ring of Fire appearance (b/c can be vascular)

64
Q

theca lutein cysts (how do they occur? bilateral or unilateral? overstimulation by what? what do you see on U/S?)

A

Ovarian Hyperstimulation

-Bilateral

Hormonal Overstimulation by Beta-hCG
E.g. Gestational Trophoblastic Disease (Molar pregnancy); Hormonal therapy (ex: infertility tx); seldom in singleton pregnancy

doesn’t show enhancement on U/S

65
Q

endometrioma (what is it? M/C sx? responsive to what? tx?)

A

Cyst formed with endometrial tissue - “Chocolate Cyst”

***Chronic pelvic pain

Hormonally responsive

Yearly follow-up with U/S or surgical removal

66
Q

polycystic ovarian syndrome (what do you see on images? what is its characteristic appearance?)

A

10 or more peripheral simple cysts

Characteristic “string-of-pearls” appearance

67
Q

Mature Cystic Teratoma aka?

A

Dermoid cyst

68
Q

what are Mature Cystic Teratomas? how do they appear?

A

benign germ cell tumors

appear cystic with calcifications, fat, sebaceous tissue, HAIR, TEETH

69
Q

tx for Mature Cystic Teratomas?

A

MUST BE REMOVED

70
Q

what are Mature Cystic Teratoma associated with?

A

associated with ovarian torsion if >5cm

71
Q

Serous Cystadenoma (filled with? common at what age?)

A

Simple, filled with serum

Benign ovarian tumors

Common in women 40-50 y/o

72
Q

Mucinous Cystadenoma (filled with? common at what age?)

A

Thicker, get protein filled debris

Can be very large

Age 20-40 y/o

73
Q

Cystadenofibroma (what type of tumor? what’s it look like? resembles what? tx?)

A

Benign surface epithelial tumor

Complex cystic to solid appearing mass

Resembles malignant tumor

Tx: Oophorectomy

74
Q

Ovarian cysts and benign tumors signs and sx’s

A

can be asx, abd pain, fullness, heaviness, pressure, bloating, irregular bleeding or abnormal vaginal bleeding

75
Q

sx of cyst rupture?

A

sudden onset sharp pain

76
Q

what are complications of ovarian cysts and benign tumors?

A

Ovarian torsion -> SURGICAL EMERGENCY

Hemorrhagic cyst
-rupture and internal bleeding

77
Q

sx’s of ovarian torsion?

A

sharp sudden pain, then waxing/waning pain

78
Q

what is the first line dx test for ovarian cysts and benign tumors?

A

US

-helps distinguish complex, simple, or solid lesions

79
Q

diagnostics for ovarian cysts and benign tumors

A

US

CT Pelvis for malignancy staging

MRI - for surgery

hCG (preg test)

CA-125
-marker for ovarian cancer

80
Q

US management at reproductive age for simple ovarian cysts and benign tumors (<5cm, 5-7cm, >7cm)

A

<5cm -> observe

5-7cm -> follow-up annually with US

> 7cm -> either MRI or surgery

81
Q

US management at reproductive age for hemorrhagic ovarian cysts and benign tumors (>5cm)

A

> 5cm f/u US 6-12 weeks

82
Q

US management at post-menopausal for ovarian cysts and benign tumors (>1cm-7cm)

A

> 1cm-7cm U/S annually +/- CA-125

  • Monitor pt
  • If CA-125 positive then do bx
83
Q

US management for dermoid cyst

A

US q6-12 months

cystectomy

84
Q

US management for endometrioma

A

initial f/u US 6-12 weeks

US annually

Cystectomy

85
Q

Tx of Ovarian Cysts

A

Analgesia - NSAIDs

OCPS - recurrent functional cysts

Surgery not indicated/required for Follicular or Corpus Luteal Cyst unless very large or hemorrhagic with rupture

86
Q

what are the indications for ovarian cystectomy or oophorectomy?

A

Symptomatic cysts

Persistent 5-10cm cysts (esp. symptomatic)

Ovarian Torsion

Suspected malignancy

87
Q

what is the primary pelvic floor muscle? what muscles make up the complex?

A

Levator ani muscle complex - primary support

  • Pubococcygeus
  • Puborectalis
  • Iliococcygeus
88
Q

what is a pelvic organ prolapse (POP)?

A

Herniation of pelvic organs to or beyond vaginal wall

89
Q

what is an anterior compartment prolapse (cystocele)?

A

Hernia of anterior vaginal wall with descent of bladder (bladder pushes on anterior vaginal wall)

90
Q

what is posterior compartment prolapse (rectocele)?

A

Hernia of posterior vaginal segment with descent of the rectum (rectum pushes up into the vagina)

91
Q

what is an enterocoele? occurs when? seen in conjunction with what other prolapse?

A

Hernia of the intestines to or through the vaginal wall

  • Occurs when no uterus or cervix in place any more
  • Seen in conjunction with rectoceles
92
Q

what is apical compartment (uterine prolapse)?

A

Descent of apex of vagina into lower vagina, to or beyond the vaginal introitus

93
Q

what is uterine procidentia?

A

Hernia of all three compartments through the vaginal introitus

-Vaginal vault flips backwards and get prolapse of everything

94
Q

number 1 risk factor for pelvic organ prolapse? others?

A

1 = parity - vaginal delivery

others: advanced age, obesity - BMI>25, hysterectomy (increase apical prolapse)

95
Q

most common defecatory sx of pelvic organ prolapse? others?

A

constipation - M/C

others: fecal urgency, fecal incontinence (ex: during intercourse), incomplete emptying

96
Q

pelvic organ prolapse urinary sx’s?

A

slow urine stream, sensation of incomplete emptying, overactive bladder (urgency, frequency, incontinence)

97
Q

do pts with pelvic organ prolapse have sex?

A

they avoid sex b/c feel shame

98
Q

what dx exam for pelvic organ prolapse? what exam is done to measure the prolapse?

A

Pelvic Exam (external, internal, bimanual, rectovaginal)

do POP-Q exam to measure prolapse

99
Q

POP-Q staging has how many stages?

A

0-4

100
Q

stage 0 of POP-Q?

A

no prolapse

101
Q

stage 1 of POP-Q?

A

prolapse 1cm above hymenal plane (comes 2/3rds the way of the vagina)

102
Q

stage 2 of POP-Q?

A

Prolapse descends to introitus (but doesn’t come outside)

103
Q

stage 3 of POP-Q?

A

Prolapse greater than 1cm past hymenal remnant, but doesn’t cause complete vaginal vault eversion or complete uterine procidentia

104
Q

stage 4 of POP-Q?

A

Complete vaginal vault eversion or complete uterine pocidentia

105
Q

tx of pelvic organ prolapse indicated for who?

A

only for symptomatic (urinary, bowel, or sexual dysfunction)

106
Q

what is conservative therapy for pelvic organ prolapse?

A
  • **use of Pessary
  • silicone devices varying in size and shape
  • 50% D/C use after 1-2 years
  • must be removed and cleaned on regular basis (every 3 months)

also do pelvic floor muscle exercise

107
Q

surgical tx of pelvic organ prolapse?

A

Anterior vaginal wall prolapse repair (Anterior colporrhaphy - highly recurrent, but fixes cystoceles)

Posterior vaginal wall prolapse repair (Posterior colporrhaphy)

Apical Defect
-Sacral colpopexy - best surgery

108
Q

what is the best surgery for pelvic organ prolapses, but not done right away? when is it done?

A

Sacral colpopexy

Done in pts with recurrent prolapses

Most of the time done in pts who have had a hysterectomy

109
Q

do pelvic organ prolapses cause pain?

A

NO!!! PROLAPSES DON’T CAUSE PAIN!!!

110
Q

what are the main concerns of pelvic organ prolapses?

A

inability to empty bladder (increase risk for infections) and defecatory dysfunction

111
Q

if unsure about a pelvic organ prolapse, then do what?

A

refer to Urogyn!

Clin Med 3 - Exam 3 (Women's Health) (9 decks)

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