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)
2
Q
what is the MOST COMMON pelvic tumor in women?
A
Leiomyomas (Fibroids)
3
Q
who are Fibroids MOST COMMON in?
A
black women
- present younger and grow faster
- also higher rate of hysterectomy d/t fibroids
4
Q
Pathophysiology of Fibroids?
A
- Benign tumors
- Resemble normal tissue
- Feel firm and smooth
5
Q
Fibroids are classified by what?
A
their location of occurrence
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
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)
8
Q
Physical exam findings of Fibroids?
A
Enlarged uterus, irregular uterus, +/- tender uterus
these are found on bimanual exam
9
Q
Dx of Fibroids?
A
Bimanual exam, but to confirm -> TRANSVAGINAL U/S
can do MRI if pt going to surgery
10
Q
when do you treat pts with Fibroids?
A
only if they are symptomatic
11
Q
growth of fibroids related to what?
A
to estrogen production
FIBROIDS REGRESS AFTER MENOPAUSE
12
Q
Fibroids regress after?
A
Menopause d/t decreased estrogen
13
Q
Fibroid tx options?
A
Watchful waiting (most don’t need tx)
Meds
Surgery (Mainstay of tx)
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)
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
16
Q
what is the goal of using Leuprolide for tx of Fibroids?
A
goal is to decrease fibroid size pre-op
17
Q
what are the indications for surgery to treat Fibroids?
A
abnormal uterine bleeding, bulk related sx’s, infertility, recurrent miscarriages
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)
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
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
21
Q
what’s the uterus like in Adenomyosis?
A
Diffusely enlarged uterus (“Globular”) -> “Boggy Uterus”
22
Q
Buzz word for Adenomyosis?
A
Boggy Uterus
23
Q
does the tissue in Adenomyosis look like normal tissue?
A
tissue in Adenomyosis not well differentiated from surrounding tissue -> difficult to excise
24
Q
what is Adenomyoma?
A
when ectopic is confined to a discrete area
25
what do Adenomyomas resemble?
fibroids -> only way to tell what it is, is by bx
26
how do you definitively dx Adenomyosis?
via histology (bx) s/p hysterectomy
27
at what age does Adenomyosis commonly present?
age 40-50
28
Adenomyosis can coexist with what?
endometriosis and fibroids
29
Adenomyosis more common among what females?
parous females, esp with hx of C-section or hx of D&C
| -d/t scar tissue that forms when have these procedures done
30
M/C symptoms of Adenomyosis?
Heavy Menstrual Bleeding and dysmenorrhea
also chronic pelvic pain
31
imaging for Adenomyosis?
Transvaginal US and MRI (but MRI expensive)
32
Key words for US findings of Adenomyosis?
"Asymmetric thickening of the myometrium"
"Linear striations" -> stretched tissue
"Loss of clear endomyometrial border"
"Increased myometrial heterogeneity"
33
what is the only effective tx for Adenomyosis?
Hysterectomy
34
other tx of Adenomyosis besides Hysterectomy, but not FDA approved for Adenomyosis?
OCPs/IUD -> treats bleeding and pain
GnRH analogs (Lupron) and Aromatase Inhibitors (anastrozole, Letrozole)
35
what is Endometriosis?
presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity
36
what does the ectopic tissue in Endometriosis respond to?
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
37
Endometriosis is a disease dependent on what? what leads to resolution of its sx's?
it's an estrogen dependent disease
menopause leads to resolution of sx's
38
when should you consider Endometriosis?
when NSAIDs are ineffective in treating the woman's menstrual/pelvic pain
39
what is the biggest risk factor of Endometriosis? other risk factors?
Nulliparity (never given birth) - M/C
others:
- fam hx, early menarche, short cycles, long duration of menstrual flow, heavy bleeding
40
what is the most common site for Endometriosis to occur in? other sites?
Ovaries - M/C
other sites:
-posterior cut-de-sac, broad ligament/uterosacral ligament, rectosigmoid colon, bladder
41
classic triad of sx's in Endometriosis?
cyclic premenstrual pelvic pain, dysmenorrhea, dyspareunia (painful intercourse)
CAN BE ASYMPTOMATIC
42
are the physical exam findings specific for Endometriosis? what are some?
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)
43
what is the most common complication of Endometriosis? others?
Endometrioma - "Chocolate Cyst"
-M/C on ovaries
other complications: adhesion formation, infertility
44
dx tool of Endometriosis? what do you see?
Laparoscopy w/bx - Definitive dx
see classic blue black or powder burned appearance
45
dx aides of Endometriosis?
Pelvic US
| -helps r/o other pathology and identify findings suggestive of endometriosis
46
do most pts with Endometriosis respond to medical tx? how many have a return of sx's after 5 years of med management?
95% response to medical management
50% will have return of symptoms after 5 years of medical management
47
Medical tx for Endometriosis?
***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
GnRH analogues (Lupron) for tx of Endometriosis are restricted to how long of use and what are their risks?
restricted to 6 months and risk of osteoporosis and menopause adrs
49
what surgical tx of Endometriosis is considered definitive therapy?
Hysterectomy with BSO
50
what is the staging of Endometriosis how is it helpful and used for what?
Point system given to lesions and adhesions in pelvic organs
may help to determine prognosis
used to monitor response to therapy
51
what is Endometriosis Stage 1?
Minimal
Only superficial lesions and possibly a few filmy adhesions (a little bit of scar tissue, nothing bad)
52
what is Endometriosis Stage 2?
Mild
Superficial and deep lesions present in the cul-de-sac, no adhesions
53
what is Endometriosis Stage 3?
Moderate
Multiple implants + endometriomas on one or both ovaries
54
what is Endometriosis Stage 4?
Severe
Multiple implants (superficial and invasive) + large endometriomas and extensive adhesions (adhesions are what cause problems in pts)
55
when are ovarian cysts most prevalent?
during infancy, adolescence, and childbearing years
56
what is the most common ovarian cyst?
functional ovarian cysts
57
what does "functional" mean in functional ovarian cysts?
Functional means they will grow and change along with the menstrual cycle
58
what are the types of ovarian cysts? (HINT: 4)
follicular, corpus luteal cyst, theca lutein cyst, endometrioma
59
what are simple cysts?
simple fluid, thin wall
E.g. follicular, luteal, serous cystadenoma
60
what are complex cysts?
Debris, blood, varied wall thickness, septations, hemorrhagic
61
follicular cysts (how do they occur? unilateral or bilateral? when do they resolve? what do they look like on U/S?)
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
corpus luteal cysts
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
what do corpus luteal cysts look like on Doppler?
Ring of Fire appearance (b/c can be vascular)
64
theca lutein cysts (how do they occur? bilateral or unilateral? overstimulation by what? what do you see on U/S?)
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
endometrioma (what is it? M/C sx? responsive to what? tx?)
Cyst formed with endometrial tissue - "Chocolate Cyst"
***Chronic pelvic pain
Hormonally responsive
Yearly follow-up with U/S or surgical removal
66
polycystic ovarian syndrome (what do you see on images? what is its characteristic appearance?)
10 or more peripheral simple cysts
Characteristic "string-of-pearls" appearance
67
Mature Cystic Teratoma aka?
Dermoid cyst
68
what are Mature Cystic Teratomas? how do they appear?
benign germ cell tumors
appear cystic with calcifications, fat, sebaceous tissue, HAIR, TEETH
69
tx for Mature Cystic Teratomas?
MUST BE REMOVED
70
what are Mature Cystic Teratoma associated with?
associated with ovarian torsion if >5cm
71
Serous Cystadenoma (filled with? common at what age?)
Simple, filled with serum
Benign ovarian tumors
Common in women 40-50 y/o
72
Mucinous Cystadenoma (filled with? common at what age?)
Thicker, get protein filled debris
Can be very large
Age 20-40 y/o
73
Cystadenofibroma (what type of tumor? what's it look like? resembles what? tx?)
Benign surface epithelial tumor
Complex cystic to solid appearing mass
Resembles malignant tumor
Tx: Oophorectomy
74
Ovarian cysts and benign tumors signs and sx's
can be asx, abd pain, fullness, heaviness, pressure, bloating, irregular bleeding or abnormal vaginal bleeding
75
sx of cyst rupture?
sudden onset sharp pain
76
what are complications of ovarian cysts and benign tumors?
Ovarian torsion -> SURGICAL EMERGENCY
Hemorrhagic cyst
-rupture and internal bleeding
77
sx's of ovarian torsion?
sharp sudden pain, then waxing/waning pain
78
what is the first line dx test for ovarian cysts and benign tumors?
US
| -helps distinguish complex, simple, or solid lesions
79
diagnostics for ovarian cysts and benign tumors
US
CT Pelvis for malignancy staging
MRI - for surgery
hCG (preg test)
CA-125
-marker for ovarian cancer
80
US management at reproductive age for simple ovarian cysts and benign tumors (<5cm, 5-7cm, >7cm)
<5cm -> observe
5-7cm -> follow-up annually with US
>7cm -> either MRI or surgery
81
US management at reproductive age for hemorrhagic ovarian cysts and benign tumors (>5cm)
>5cm f/u US 6-12 weeks
82
US management at post-menopausal for ovarian cysts and benign tumors (>1cm-7cm)
>1cm-7cm U/S annually +/- CA-125
- Monitor pt
- If CA-125 positive then do bx
83
US management for dermoid cyst
US q6-12 months
cystectomy
84
US management for endometrioma
initial f/u US 6-12 weeks
US annually
Cystectomy
85
Tx of Ovarian Cysts
Analgesia - NSAIDs
OCPS - recurrent functional cysts
Surgery not indicated/required for Follicular or Corpus Luteal Cyst unless very large or hemorrhagic with rupture
86
what are the indications for ovarian cystectomy or oophorectomy?
Symptomatic cysts
Persistent 5-10cm cysts (esp. symptomatic)
Ovarian Torsion
Suspected malignancy
87
what is the primary pelvic floor muscle? what muscles make up the complex?
Levator ani muscle complex - primary support
- Pubococcygeus
- Puborectalis
- Iliococcygeus
88
what is a pelvic organ prolapse (POP)?
Herniation of pelvic organs to or beyond vaginal wall
89
what is an anterior compartment prolapse (cystocele)?
Hernia of anterior vaginal wall with descent of bladder (bladder pushes on anterior vaginal wall)
90
what is posterior compartment prolapse (rectocele)?
Hernia of posterior vaginal segment with descent of the rectum (rectum pushes up into the vagina)
91
what is an enterocoele? occurs when? seen in conjunction with what other prolapse?
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
what is apical compartment (uterine prolapse)?
Descent of apex of vagina into lower vagina, to or beyond the vaginal introitus
93
what is uterine procidentia?
Hernia of all three compartments through the vaginal introitus
-Vaginal vault flips backwards and get prolapse of everything
94
number 1 risk factor for pelvic organ prolapse? others?
#1 = parity - vaginal delivery
others: advanced age, obesity - BMI>25, hysterectomy (increase apical prolapse)
95
most common defecatory sx of pelvic organ prolapse? others?
constipation - M/C
others: fecal urgency, fecal incontinence (ex: during intercourse), incomplete emptying
96
pelvic organ prolapse urinary sx's?
slow urine stream, sensation of incomplete emptying, overactive bladder (urgency, frequency, incontinence)
97
do pts with pelvic organ prolapse have sex?
they avoid sex b/c feel shame
98
what dx exam for pelvic organ prolapse? what exam is done to measure the prolapse?
Pelvic Exam (external, internal, bimanual, rectovaginal)
do POP-Q exam to measure prolapse
99
POP-Q staging has how many stages?
0-4
100
stage 0 of POP-Q?
no prolapse
101
stage 1 of POP-Q?
prolapse 1cm above hymenal plane (comes 2/3rds the way of the vagina)
102
stage 2 of POP-Q?
Prolapse descends to introitus (but doesn't come outside)
103
stage 3 of POP-Q?
Prolapse greater than 1cm past hymenal remnant, but doesn't cause complete vaginal vault eversion or complete uterine procidentia
104
stage 4 of POP-Q?
Complete vaginal vault eversion or complete uterine pocidentia
105
tx of pelvic organ prolapse indicated for who?
only for symptomatic (urinary, bowel, or sexual dysfunction)
106
what is conservative therapy for pelvic organ prolapse?
* **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
surgical tx of pelvic organ prolapse?
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
what is the best surgery for pelvic organ prolapses, but not done right away? when is it done?
Sacral colpopexy
Done in pts with recurrent prolapses
Most of the time done in pts who have had a hysterectomy
109
do pelvic organ prolapses cause pain?
NO!!! PROLAPSES DON'T CAUSE PAIN!!!
110
what are the main concerns of pelvic organ prolapses?
inability to empty bladder (increase risk for infections) and defecatory dysfunction
111
if unsure about a pelvic organ prolapse, then do what?
refer to Urogyn!
