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CM III Exam III > Benign Uterine and Ovarian Disease > Flashcards

Benign Uterine and Ovarian Disease Flashcards

1
Q

Where do Leiomyomas (fibroids) arise from?

A

Myometrium, the muscular layer of the uterus

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2
Q

What’s the most common pelvic tumor in women of childbearing age?

A

Fibroid/leiomyomas

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3
Q

Etiology of leiomyomas?

A

No clue. unknown

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4
Q

What population is more likely to get a leiomyomas & subsequently a hysterectomy

A

Black women. AA»>WW

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5
Q

How do leiomyomas feel on a bimanual exam?

A

Firm and smooth. They’re benign tumors, it’s just the normal tissue that’s there plus a lil’ extra

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6
Q

4 Locations we might see a leiomyoma/what’s the most common one?

A

1) Intramural myoma (most common)
2) Subserosal myoma
3) Cervical myoma
4) Submucosal myoma

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7
Q

What does it mean if a fibroid is an intramural myoma?

A

Means it’s completely within the muscular layer

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8
Q

What is the only fibroid visible w/o cutting into the uterus?

A

Serosal fibroids

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9
Q

Pathognomonic symptom for fibroids

A

Heavy or prolonged menstrual bleeding. We’ll see increased clots and dysmenorrhea

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10
Q

Other, less common symptoms for fibroids

A 
Most are small and asymp, but we can have things like
Pelvic pressure & pain
Urinary freq
Difficulty emptying bladder completely
Reproductive dysf
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11
Q

Working up a fibroid

A

Palpable with bimanual exam, uterus will be enlarged/irregular. +/- tenderness.

Confirm w/ transvag US

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12
Q

What is fibroid treatment based on?

A

Symptomatic relief! Bleeding? stop it. Big enough to push on the bladder and cause issues? Get it out.

We’ll usually try out tx in this order

1) Watchful waiting
2) Rx management
3) Surgery

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13
Q

What does menopause do to fibroids?

A

Causes them to shrink and reduces symptoms. That’s why We’ll sometimes use GnRH and do an artificial menopause to lessen symptoms

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14
Q

Rx management of fibroids

A

1) NSAIDS - for dysmenorrhea
2) OCP
3) IUD
4) GnRH- induces temporary menopause. We’ll do this for preop to reduce the size

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15
Q

Indications for surgical management of fibroids

A

abnormal uterine bleeidng, bulk related symptoms, infertility, recurrent miscarriages

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16
Q

Surgical options for fibroids

A

1) Hysterectomy
2) Myomectomy (only for submucosal since they’re the only ones visible thru the muscle)
3) Uterine artery ablation (clot the artery feeding the fibroid)
4) Endometrial ablation

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17
Q

What is adenomyosis?

A

Ectopic endometrial tissue that grows backwards into the myometrium. Makes you have this huge boggy uterus

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18
Q

Adenomyosis on exam

A

Diffusely enlarged uterus, will feel “boggy”.

This tissue is not well differentiated from the surrounding tissue, just kind of looks like a giant endometrium. This makes it really difficult to excise. Tissue can be diffuse or local

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19
Q

Caveat of diagnosing adenomyosis

A

We can make a clinical observation, but it’s not a true diagnosis until a sample is sent down and pathology makes the call based on the histology

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20
Q

Epidemiology of adenomyosis

A

40-50yo, coexists with endometriosis and fibroids, most common w/ parous women w/ a hx of c-section or D&C

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21
Q

Adenomyosis sx

A

Heavy menstrual bleeding
Dysmenorrhea
Chronic pelvic pain
Diffusely enlarged boggy uterus

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22
Q

Key words to working up adenomyosis on US

A

1) Assymmetric thickening of the myometrium
2) Linear striations
3) Loss of clear endomyometrial border
4) Increased myometrial heretogeneity

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23
Q

Only guarenteed tx for adenomyosis

A

Hysterectomy

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24
Q

Hormonal tx for adenomyosis

A

GnRH analogs or Amoratase inhibitors

They will inhibit estrogen and do a little baby chemical menopause. Will work for a little bit but the patient can’t stay on these guys for too long, they’ve got nasty SE

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25
Q

Endometriosis is a ______ dependent disease

A

Estrogen! Menopause leads to resolution of symptoms

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26
Q

What is endometriosis?

A

It’s when the normal endometrial tissue is implanted in locations other than the uterus. Wicked painful and fairly common. Consider this diagnosis when NSAIDS are ineffective for txing a woman with pelvic pain (since it’s estrogen dependent)

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27
Q

RF for endometriosis

A 
Fx hx
Nullpar
Early menarche
Short menstrual cycles (packing a lot of hormones in a short time)
Long duration of menstruation
Heavy menstrual bleeding
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28
Q

Most common site for endometriosis implantation

A

Ovaries!

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29
Q

Sx of endometriosis

A 
Can be asymptomatic
Dysmenorrhea
Heavy or irregular bleeding
Pelvic pain
Lower abd pain/back pain
Dyspareuria
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30
Q

Endometriosis on PE

A

Non specific.
Localized tenderness in pouch of douglas (posterior)
Endometrioma (palpable tender nodule in douglas)
Pain with movement of uterus
Severe abd pain if ruptured endometrioma

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31
Q

What should we consider if a pt comes in w/ severe pain and a hx of endo?

A

Ruptured endometrioma

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32
Q

What is an endometrioma? Where is it most commonly found?

A

Chocolate cyst. Most commonly found on the ovaries

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33
Q

Besides an endometrioma, what are some other complications of endometriosis?

A

Adhesions
Pain
Infertility

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34
Q

Gold standard for diagnosing endometriosis (not necessarily first line)

A

Laparoscopy w/ bx. We’ll see the classic “blue black/power burned appearance” lesions in the vagina

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35
Q

Pathognomonic findings in the vagina for endometriosis

A

Blue back/powder burned appearance

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36
Q

For line for working up endometriosis

A

Transvag US! We can r/o the scary differentials real quick and then get to work on what’s actually going on

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37
Q

Is most endo surgically or medically managed?

A

Most are medical! 95% are successfully medically managed. However 50% of those women will report return of symptoms following medical management.

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38
Q

Medical management options for endometriosis

A

1) OCPs (combo or solo prog)
2) GnRH analog –> medical menopause. Only 6 mo though
3) Danazol (androgenic steroid)

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39
Q

Surgical options for hysterectomy

A

1) Hysterectomy w or w/o bilateral oopherectomy (w/BSO is considered definitive tx)
2) Laproscopic uterine nerve ablation
3) Lap and surg endometrial implant ablation (high reop rate, 50%)

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40
Q

Endometriosis Staging

A

Stage 1: Minimal, only superficial lesions and a few adhesions
Stage 2: Mild, superficial & deep lesions present in douglas. No adhesions
Stage 3: Moderate, multiple implants + endometriomas
Stage 4: Severe, multiple implants, large endometriomas, and extensive adhesions

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41
Q

What is a cyst

A

Sac filled with fluid or semiliquid material

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42
Q

What age group to ovarian cysts target

A

None! These suckers can happen at any age, including neonatal/infancy phase. Just slightly less likely to happen to post-menopausal women.

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43
Q

Most common type of cystic ovarian lesion

A

Functional ovarian cyst. These guys are so lowkey, most ovarian cysts are found incidentally.

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44
Q

Types of functional ovarian cysts

A

Follicular
Corpus luteal cyst
Theca lutein cyst
Endometrioma

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45
Q

Simple cyst

A

Full of simple fluid with a thin wall.

46
Q

Complex cyst

A

Filled with fluid and gunk, like debris and blood. These guys can have thick walls, and are a bit more problematic since they can trigger sepsis or hemorrhagically rupture.

47
Q

What triggers development of a follicular cyst

A

When the rupture of a mature follicle doesn’t occur

48
Q

Description of a follicular cyst on US

A

“Simple unilocular anechoic cysts with a thin, smooth wall”

49
Q

Should we be worried about follicular cysts?

A

Nah. These guys will resolve on their own in about 2-3 months 80% of the time

50
Q

When does a corpus luteal cyst occur

A

After ovulation

51
Q

Corpus luteal cyst on US

A

“Ring of fire” on doppler. Because these guys can be vascular, we worry about hemorrhages with these.

52
Q

What causes a theca lutein cyst?

A

Ovarian hyperstimulation! These guys are wicked rare. Seen more when mom is on hormonal IVF therapy, rarely seen in singleton pregnancy.

53
Q

Theca lutein cysts on US

A

Septations do now show enhancement on US. Whatever the heck that means

54
Q

What is an endometrioma

A

It’s a cyst formed with endometrial tissue. These are our “chocolate cysts”.

55
Q

What population of women get endometriomas

A

These are our women in their reproductive years. Oftentimes these will be your chronic pelvic pain patients

56
Q

How do we treat an endometrioma

A

Hormones! These guys are hormonally responsive. Do yearly fu w/ US or surgically remove them if this doesn’t work

57
Q

What is another name for a mature cystic teratoma (MCT)

A

Dermoid! These guys are benign germ cell tumors

58
Q

What are MCTs (mature cystic teratoma) associated with?

A

Ovarian torsion

59
Q

Mature cystic teratoma cyst contents

A

Calcifications, fat, sebaceous tissue, hair, even teeth. These are our classic teratomas

60
Q

Two types of cystadadenomas

A

Serous and Mucinous

61
Q

What is a serous cystadenoma? What is it filled with

A

Benign ovarian tumor, common in postmenopausal women. Filled with simple serous fluid

62
Q

What is a mucinous cystadenoma?

A

Large cystadenoma, filled with mucinous material (protein & debris). Found in premenopausal women

63
Q

Which is more the more common type of cysadenoma?

A

Serous!

64
Q

Who gets cysadenofibroma (rare as they are)

A

any menstruating women

65
Q

Cysadenofibroma tx?

A

Oopherectomy

66
Q

Signs and symptoms for any kind of ovarian cyst/benign ovarian tumors

A

Can be asymptomatic
Abd pain
Discomfort in lower abd/pelvis
Fullness, heaviness, pressure, bloating,
Irregular bleeding or abnormal vaginal bleeding

67
Q

If a woman has a history of ovarian cyst/benign ovrian tumor and they come in with sudden onset severe sharp pain?

A

Think rupture of an ovarian cyst

68
Q

Big complication of an ovarian cyst/benign tumor

A

Ovarian torsion. These guys can grow big enough to compress the ovary and cause torsion

69
Q

Typical presentation of an ovarian torsion secondary to an enlarged cyst/tumor

A

Woman 20-39yo, sharp sudden pain, then waxing/waning. N/V

70
Q

Besides ovarian torsion, what is another complication of an ovarian cyst and what cyst is the most common culprit of this

A

Hemorrhage. Corpus luteal cysts love to do this on days 20-28 of the cycle

71
Q

Tx for ovarian torsion secondary to an enlarged cyst/tumor

A

Emergent lap detorsion for the adnexa and ovarian salvage. Time is ovary

72
Q

Imaging for working up cyst/benign tumor

A

1) US- helps you rule out anything scary
2) CT pelvis (only for malignancy staging)
3) MRI (done after US only if needed. Can help with evaluating complex masses. Do not delay care because you haven’t gotten an MRI yet)

73
Q

What cancer antigen might we order a serology of when working up a possible ovarian carcinoma?

A

CA125. This is a board question and a question for the test. In reality, this is hardly ever used to make a diagnosis.

74
Q

US management of a mass in a woman of reproductive age (simple vs hemorrhagic)

A

Simple:
<5cm just observe
5-7cm US annually
>7 MRI/surg

Hemorrhagic:
>8cm FU ultrasound within a few months

75
Q

What does it mean if a mass is hemorrhagic

A

Blood seen on US. Can’t miss it, blood looks much different than serous fluid on US

76
Q

US management of a mass seen on a post-menopausal woman

A

<7cm US annually. Consider getting a CA125 for these women

77
Q

US management of a dermoid cyst

A

Remember these guys will not resolve spontaneous.

US q6-12 months
Cystectomy

78
Q

US management of an endometrioma

A

Initially fu w/ US in 6-12wks
After than US annually
Still there? Get a cystectomy

79
Q

Indicatinos for an ovarian cystectomy or oopherectomy

A

1) Symptomatic cysts
2) Persistent 5-10cm cysts (especially if symptomatic)
3) Ovarian torsion
4) Suspected malignancy

80
Q

Treatment of ovarian cysts

A

1) Analgesia (NSAIDS work fine)
2) Hormonal OCPS for recurrent functional cysts
3) Surgery

81
Q

What kind of cysts typically need surgery

A

Follicular, corpus luteal, very large or hemorrhagic cysts

82
Q

Why do OCP’s work so well for recurrent functional cysts

A

They work so well because they suppress ovulation, but sometimes even when you’re on the pill your body still goes through the motions and you’ll get a follicular cyst

83
Q

Which muscle group is the primary support of the pelvic floor

A

Levator ani muscle complex

pubococcygeus puborectalis, iliococcygeus

84
Q

What is pelvic organ prolapse (POP)

A

Herniation of pelvic organs to/beyond vaginal walls

85
Q

What is Anterior compartment prolapse (cystocele)

A

Bladder prolapsing into the anterior vaginal wall

86
Q

What is Posterior compartment prolapse (rectocele)

A

Rectum prolapsing into the posterior vaginal wall

87
Q

What is Enterocele

A

Herniation of the intestines to or through the vaginal wall

88
Q

What is apical compartment (uterine prolapse)

A

Cervix/uterus prolapsing into the lower vagina or beyond (dear god)

89
Q

What is uterine procidentia

A

Herniation of all three compartments into the vagina (jesus)

90
Q

What two prolapses like to happen together?

A

Enterocele and rectocele

91
Q

When do we most commonly see an enterocele

A

This happens when we don’t have a uterus/cervix. The intestines will just hang out around here and poke around when they’re feeling it.

92
Q

RF for prolapse

A 
Parity (vag deliveries are rough)
Adv age
OBesity jumps your risk so much
Hysterectomy (enterocele esp)
Other things like chronic constipation, heavy lifting, CT Dx, Ehlers danlos
93
Q

Three types of prolapse symptoms

A

Defecatory
Urinary
Sexual

94
Q

Defecatory symptoms in a prolapse patient

A

Constipation (most common)
Fecal urgency
Fecal incontinence (during intercourse)
Incomplete emptying

95
Q

Urinary symptoms in a prolapse pt

A

Slow urine stream
Sensation of incomplete emptying
Overactive bladder (urgency, freq, incontinence)

96
Q

Why do we get the overactive bladder symptoms in a prolapse patient

A

Because the urine that doesn’t make it past the urethral kink will build up, and then overnight when the prolapse isn’t protruding as much they’ll have to pee like every half hour

97
Q

Sexual symptoms in a prolapse pt

A

Avoidance/shame

+/- dyspareurnia

98
Q

WU for a prolapse

A

All in the the PE.

External pelvix
Internal exam 
Bimanual exam
Rectovag exam
Consider a neuromuscular exam?
\+/- urodynamic testing in women w/ incontinence symptoms
99
Q

How to grade a prolapse

A

POP-O, POP stages 0-IV

100
Q

Prolapse grading POP-O

A

Stage 0: No prolapse
Stage I: Prolapse 1cm above hymenal plane
Stage II: Prolapse descends to introitus
Stage III: Prolapse >1cm past hymanal remnant, but does not cause complete vaginal vault eversion or complete uterine procidentia
Stage IV: Complete vaginal vault ecersion or complete uterine pocidentia. AKA vagina and/or uterus is maximally prolapse with entire vaginal mucosa everted

101
Q

Tx options for a prolapse patient

A

Symptomatic! (urinary vs bowel vs sexual)

1) Expectant
2) Conservative
3) Surgical

102
Q

Two methods of conservative therapy

A

1) Pessary

2) Pelvic floor PT.

103
Q

Will PT make the prolapse go back in?

A

Nah, but it will stop it from getting any worse.

104
Q

What is a pessary? Who are they intended for?

A

Silicone devices that plug the prolapse. Must be removed and cleaned reguarly.
These are great for patients who don’t want or can’t get surgery

105
Q

Surgical options for prolapse patients

A

1) Anterior wall repair (colporrhaphy)
2) Posterior wall repair (colporrhaphy)
3) If there’s an apical defect, we’ve got sacral colpopexy and a hysterectomy.

106
Q

What exactly is sacral colpopexy?

A

SUPER COOL SURGERY. Basically post hysterectomy you tie the posterior wall of the vagina off to some nails in the sacrum. Really keeps it taut

107
Q

What exactly is colporrhaphy?

A

Pretty cool surg. Basically cut out the weakened vaginal tissue and then stitch together the stronger tissue surrounding it with fascia

108
Q

Do prolapses cause pain?

A

Nah dude

109
Q

Main concerns of a prolapse

A

Inability to empty bladder (inc risk of infection) and defecatory dysfunction

110
Q

Do we have to tx a prolapse if asymptomatic and the patient doesn’t care?

A

Nope!

CM III Exam III (8 decks)

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