Benign Uterine and Ovarian Disease Flashcards
Where do Leiomyomas (fibroids) arise from?
Myometrium, the muscular layer of the uterus
What’s the most common pelvic tumor in women of childbearing age?
Fibroid/leiomyomas
Etiology of leiomyomas?
No clue. unknown
What population is more likely to get a leiomyomas & subsequently a hysterectomy
Black women. AA»>WW
How do leiomyomas feel on a bimanual exam?
Firm and smooth. They’re benign tumors, it’s just the normal tissue that’s there plus a lil’ extra
4 Locations we might see a leiomyoma/what’s the most common one?
1) Intramural myoma (most common)
2) Subserosal myoma
3) Cervical myoma
4) Submucosal myoma
What does it mean if a fibroid is an intramural myoma?
Means it’s completely within the muscular layer
What is the only fibroid visible w/o cutting into the uterus?
Serosal fibroids
Pathognomonic symptom for fibroids
Heavy or prolonged menstrual bleeding. We’ll see increased clots and dysmenorrhea
Other, less common symptoms for fibroids
Most are small and asymp, but we can have things like Pelvic pressure & pain Urinary freq Difficulty emptying bladder completely Reproductive dysf
Working up a fibroid
Palpable with bimanual exam, uterus will be enlarged/irregular. +/- tenderness.
Confirm w/ transvag US
What is fibroid treatment based on?
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
What does menopause do to fibroids?
Causes them to shrink and reduces symptoms. That’s why We’ll sometimes use GnRH and do an artificial menopause to lessen symptoms
Rx management of fibroids
1) NSAIDS - for dysmenorrhea
2) OCP
3) IUD
4) GnRH- induces temporary menopause. We’ll do this for preop to reduce the size
Indications for surgical management of fibroids
abnormal uterine bleeidng, bulk related symptoms, infertility, recurrent miscarriages
Surgical options for fibroids
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
What is adenomyosis?
Ectopic endometrial tissue that grows backwards into the myometrium. Makes you have this huge boggy uterus
Adenomyosis on exam
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
Caveat of diagnosing adenomyosis
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
Epidemiology of adenomyosis
40-50yo, coexists with endometriosis and fibroids, most common w/ parous women w/ a hx of c-section or D&C
Adenomyosis sx
Heavy menstrual bleeding
Dysmenorrhea
Chronic pelvic pain
Diffusely enlarged boggy uterus
Key words to working up adenomyosis on US
1) Assymmetric thickening of the myometrium
2) Linear striations
3) Loss of clear endomyometrial border
4) Increased myometrial heretogeneity
Only guarenteed tx for adenomyosis
Hysterectomy
Hormonal tx for adenomyosis
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
Endometriosis is a ______ dependent disease
Estrogen! Menopause leads to resolution of symptoms
What is endometriosis?
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)
RF for endometriosis
Fx hx Nullpar Early menarche Short menstrual cycles (packing a lot of hormones in a short time) Long duration of menstruation Heavy menstrual bleeding
Most common site for endometriosis implantation
Ovaries!
Sx of endometriosis
Can be asymptomatic Dysmenorrhea Heavy or irregular bleeding Pelvic pain Lower abd pain/back pain Dyspareuria
Endometriosis on PE
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
What should we consider if a pt comes in w/ severe pain and a hx of endo?
Ruptured endometrioma
What is an endometrioma? Where is it most commonly found?
Chocolate cyst. Most commonly found on the ovaries
Besides an endometrioma, what are some other complications of endometriosis?
Adhesions
Pain
Infertility
Gold standard for diagnosing endometriosis (not necessarily first line)
Laparoscopy w/ bx. We’ll see the classic “blue black/power burned appearance” lesions in the vagina
Pathognomonic findings in the vagina for endometriosis
Blue back/powder burned appearance
For line for working up endometriosis
Transvag US! We can r/o the scary differentials real quick and then get to work on what’s actually going on
Is most endo surgically or medically managed?
Most are medical! 95% are successfully medically managed. However 50% of those women will report return of symptoms following medical management.
Medical management options for endometriosis
1) OCPs (combo or solo prog)
2) GnRH analog –> medical menopause. Only 6 mo though
3) Danazol (androgenic steroid)
Surgical options for hysterectomy
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%)
Endometriosis Staging
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
What is a cyst
Sac filled with fluid or semiliquid material
What age group to ovarian cysts target
None! These suckers can happen at any age, including neonatal/infancy phase. Just slightly less likely to happen to post-menopausal women.
Most common type of cystic ovarian lesion
Functional ovarian cyst. These guys are so lowkey, most ovarian cysts are found incidentally.
Types of functional ovarian cysts
Follicular
Corpus luteal cyst
Theca lutein cyst
Endometrioma
Simple cyst
Full of simple fluid with a thin wall.
Complex cyst
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.
What triggers development of a follicular cyst
When the rupture of a mature follicle doesn’t occur
Description of a follicular cyst on US
“Simple unilocular anechoic cysts with a thin, smooth wall”
Should we be worried about follicular cysts?
Nah. These guys will resolve on their own in about 2-3 months 80% of the time
When does a corpus luteal cyst occur
After ovulation
Corpus luteal cyst on US
“Ring of fire” on doppler. Because these guys can be vascular, we worry about hemorrhages with these.
What causes a theca lutein cyst?
Ovarian hyperstimulation! These guys are wicked rare. Seen more when mom is on hormonal IVF therapy, rarely seen in singleton pregnancy.
Theca lutein cysts on US
Septations do now show enhancement on US. Whatever the heck that means
What is an endometrioma
It’s a cyst formed with endometrial tissue. These are our “chocolate cysts”.
What population of women get endometriomas
These are our women in their reproductive years. Oftentimes these will be your chronic pelvic pain patients
How do we treat an endometrioma
Hormones! These guys are hormonally responsive. Do yearly fu w/ US or surgically remove them if this doesn’t work
What is another name for a mature cystic teratoma (MCT)
Dermoid! These guys are benign germ cell tumors
What are MCTs (mature cystic teratoma) associated with?
Ovarian torsion
Mature cystic teratoma cyst contents
Calcifications, fat, sebaceous tissue, hair, even teeth. These are our classic teratomas
Two types of cystadadenomas
Serous and Mucinous
What is a serous cystadenoma? What is it filled with
Benign ovarian tumor, common in postmenopausal women. Filled with simple serous fluid
What is a mucinous cystadenoma?
Large cystadenoma, filled with mucinous material (protein & debris). Found in premenopausal women
Which is more the more common type of cysadenoma?
Serous!
Who gets cysadenofibroma (rare as they are)
any menstruating women
Cysadenofibroma tx?
Oopherectomy
Signs and symptoms for any kind of ovarian cyst/benign ovarian tumors
Can be asymptomatic
Abd pain
Discomfort in lower abd/pelvis
Fullness, heaviness, pressure, bloating,
Irregular bleeding or abnormal vaginal bleeding
If a woman has a history of ovarian cyst/benign ovrian tumor and they come in with sudden onset severe sharp pain?
Think rupture of an ovarian cyst
Big complication of an ovarian cyst/benign tumor
Ovarian torsion. These guys can grow big enough to compress the ovary and cause torsion
Typical presentation of an ovarian torsion secondary to an enlarged cyst/tumor
Woman 20-39yo, sharp sudden pain, then waxing/waning. N/V
Besides ovarian torsion, what is another complication of an ovarian cyst and what cyst is the most common culprit of this
Hemorrhage. Corpus luteal cysts love to do this on days 20-28 of the cycle
Tx for ovarian torsion secondary to an enlarged cyst/tumor
Emergent lap detorsion for the adnexa and ovarian salvage. Time is ovary
Imaging for working up cyst/benign tumor
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)
What cancer antigen might we order a serology of when working up a possible ovarian carcinoma?
CA125. This is a board question and a question for the test. In reality, this is hardly ever used to make a diagnosis.
US management of a mass in a woman of reproductive age (simple vs hemorrhagic)
Simple:
<5cm just observe
5-7cm US annually
>7 MRI/surg
Hemorrhagic:
>8cm FU ultrasound within a few months
What does it mean if a mass is hemorrhagic
Blood seen on US. Can’t miss it, blood looks much different than serous fluid on US
US management of a mass seen on a post-menopausal woman
<7cm US annually. Consider getting a CA125 for these women
US management of a dermoid cyst
Remember these guys will not resolve spontaneous.
US q6-12 months
Cystectomy
US management of an endometrioma
Initially fu w/ US in 6-12wks
After than US annually
Still there? Get a cystectomy
Indicatinos for an ovarian cystectomy or oopherectomy
1) Symptomatic cysts
2) Persistent 5-10cm cysts (especially if symptomatic)
3) Ovarian torsion
4) Suspected malignancy
Treatment of ovarian cysts
1) Analgesia (NSAIDS work fine)
2) Hormonal OCPS for recurrent functional cysts
3) Surgery
What kind of cysts typically need surgery
Follicular, corpus luteal, very large or hemorrhagic cysts
Why do OCP’s work so well for recurrent functional cysts
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
Which muscle group is the primary support of the pelvic floor
Levator ani muscle complex
pubococcygeus puborectalis, iliococcygeus
What is pelvic organ prolapse (POP)
Herniation of pelvic organs to/beyond vaginal walls
What is Anterior compartment prolapse (cystocele)
Bladder prolapsing into the anterior vaginal wall
What is Posterior compartment prolapse (rectocele)
Rectum prolapsing into the posterior vaginal wall
What is Enterocele
Herniation of the intestines to or through the vaginal wall
What is apical compartment (uterine prolapse)
Cervix/uterus prolapsing into the lower vagina or beyond (dear god)
What is uterine procidentia
Herniation of all three compartments into the vagina (jesus)
What two prolapses like to happen together?
Enterocele and rectocele
When do we most commonly see an enterocele
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.
RF for prolapse
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
Three types of prolapse symptoms
Defecatory
Urinary
Sexual
Defecatory symptoms in a prolapse patient
Constipation (most common)
Fecal urgency
Fecal incontinence (during intercourse)
Incomplete emptying
Urinary symptoms in a prolapse pt
Slow urine stream
Sensation of incomplete emptying
Overactive bladder (urgency, freq, incontinence)
Why do we get the overactive bladder symptoms in a prolapse patient
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
Sexual symptoms in a prolapse pt
Avoidance/shame
+/- dyspareurnia
WU for a prolapse
All in the the PE.
External pelvix Internal exam Bimanual exam Rectovag exam Consider a neuromuscular exam? \+/- urodynamic testing in women w/ incontinence symptoms
How to grade a prolapse
POP-O, POP stages 0-IV
Prolapse grading POP-O
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
Tx options for a prolapse patient
Symptomatic! (urinary vs bowel vs sexual)
1) Expectant
2) Conservative
3) Surgical
Two methods of conservative therapy
1) Pessary
2) Pelvic floor PT.
Will PT make the prolapse go back in?
Nah, but it will stop it from getting any worse.
What is a pessary? Who are they intended for?
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
Surgical options for prolapse patients
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.
What exactly is sacral colpopexy?
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
What exactly is colporrhaphy?
Pretty cool surg. Basically cut out the weakened vaginal tissue and then stitch together the stronger tissue surrounding it with fascia
Do prolapses cause pain?
Nah dude
Main concerns of a prolapse
Inability to empty bladder (inc risk of infection) and defecatory dysfunction
Do we have to tx a prolapse if asymptomatic and the patient doesn’t care?
Nope!
