benign uterine and ovarian diseases Flashcards
leiomyomas
- aka fibroids
- most common pelvic tumor in women
- benign
- come from SMC of myometrium
locations of leiomyomas
- intramural myoma- most common
- subserosal
- submucosal
- cervical
- if stemmed= pedunculated
si/sx of leiomyomas
- most are small and asymptomatic
- heavy or prolonged menstrual bleeding
- pelvic pain/pressure
- urinary frequency, difficulty emptying bladder
- LBP
- dyspareunia
- reproductive dysfunction
PE findings and diagnosis for leiomyomas
- enlarged and irregular uterus
- +/- tenderness
- dx with transvaginal US
treatment for leiomyomas
- based on type of fibroid and severity of sx
- menopause causes fibroids to shrink
- watchful waiting
- medical mgmt
- surgery* mainstay of tx
medical management for leiomyoma
- NSAIDs- only for dysmenorrhea
- OCPs or IUDs
- GnRH- leuprolide (leupron) to induce menopause state
surgical options for leiomyoma
- hysterectomy
- myomectomy- cut out fibroid layer, must be submucosal fibroid
- endometrial ablation- burn tissue to stop BF
- uterine artery embolization
indications for leiomyoma surgery
- abnormal uterine bleeding
- bulk related sx
- infertility
- recurrent miscarriages
adenomyosis
- ectopic endometrial tissue within myometrium
- causes hypertrophy and hyperplasia
- boggy uterus
- not well differentiated from surrounding tissue, difficult to excise
- more common in parous females
adenomyoma
- adenomyosis confined to one area
- resembles fibrouds
si/sx of adenomyosis
- heavy menstrual bleeding*
- dysmenorrhea*
- chronic pelvic pain
- diffusely enlarged uterus- globular
dx of adenomyosis
- pathology after hysterectomy
- transvag US or MRI may be helpful in assessment
key words on imaging for adenomyosis
- asymmetric thickening of myometrium
- linear striations
- loss of clear endomyometrial border
- increased myometrial heterogeneity
treatment for adenomyosis
- hysterectomy*
- +/- uterine artery embolization
- OCPs and IUDs may decrease bleeding and pain
- GnRH analogs and aromatase inhibitors
endometriosis
- abnormal endometrial mucosa implanted in locations other than uterine cavity
- estrogen dependent
risk factors for endometriosis
- family hx
- nulliparity
- early age menarche
- short menstrual cycles
- long duration of menstrual flow
- heavy menstrual bleeding
common sites of endometriosis
- ovaries- most common
- uterus
- posterior cul-de-sac
- broad ligament/ uterosacral ligament
- rectosigmoid colon
- bladder
si/sx of endometriosis
- severity of sx doesnt always correlate to extent of disease
- asymptomatic
- dysmenorrhea
- heavy or irregular bleeding
- pelvic pain*
- lower abd pain/ LBP
- dyspareunia
PE findings for endometriosis
- lateral displacement of cervix
- localized tenderness in posterior cul-de-sac
- palpable tender nodule in posterior cul-de-sac
- pain with mvmt of uterus
- severe abd pain- ruptured endometrioma
complications of endometriosis
- endometrioma “chocolate cysts”
- adhesion formation
- pain
- anatomic distortion
- infertility
- implantation onto nearby structures
diagnosis of endometriosis
- laparoscopy with biopsy*
- blue black or powder burned appearance
- transvag US to r/o other pathology
medical management of endometriosis
- 95% responsive to medical mgmt but half have sx relapse in 5 yrs
- combined OCPs
- GnHR analogs
- danazol- androgenic steroid
surgical mangament of endometriosis
- hysterectomy +/- oophorectomy= definitive
- laparoscopic uterine nerve ablation
- drainage and laparoscopic cystectomy
- laparoscopy and surgical endometrial implant ablation- high rate reoperation
ovarian cysts
- occurs in all ages including neonatal/ infancy
- usu found on routine pelvic exam or US incidentally
functional ovarian cyst
- most common cystic ovarian lesion
- usu in reproductive age
- follicular cyst
- corpus luteal cyst
- theca lutein cyst
- endometrioma
simple cyst
- fluid filled
- thin walled
complex cyst
- debris, blood
- varied wall thickness
- septations
- hemorrhagic
follicular cyst
- rupture of mature follicle doesnt occur
- unilateral
- most resolve on their own in 2-3 mo
- usu present as simple cyst on us
corpus luteal cyst
- occur after ovulation
- thicker walls
- can be vascular- more likely to be hemorrhagic
- ring of fire on US
theca lutein cyst
- due to ovarian hyperstimulation
- rare
- hormonal overstim of bHCG
- usu bilateral
PCOS
- aka stien leventhal syndrome
- 10 or more peripheral simple cysts
- chara string of pearls appearance
mature cystic teratoma
- aka dermoid cyst
- benign germ cell tumor
- has calcifications, fat, sebaceous tissue, hair and/ or teeth
- dont spont resolve
- assoc with ovarian torsion if > 5 cm
- can become malignant
cystadenoma
- serous- thinner fluid, usu bilat
- mucinous- very large, material inside is thicker, bilat
cystadenofibroma
- rare, benign
- resembles malignant tumor
- complex cystic to solid appearance
- surface epithelial tumor
- tx- oophorectomy
si/sx of cysts and benign tumors
- asymptomatic*
- abd pain
- fullness, heaviness, pressure, bloating
- irreg/ abnormal bleeding
- if sudden onset sharp pain think ruptured cyst
complications of cysts and benign tumors
- ovarian torsion*, esp if > 5 cm
- hemorrhagic cyst -> rupture and internal bleeding
- persistent pain and pressure
dx of cysts and benign tumors
- US first line
- CT pelvis for malignancy
- MRI if complex mass
- hCG
- CA125- tumor marker for ovarian cancer
- diagnostic laparoscopy
US monitoring for simple cysts
- < 5 cm- observe
- 5-7 cm- f/u annually
- > 7 cm either MRI or surgery, high risk of torsion
US monitoring for post menopausal cysts
- annually
- +/- CA125
US monitoring for dermoid cysts
- US q6-12 mo
- cystectomy
US monitoring for endometrioma
- initial f/u q 6-12 weeks
- US annually
- cystectomy of sx
treatment for cysts
- analgesia
- contraceptives if recurrent functional cysts
- ovarian cystectomy or oophorectomy
- surgery not indicated for follicular or corpus luteal cysts unless lg/ hemorrhagic
what makes up the pelvic floor
- levator ani
pelvic organ prolapse
- herniation of pelvic organs to or beyond vaginal walls
anterior compartment prolapse
- aka cystocele
- hernia or anterior vaginal wall with descent of bladder
posterior compartment prolapse
- aka rectocele
- hernia of posterior vaginal segment with descent of rectum
enterocele
- hernia of intestines to or through vaginal wall
apical compartment prolapse
- aka uterine prolapse
- descent of apex of vagina into lower vagina
uterine procidentia
- hernia of all three compartments through vaginal introitus
risk factors for pelvic organ prolapse
- parity- vaginal delivery
- advanced age
- obesity > 25
- hysterectomy
- chronic constipation
- heavy lifting
- CT disorders
si/sx of pelvic organ prolapse
- constipation*
- fecal urgency or incontinence
- incomplete fecal or bladder emptying
- slow urine stream
- OAB
- often have sexual avoidance, +/- dyspareunia
pelvic organ prolapse stage 0
- no prolapse
pelvic organ prolapse stage 1
- 1 cm above hymen
pelvic organ prolapse stage 2
- descends into introitus
pelvic organ prolapse stage 3
- 1 cm past hymen but does not cause complete vaginal vault eversion or uterine procidenta
pelvic organ prolapse stage 4
- complete vaginal vault eversion or complete uterine procidenta
conservative therapy options for pelvic organ prolapse
- pessary- silicone device that pt puts in and removes themself
- pelvic floor muscle exs
surgical repair optios for pelvic organ prolapse
- anterior colporrhaphy
- posterior colporrhaphy
- sacral colopexy
- hysterectomy with uterosacral or sacrospinous ligament suspension
