Ch. 18 The Ovaries and Fallopian Tubes Flashcards
______ are paired, oval-shaped, intraperitoneal organs that have a dual blood supply from both the ovarian artery and ovarian branches of the uterine arteries
Ovaries
As endocrine glands, the ovaries are responsible for releasing ______and _______ in varying amounts throughout the menstrual cycle.
estrogen,progesterone
They may be located anywhere within the true pelvis, excluding the ______ cul-de-sac.The ovarian fossa is located posterior to the ureter and internal iliac artery and superior to the external iliac artery.
anterior
Dual blood supply to ovaries is from where?
ovarian artery and ovarian branch of the uterine arteries
Right ovarian vein drains into the ___ and the left ovarian vein drains into the ___.
IVC, left renal vein
The ovaries are responsible for releasing __ & __ in varying amount during the menstraul cycle.
estrogen & progesteron
What is the layer covering the ovaries?
surface epithelium
What serves as a protective layer of the ovary?
tunica albuginea
The medulla of the ovaries contains the ovarian ___ & ___.
vasculature and lymphatics
The cortex of the ovaries is the site for
oogenesis (creation of ovum)
A normal follicle measures ______
3cm or higher
At approximately day __ of the menstrual cycle ovulation occurs when the dominant follicle ruptures.releasing the mature ovum and a small amount of follicular fluid into the peritoneal cavity
14
Only one follicle will become the dominant follicle, or Graafian follicle, before ovulation, whereas all other follicles undergo _______.
atrophy
The ovum is contained within the _______ of the dominant follicle
cumulus oophorus
The cumulus oophorus may be seen within the ovary during a sonographic examination, with the sonographic appearance resembling that of a _______.
daughter cyst
a small cyst within a large cyst
daughter cyst
______, which means middle pain, describes pain at the time of ovulation, typically on the side of the dominant follicle.
Mittelschmerz
After the Graafian follicle has ruptured, its structure is converted into the _______.
corpus luteum
If fertilization occurs, the corpus luteum is maintained and becomes the corpus luteum of pregnancy. If fertilization does not occur, the corpus luteum regresses and becomes the ________.
corpus albicans
the remaining structure of the corpus luteum after its deterioration
corpus albicans
the corpus luteum that is maintained during an early pregnancy for the purpose of producing estrogen and primarily progesterone
corpus luteum of pregnancy
Sonographic appearance of a normal ovary
homogeneous, medium to low level echogenicity
Mean premenopausal ovarian volume
9.8cm ^3
Mean postmenopausal ovarian volume
5.8cm ^3
The size of the ovary depends on the _______and ______of the patient. Ovarian volume can be determined sonographically by utilizing the following formula: volume = length × width × height × 0.523. It can be provided in cm3 or milliliters (mL).
physiologic state,age
an abnormality that results from the ovary twisting on its mesenteric connection, consequently cutting off the blood supply to the ovary
ovarian torsion
a syndrome resulting from hyperstimulation of the ovaries by fertility drugs; results in the development of multiple, enlarged follicular ovarian cysts
ovarian hyperstimulation syndrome
Typical ovarian flow is said to be ______resistant during the early follicular phase and late luteal phase, and ____ resistant during the late follicular phase and early luteal phase.
high,low
Ovarian arterial flow during early follicular (day0-7) phase
high impedance (resistance) with absent or low end diastolic flow, RI=1
Ovarian arterial flow during late follicular phase (day7-17)
low impedance (resistance) with increased diastolic flow, RI=0.5
Ovarian arterial flow during early luteal phase(day7-17)
low impedance (resistance) with increased diastolic flow, RI=0.5
Ovarian arterial flow during late luteal (day 18-28) phase
high impedance (resistance) with absent or low end diastolic flow, RI=1.0
How many weeks before a follicular cyst typically resolves?
6 weeks
The ovarian-adnexal reporting and data system (_____) was established by the American College of Radiology (ACR) and other medical organizations to standardize the ultrasound lexicon in gynecologic imaging in relation to adnexal pathology, such as ovarian cysts.
O-RADS
Follicular cysts range in size from ___ to ___cm; however, larger cysts have been documented.
3,8
The surgical removal of an ovarian cyst is referred to as _______
ovarian cystectomy
A large mass or cyst on the ovary increases the patient’s risk for ______.
ovarian torsion
Hyperstimulation of the ovaries, or ovarian hyperstimulation syndrome, from fertility treatment will also result in the development of multiple, enlarged _______.
follicular cysts
Clinical Findings of _______
Asymptomatic
Pain associated with hemorrhage and enlargement of cyst
Follicular Cysts
Sonographic Findings of _________
1.Simple cyst—anechoic, thin walled, unilocular, round, posterior enhancement
2.Hemorrhagic cyst—variable appearances, including complex components or entirely echogenic, depending on the amount of blood and the stage of lysis; may have a fluid–debris level, fishnet, weblike or lacy appearance as well
Follicular Cysts
__________is a physiologic (functional) cyst that develops after ovulation has occurred. After the Graafian follicle ruptures, the structure hemorrhages and forms the corpus hemorrhagicum, but within hours, the corpus luteum develops
corpus luteum cyst
The ______is primarily responsible for producing progesterone, thereby maintaining the endometrium during an early pregnancy in preparation for implantation.
corpus luteum
When regression of the corpus luteum takes place, a small, echogenic structure may be noted within the ovary, representing the _______.
corpus albicans
Corpus luteum cysts resolve after
1-2 months in a menstruating patient
Corpus luteum cysts may reach sizes up to 8 cm, with resolution of the cyst taking place within________months in menstruating patients. Pain is associated with enlargement of the cyst, hemorrhage, and rupture. If the cyst is large, it increases the risk for ovarian torsion.
1 to 2
Most common pelvic masses seen during 1st trimester, most often resolving within 16 weeks of gestation, “ring of fire” with color Doppler
corpus luteum of preganancy
A complex or thick-walled corpus luteum cyst can resemble an ________, so precaution to establish the presence of an intrauterine pregnancy should be taken in this regard, as well as careful consideration of the entire clinical picture.
ectopic pregnancy
Clinical Findings of ________
Asymptomatic
Pain associated with hemorrhage and enlargement of cyst
Corpus luteum of pregnancy accompanies a pregnancy
Corpus Luteum Cysts and Corpus Luteum of Pregnancy
Sonographic Findings of _______
1.Simple cyst appearance
2.May have a thick wall, be completely echogenic, and may be difficult to differentiate from other solid and cystic adnexal masses
3.Hemorrhagic components may appear complex or have a weblike or lacy appearance depending on the amount of blood and stage of lysis
4.“Ring of fire” around the cyst may be detected with color Doppler
Corpus Luteum Cysts and Corpus Luteum of Pregnancy
are the largest and least common of the functional cysts. They are found in the presence of elevated levels of hCG, occasionally exceeding 100,000 mIU per mL. These cysts may reach sizes of up to 15cm
Theca lutein cysts
gestational trophoblastic disease (molar pregnancy) and ovarian hyperstimulation syndrome are common conditions associated with ________.
theca lutein cysts
a disease associated with an abnormal proliferation of the trophoblastic cells during pregnancy; may also be referred to as a molar pregnancy
gestational trophoblastic disease (molar pregnancy)
Clinical Findings of _______
1.Markedly elevated levels of hCG (as seen in cases of gestational trophoblastic disease, ovarian hyperstimulation, and twin gestations)
2.Nausea and vomiting (hyperemesis)
3.Pelvic fullness
4.Pain associated with hemorrhage, rupture, and ovarian torsion
Theca Lutein Cysts
Sonographic Findings of _______
1.Large, bilateral, multiloculated ovarian cystic masses
2.May contain hemorrhagic components
Theca Lutein Cysts
_________ are large, bilateral, multiloculated ovarian cystic masses that result from high levels of hCG as seen in patients with twins and those suffering from gestational trophoblastic disease or ovarian hyperstimulation syndrome.
Theca lutein cysts
Small cysts adjacent to the ovary and most likely arising from the fallopian tube or broad ligaments, thought to be remnants of the Wolffian duct. Can range in size from 1.5 to 19cm
paraovarian cyst (simple cyst)
Clinical Findings of ______
Asymptomatic
If cyst is large, patients may present with pelvic pain and increased lower abdominal girth
Paraovarian Cysts
Sonographic Findings of _______
Simple cyst located adjacent, but not attached, to the ovary
If hemorrhagic, will appear complex
Paraovarian Cysts
Most common benign ovarian tumor, resulting from the retention of an unfertilized ovum (most often asymptomatic); As a result of the combination of these germ cells, a cystic teratoma may contain any number of tissues, including glandular thyroid components, bone, hair, sebum, fat, cartilage, and digestive elements. They frequently will contain fully formed or rudimentary teeth as well.
cystic teratoma (dermoid)- composed of 3 germ cell layes called ectoderm, mesoderm, endoderm
Dermoids are commonly found in the ___ aged group
reproductive
developing into cancer
malignant degeneration
Dermoids also have the capability of _______, but this is rare.
malignant degeneration
Clinical Findings of a _______
Often asymptomatic
If torsion or rupture occurs, the patient may present with acute pelvic pain
Cystic Teratoma
Sonographic Findings of a _______
1.Complex, partially cystic mass in the ovary that includes one or more echogenic structures that may shadow
2.“Tip of the iceberg” sign—only the anterior element of the mass is seen, while the greater part of the mass is obscured by shadowing
3.Dermoid plug—produces posterior shadowing
4.Dermoid mesh—produced by hair and will appear as numerous linear interfaces within the cystic area of the mass
Cystic Teratoma
benign ovarian sex cord–stromal tumor that produces estrogen in older women
thecoma
ovarian tumors that arise from the gonadal ridges
sex cord–stromal tumor
Benign ovarian sex cord stromal tumor most often found in postmenopausal women and associated with Meigs syndrome
thecoma
ascites and pleural effusion in the presence of a benign ovarian tumor
Meigs syndrome
_______ are estrogen-producing tumors; therefore, patients often complain of postmenopausal vaginal bleeding associated with the unconstrained estrogen stimulation upon the endometrium. As the term denotes, these tumors are masses that are composed of multiple ovarian thecal cells.
Thecomas
Clinical Findings of a _______
May be asymptomatic
Postmenopausal vaginal bleeding or abnormal vaginal bleeding secondary to estrogen stimulation
Meigs syndrome (ascites and pleural effusion)
Thecoma
Sonographic Findings of a ______
Hypoechoic, solid mass with posterior attenuation
No posterior enhancement
If large, it may mimic a pedunculated leiomyoma
Thecoma
Most common estogenic tumor, sex cord stromal tumor
granulosa cell tumor
Reproductive aged and postmenopausal women will present with what clinical finding with a granulosa cell tumor?
abnormal vaginal bleeding
Adolescence may present with what clinical finding with a ganulosa cell tumor?
pseudoprecocious puberty (secondary sex development induced by sex steroids or other sources)
_________also referred to as the granulose theca cell tumor, is considered to be the most common estrogenic tumor.
granulosa cell tumor
As a result of consistent estrogen stimulation, postmenopausal patients with granulosa cell tumors have approximately a 10% to 15% chance of developing _______.Granulosa cell tumors can reach sizes up to 40 cm and do have malignant potential.
endometrial carcinoma
Clinical Findings of ______
Adolescence—pseudoprecocious puberty
Reproductive-aged and postmenopausal women will have abnormal vaginal bleeding
Granulosa Cell Tumors
Sonographic Findings of ________
Solid, hypoechoic mass
Complex or partially cystic mass
Granulosa Cell Tumors
An ovarian ______ is also considered a sex cord–stromal tumor. Unlike thecomas and granulosa cell tumors, however, _______ are not associated with estrogen production. _______ are most often found in middle-aged women.
fibroma
an ovarian sex cord–stromal tumor found in middle-aged women
fibroma
Clinical Findings of a ________
May be asymptomatic
Meigs syndrome (ascites and pleural effusion)
Fibroma
Sonographic Findings of a ______
1.Hypoechoic, solid mass with posterior attenuation
2.No posterior enhancement
3.If large, it may mimic a pedunculated leiomyoma
Fibroma
Transitional cell tumor, most often small, solid, hypoechoic, unilateral and may contain calcifications. They are almost always benign, but they can undergo malignant degeneration.
brenner tumor
small benign ovarian tumors
brenner tumor
Clinical Findings of a ________
1.May be asymptomatic, or may present with a palpable mass or pain
2.Meigs syndrome (ascites and pleural effusion)
Brenner Tumor
Sonographic Findings of a _______
1.Small, solid, hypoechoic mass
2.May contain calcifications
Brenner Tumor
Forms from the implantation of ectopic endometrial tissue, can be located anywhere outside the endometrial cavity but more common on the ovary
endometrioma
An ________is a benign, blood-containing tumor that is associated with endometriosis and forms from the implantation of ectopic endometrial tissue. This ectopic endometrial tissue is functional.
endometrioma
Endometriomas have been nicknamed ______because they appear as dark, thick bloody masses during gross examination.
“chocolate cysts”
Endometriomas can be located anywhere outside the endometrial cavity, including on any other pelvic organ, such as the bladder and bowel, but are more commonly found on the _______. Most often, these masses are multiple and seen more often in the reproductive years.
ovary
Clinical Findings of ________
Patient may be asymptomatic
Pelvic pain
Infertility
Dysmenorrhea
Menorrhagia
Dyspareunia
Painful bowel movements (dyschezia)
Endometriomas
Sonographic Findings of _________
1.Predominantly cystic mass with low-level internal echoes (may resemble a hemorrhagic cyst)
2.Anechoic or complex, mostly cystic mass with posterior enhancement and may have a fluid–fluid level
Endometriomas
Together, serous cystadenomas and cystic teratomas comprise most neoplasms of the ovary. Approximately 50% to 70% of ________ are benign, occurring more often in women in their forties and fifties as well as during pregnancy.
serous cystadenomas
Clinical Findings of a ______Cystadenoma
Patients are often asymptomatic
Serous
Sonographic Appearance of a ______Cystadenoma
1.Predominately anechoic lesion that contains septations and/or papillary projections
2.often large and bilateral
Serous
________cystadenomas are often larger than serous cystadenomas and can even reach sizes up to 50 cm. They are not as often bilateral like serous cystadenomas
Mucinous
Mucinous cystadenomas are often larger than serous cystadenomas, and they tend to contain _______ material within their cystic components.
echogenic
Clinical Findings of a ______ Cystadenoma
Pelvic pressure and swelling
Mucinous
Sonographic Appearance of a ________Cystadenoma
1.Large, predominately anechoic lesion that contains septations and/or papillary projections
2.May contain some recognizable internal, echogenic, layering debris
Mucinous
the survival rate for ovarian cancers that are discovered in the advanced stages is only around 15%. Ovarian cancer has a strong familial incidence, including those individuals who are known carriers of the ____, _____, and _____ gene mutations. These patients will likely have a family history of breast cancer as well. Patients with these gene mutations may choose to undergo a prophylactic bilateral oophorectomy and, possibly, a hysterectomy as well.Other risk factors for ovarian cancer include an age of over 50 years, nulliparity, delayed childbearing, early onset of menses, late menopause, and estrogen use for hormone replacement therapy following menopause for more than 10 years.
BRCA1,BRCA2, and HER2/neu gene mutations
The largest number of ovarian cancers are ___ in origin. Other ovarian cancers are referred to as malignant germ cell tumors, malignant sex cord–stromal tumors, or metastatic disease.
epithelial
Most common malignancy of the ovary, frequently bilateral
serous cystadenocarcinoma
Patients with ovarian cancer may complain of weight loss, pelvic pressure and swelling, abnormal vaginal bleeding, and gastrointestinal problems. Although not always specific, they may also have an elevated _____.
CA 125
Clinical Findings of _____ and _______ Cystadenocarcinomas
Weight loss
Pelvic pressure and swelling
Abnormal vaginal bleeding
Gastrointestinal symptoms
Acute abdominal pain associated with torsion or rupture
Elevated CA 125
Serous and Mucinous
Sonographic Appearance of ______Cystadenocarcinoma
1.Large, multilocular cystic masses
2.Papillary projections and septations are often noted within the mass (w/ malignancy papillary projections are more prominent and thicker septations)
3.Ascites
Serous
Mucinous cystadenocarcinoma is associated with
pseudomyxoma peritonei
Sonographic Appearance of _______Cystadenocarcinoma
1.Large, multilocular cystic mass
2.Papillary projections and septations are often noted within the mass
3.Echogenic material within the cystic components of the mass
4.Pseudomyxoma peritonei (complex ascites)
Mucinous
intraperitoneal extension of mucin-secreting cells that results from the rupture of a malignant mucinous ovarian tumor or, possibly, a malignant tumor of the appendix
pseudomyxoma peritonei
Metastatic tumor to the ovary most often from gastrointestinal tract like stomach cancer
Kruenberg tumor
The key to histologic diagnoses is the presence of ___ in a krukenberg tumor.
“signet ring” cells
Krukenberg tumor appearance
“moth eaten”
Krukenberg tumors are metastatic tumors to the ovary, most often from gastrointestinal cancers, like _______ cancer.
stomach
Clinical Findings of a _______Tumor
Asymptomatic
History of gastric or colon cancer
Possible weight loss
Pelvic pain
Krukenberg
Sonographic Findings of a _______Tumor
1.Bilateral, smooth-walled, hypoechoic or hyperechoic ovarian masses
2.“Moth-eaten” appearance (solid mass containing cystic spaces)
3.May have ascites
Krukenberg
Sertoli leydig cell tumors (androblastoma) are found more often in women younger than ___ years.
30
A _______, or androblastoma, is a sex cord–stromal ovarian neoplasm that is associated with virilization; thus, patients may present with abnormal menstruation and hirsutism because of androgen production.
Sertoli–Leydig cell tumor
(female) changes within the female that are typically associated with males; caused by increased androgens and may lead to deepening of the voice and hirsutism
virilization
Clinical Findings of _______
Virilization
Abnormal menstruation
Hirsutism
Sertoli–Leydig Cell Tumors
Sonographic Findings of _____
1.Solid, hypoechoic ovarian mass
2.Complex or partially cystic mass
Sertoli–Leydig Cell Tumors
a type of neoplasm derived from germ cells of the gonads; may also be found outside the reproductive tract
germ cell tumor
Most common malignant germ cell tumor of the ovary, more often in patients under 30 years with an elevated serum hCG. May be found in pregnancy.
dysgerminoma (ovarian equivalent to testicular seminoma)
The ______ is the most frequent ovarian malignancy found in childhood.
dysgerminoma
the tumor marker used for dysgerminoma is an elevation in _______
serum lactate dehydrogenase
Clinical Findings of _____
Children—pseudoprecocious puberty
Elevated serum lactate dehydrogenase
Possible elevated serum hCG
Dysgerminoma
Sonographic Findings of _______
Ovoid, solid echogenic mass on the ovary
May contain some cystic components
Dysgerminoma
Endodermal sinus tumor, second most common malignant germ cell tumor of the ovary, rapid growth in women under 20. Highly malignant and carries a poor prognosis
yolk sac tumor
Yolk sac tumors are highly malignant and will present with an elevation in
AFP (alpha-fetoprotein)
Clinical Findings of ______ Tumor
Elevation in serum AFP
Yolk Sac tumor
Sonographic Findings of ______ Tumor
1.Homogeneous hyperechoic or complex mass
2.Varying sonographic appearances
Yolk Sac Tumor
Most common cancer to originate within the endometrioma, most often in women in their 50-60’s
endometrioid tumor (carcinoma)
a typically malignant ovarian tumor that is often associated with a history of endometrial cancer, endometriosis, and endometrial hyperplasia
endometrioid tumor(carcinoma)
Clinical Findings of _______ Tumor
History of endometrial cancer or endometriosis
Endometrioid
Sonographic Findings of _______Tumor
Complex mass with solid components
Cystic mass with papillary projections
Endometrioid
Doppler analysis of malignant ovarian masses often reveals ______ diastolic flow velocities because of the abnormal vessels that are created with malignancy. Specifically, malignant tumors tend to have resistive indices less than 0.4 and pulsatility indices less than 1.0.
higher
Worrisome Sonographic Findings for ________Carcinoma
*Complex ovarian mass
*Solid wall nodules within a cystic mass (the larger the solid component, the more likely for malignancy)
*Thick septations (>3 mm)
*Wall thickening
*Irregular wall or poorly defined margins
*Blood flow within the septations, wall, or nodules
*Ascites
Ovarian
______, also referred to as adnexal torsion because it can involve the fallopian tube as well, results from the adnexal structures twisting on their mesenteric connection, consequently cutting off its blood supply.
Ovarian torsion
Ovarian torsion is more common on what side?
right, may have “whirlpool sign” most common cause being an ovarian cyst or mass
Stage I of ovarian carcinoma
Tumor is confined to the ovary
Stage II of ovarian carcinoma
Tumor involves one or both ovaries with pelvic extension
Stage III of ovarian carcinoma
tumor involves one or both ovaries with confirmed peritoneal metastasis outside the pelvis and/or regional lymph node involvement
Stage IV of ovarian carcinoma
Distant metastasis beyond peritoneal cavity
In one study, the torsed ovary most often measured greater than 5 cm, with a mean of ____ cm
9.5
The sonographic appearance of the torsed ovary is that of an ______ ovary, with or without multifollicular development.
enlarged
Clinical Findings of ______
1.Acute unilateral abdominal or pelvic pain
2.Nausea and vomiting
3.Slight leukocytosis
Ovarian Torsion
Sonographic Findings of _____
1.Enlarged ovary
2.Enlarged ovary in the presence of multifollicular development
3.Small peripherally located follicles on the enlarged ovary as a result of edema
4.Lack of or diminished flow patterns compared with the nonaffected ovary
5.“Whirlpool” sign
6.Excessive free fluid
Ovarian Torsion
The ________ may be referred to as oviducts, uterine tubes, or salpinges.
fallopian tubes
Primary purpose of the fallopian tube
provide an area for fertilization (conception) to occur and to offer a means of transportation for the products of conception to reach the uterine cavity
Fallopian tube experiences peristalsis, within its lumen, small, hairlike structures referred to as _____ shift, thereby offering a mechanism for the transportation of the fertilized ovum.
cilia
Fallopian tubes have three layers called
outer serosa, middle muscular layer, inner mucosal layer
The primary role of fimbria
to draw the unfertilized egg into the tube
The ______ is the longest and most tortuous segment of the tube. It is a significant portion of the tube because it is the most likely location of fertilization and the area where ectopic pregnancies often embed.
ampulla
the segment of the fallopian tube that lies within the uterine horn (cornu)
interstitial
tube: the segment of the fallopian tube that is located between the interstitial and ampulla; uterus: area of the uterus between the corpus and the cervix
isthmus
the longest and most tortuous segment of the fallopian tube
ampulla
the distal segment of the fallopian tube
infundibulum
The 7- to 12-cm paired _______ extend from the cornu of the uterus, travel within the broad ligaments, and are composed of five parts
fallopian tubes
Cancer of the fallopian tube is rare and usually in the form of ___.
adenocarcinoma (solid mass within adnexa)
a condition that is thought to result from the compression of the left renal vein at the origin of the superior mesenteric artery, a condition termed Nutcracker syndrome
pelvic congestion syndrome
an anomaly where left renal vein entrapment occurs between the superior mesenteric artery and the abdominal aorta
Nutcracker syndrome
uterine/ovarian varicose veins and chronic pelvic pain for more than 6 months (dilated venous structures adjacent to uterus >4-5mm in diameter, ovarian vein > 6mm and these dilated veins yields slow velocity)
pelvic congestion syndrome
______is the chosen imaging modality, sonography can be used to confirm PCS, and occasionally be the initial imaging tool where PCS is suspected.
venography
Clinical Findings of _______
Persistent lower abdominal and back pain after standing for long periods of time
Dull, chronic pelvic pain
Dyspareunia
Dysmenorrhea
Abnormal uterine bleeding
Chronic fatigue
Bowel issues
Coexisting vulvar, perineal, and lower extremity varices
Pelvic Congestion Syndrome
Sonographic Findings of ________
1.Multiple tortuous and dilated venous structures adjacent to the uterus and ovaries
2.These dilated veins will yield measure greater than 4 to 5 mm in diameter and demonstrate a slow flow velocity with spectral imaging
3.Ovarian vein exceeds 6 mm in diameter
Pelvic Congestion Syndrome
A complication of bilateral salpingo-oophorectomy, resulting from ovarian tissue left behind following a procedure
ovarian remnant syndrome
Clinical Findings of ______ Remnant Syndrome
History of bilateral salpingo-oophorectomy
Chronic pelvic pain
Cyclic pelvic pain
Possible pelvic mass
Ovarian
Sonographic Findings of ______Remnant Syndrome
Identifiable ovarian tissue
Possible ovarian/adnexal mass
Ovarian
Which of the following would be least likely associated with PCS- pelvic congestion syndrome? (right renal vein entrapment, abnormal uterine bleeding, chronic fatigue)
right renal vein entrapment
