chapter 40: gynecology Flashcards
ligament: allows anteversion of the uterus
round ligament
ligament: contains uterine vessels
broad ligament
ligament: contains ovarian artery, nerve, and vein
infundibular ligament
ligament: holds cervix and vagina
cardinal ligament
very good at diagnosing disorders of the female genital tract
ultrasound
when can you see pregnancy on ultrasound?
6 weeks
beta-HCG: gestational sac
1,500
beta-HCG: fetal pole
6,000
abortion: 1st trimester bleeding, closed os, positive sac on ultrasound and no heartbeat
missed abortion
abortion: 1st trimester bleeding, positive heartbeat
threatened
abortion: tissue protrudes through os
incomplete
(life threatening) - acute abdominal pain; positive beta-hcg, negative ultrasound for sac; can have missed period, vaginal bleeding, hypotension
ectopic pregnancy
risk factors for ectopic pregnancy
previous tubal manipulation
pid
previous ectopic pregnancy
why is ectopic pregnancy life threatening?
significant shock and hemorrhage can occur
dysmenorrhea, infertility, dyspareunia
- can involve the rectum and cause bleeding during menses
endometriosis
what will endoscopy show in endometriosis involving the rectum?
endoscopy shows blue mass
most common site of endometriosis
ovaries
tx: endometriosis
OCPs
- has increased risk of infertility and ectopic pregnancy
- pain, nausea, vomiting, fever, vaginal discharge
- most commonly occurs in the first half of the menstrual cycle
pelvic inflammatory disease
risk factors: pid
multiple sexual partners
dx: pid
cervical motion tenderness, cervical cultures, positive gram stain
tx: pid
ceftriaxone, doxycycline
complications: pid
persistent pain, infertility, ectopic pregnancy
pid: vesicles
HSC
pid: condylomata
HPV
pid: positive dark-field microscopy, chancre
syphilis
pid: diplococci
gonococus
- rupture of graafian follicle
- causes pain that can be confused with appendicitis
- occurs 14 days after the 1st day of menses
mittelschmerz
1 primary vaginal cancer
squamous cell CA
can cause clear cell CA of vagina
DES (diethlstilbestrol)
rhabdosarcoma that occurs in young girls
botryoides
tx: used for most cancers of vagina
XRT
elderly, nulliparous, obese; usually unilateral
vulvar cancer
tx:
WLE and ipsilateral inguinal node dissection
tx: > 2cm (stage 2 or greater)
radical vulvectomy (Bilateral labia) with bilateral inguinal dissection, posted XRT if close margins (
premalignant lesion in vulvar cnacer
paget’s VIN 3 or higher
define VIN
vulvar intra-epithelial neoplasia
leading cause of gynecologic death
ovarian cancer
abdominal or pelvic pain; change in stool or urinary habits; vaginal bleeding
ovarian cancer
decreases risk of ovarian cancer
OCPs, bilateral tubal ligation
increases risk of ovarian cancer
nulliparity, late menopause, early menarche
types of ovarian cancer (x8)
.1. teratoma
- granulosa-theca
- sertoli-leydig
- struma ovarii
- choriocarcinoma
- mucinous
- serous
- papillary
ovarian CA: estrogen secreting, precocious puberty
granulosa-theca
ovarian CA: androgens, masculinization
Sertoli-Leydig
ovarian CA: thyroid tissue
struma ovarii
ovarian CA: beta-hcg
choriocarcinoma
worst prognosis in ovarian CA
clear cell type
Ovarian CA: stage 1
one or both ovaries only
ovarian CA: stage 2
limited to pelvis
ovarian CA: stage 3
spread throughout abdomen
ovarian CA: stage 4
distant metastases
stage ovarian CA: bilateral ovary involvement
stage 1
mc initial site of regional spread in ovarian CA
other ovary
how does debulking tumor help in ovarian CA?
can be effective; including omentectomy (helps chemo and XRT)
tx: ovarian CA
total abdominal hysterectomy and bilateral oophorectomy for all stages, plus:
- pelvic and para-aortic LN dissection
- omentectomy
- 4 quadrant washes
- chemotherapy (Cisplatin and paclitaxel (taxol))
chemotherapy: ovarian CA
cisplatin and paclitaxel (Taxol)
stomach CA that has metastasized to ovary
- pathology classically shows signet ring cells
krukenberg tumor
pelvic ovarian fibroma that causes ascites and hydrothorax
- excision of tumor cures syndrome
meige’s syndrome
most common malignant tumor in female genital tract
endometrial cancer
risk factors: endometrial cancer
nulliparity, late 1st pregnancy, obesity, tamoxifen, unopposed estrogen
vaginal bleeding in postmenopausal patient
endometrial CA until proven otherwise
chance of malignancy in uterine polyps
very low chance of malignancy (0.1%)
polyps: worst prognosis in endometrial cancer
serous and papillary subtypes
stage 1 endometrial cancer: tx
- endometrium
- tx: TAH and BSO or XRT
stage 2 endometrial cancer: tx
- cervix
- TAH and BSO or XRT
stage 3 endometrial cancer: tx
- vagina, peritoneum, and ovary
- TAH and BSO and XRT
stage 4 endometrial cancer: tx
- bladder and rectum
- TAH and BSO and XRT
where does cervical cancer go first?
obturator nodes
what is cervical cancer associated with?
HPV 16 and 18
most common cervical cancer
squamous cell CA
location: stage 1 cervical cancer
cervix
location: stage 2 cervical cancer
upper 2/3 of vagina
location: stage 3 cervical cancer
pelvis, side wall, and lower 1/3 of vagina; hydronephrosis
location: stage 4 cervical cancer
bladder and rectum
tx: cervical cancer - microscopic disease with basement membrane invasion
cone biopsy (conization sufficienct to remove disease)
tx: stages 1 and 2a cervical cancer
total abdominal hysterectomy (TAH)
tx: stages 2b and 4
XRT
tx postmenopausal ovarian cyst:
septated, has increased vascular flow on Doppler, has solid components, or has papillary projections
oophorectomy with intraoperative frozen sections; TAH if ovarian cancer
tx postmenopausal patient ovarian cyst: if no septation, no vascular flow on doppler, no solid components, no papillary projections
follow with ultrasound for 1 year -> if persists or gets larger -> oophorectomy with intraoperative frozen sections; TAH if ovarian CA
tx premenopausal ovarian cyst:
septated, has increased vascular flow on Doppler, has solid components, or has papillary projections
oophorectomy with intraoperative frozen sections usual: algorithm becomes very complicated, weighing aggression of cancer (based on histology and stage at time of operation) compared with whether the pt desires future pregnancy
tx premenopausal patient ovarian cyst: if no septation, no vascular flow on doppler, no solid components, no papillary projections
can follow with ultrasound; surgery if suspicious findings appear
management: incidental ovarian mass at the time of laparotomy for another procedure
biopsy mass, 4 quadrant wash, biopsy omentum, look for metastases and biopsy.
- if original procedure elective (Eg gastric bypass), may need to abort procedure depending on findings
- do not perform oophorectomy
tx: abnormal uterine bleeding:
clomiphene citrate
tx: abnormal uterine bleeding:
GnRH agonists (leuprolide)
tx: abnormal uterine bleeding
> 40 years old - cancer or menopause
need biopsy
contraindications to estrogen therapy
endometrial CA, thromboembolic disease, undiagnosed vaginal bleeding, breast CA
can present as progressively heavier menses
uterine endometrial polyp
under hormonal influence; recurrent abortions, infertility, bleeding
uterine fibroids (leiomyomas)
most common vaginal tumor
invasion from surrounding or distant structure
malignancy risk with partial mole; complete mole is of paternal origin
- treatment?
hydatidiform mole
- tx: chemo (methotrexate)
fever, erythema, diffuse desquamation, nausea, vomiting; associated with highly absorbent tampons
toxic shock syndrome
tx: ovarian torsion
remove torsion and check for viability
tx: adnexal torsion with vascular necrosis
adnexectomy
tx: ruptures tuboovarian abscess
percutaneous drainage
dx / tx: ovarian vein thrombosis
dx: CT scan
tx: heparin
can lead to ovarian vein, IVC, and hepatic vein thrombosis, get liver failure with ascites after pregnancy
- tx: heparin and antibiotics
postpartum pelvic thrombophlebitis
