Common Gynecologic Disorders Flashcards
1
Q
Diseases of the Vulva (Vulvitis)
A
Vulvitis Imflammation of the vulva -STIs -Other infectious organisms. -Noninfectious conditions
2
Q
Diseases of the Vulva (Contact Dermatitis)
A
Caused by local irritants → i.e., detergents, bleach, tight & nonabsorbent underwear, aerosol sprays, bath oils, bubble baths, toilet paper dye, perfumed soaps & powders, vulvar deodorants.
Presents with pruritis & rash – can be vesicular.
Best treatment → eliminate source of irritation.
Hydrocortisone ointments(0.1-0.25%) → topical relief.
Advise wearing cotton underwear washed in mild detergent without bleaching.
3
Q
Diseases of the Vulva (Intertrigo & Seborrheic Dermatitis)
A
“dandruff’ of the vulva.
Extreme form → thickening & cracking of the intralabial skin folds.
Commonly seen in diabetic women.
Treatment:
Dusting with cornstarch to absorb moisture.
Low strength hydrocortisone cream for pruritis.
4
Q
Diseases of the Vulva (Folliculitis)
A
Staph invasion of sebaceous ducts & hair follicles.
Furuncle → infection spreads & causes localized cellulitis. “boils”
Carbuncle → several follicles in close proximity infected.
Sx include pain, tenderness, & lymphadenitis.
Spontaneous healing usually occurs.
5
Q
Diseases of the Vulva (Vulvodynia)
A
Vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, identifiable, neurologic disorder.” ISSVD
Pt presents with c/o ‘sensitivity of the vulva to touch’& usually no other physical findings.
6
Q
Diseases of the Vulva (Vulvodynia & proposed causes)
A
embryologic abnormalities increased urinary oxalates genetic or immune factors hormonal factors Inflammation Infection neuropathic changes.
Most likely no single cause.
7
Q
Diseases of the Vulva (Vulvodynia Treatments)
A
Vulvar care measures: Advise gentle care. Cotton underwear during day, none at night. Avoid irritants. Lubrication during intercourse. Cool gel packs.
8
Q
Diseases of the Vulva (Vulvodynia Treatments) Topical therapies
A
Use ointments.
Topical creams – more preservatives & stabilizers → often produce burning on application.
Lidocaine ointment 5% - apply prn for sx relief & 30 minutes before sexual activity.
Vaseline → provides relief for some.
Estrogen has been used with variable results.
9
Q
Diseases of the Vulva (Vulvodynia Treatments) Topical therapies - Long term therapy
A
Long-term use of overnight topical lidocaine may minimize pain & allow for healing.
Copious amount of lidocaine ointment to affected area at bedtime & a cotton ball coated with ointment place on the vestibule to assure overnight contact with area.
After 7 weeks, significant decrease in dysparunia.
10
Q
Disease of the Vulva
Vulvodynia other Treatments)
A
Oral medications – used for pain control.
Tricyclic antidepressants.
Anticonvulsants.
Biofeedback & physical therapy
Abnormally high muscle tone, or spasm, poor contraction & relaxation cycles, & instability within muscular structure of pelvic floor can be identified & relieved with specific exercises.
Majority of women had some improvement with sx with PT.
11
Q
Diseases of the Vulva (Vulvodynia- injections & surgery)
A
Intralesional injections
Trigger point steroid & anesthetic injections have been successful for some patients with localized vulvodynia.
Surgery Treatment of last resort. Local excision of small painful areas. Total vestibulectomy. Perineoplasty.
12
Q
Diseases of the Vulva
Neonneoplastic White Lesions of the Vulva
A
White lesions → refer for diagnosis by colposcopy and/or biopsy to rule out cellular atypica.
13
Q
Diseases of the Vulva- Hyperkeratosis
A
Increased deposit of keratin often occurring with inflammation or irritation.
Deposition of keratin occurs as protective response to original irritative lesion.
Appears as a white or greyish-white area.
Tx with local corticosteroid therapy.
14
Q
Diseases of the Vulva Lichen sclerosus
A
Patchy white change in the labia.
Most common in midlife.
Asymptomatic in early stage.
In postmenopausal woman → may cause severe pruritus & may lead to malignancy.
15
Q
Diseases of the Vulva Bartholin’s gland cyst
A
Bartholin’s glands are duplicate structures located on either side of the vaginal orifice & slightly posterior to it.
Cysts usually found in menstruating women.
Cysts may be asymptomatic & present only as a mass → tx unnecessary.
Recurrent cysts may be tx with marsupialization.
16
Q
Diseases of the Vulvus- Bartholin’s gland abscess
A
Pt may present with localized pain & systemic manifestations including fever, chills, malaise.
Usual causes → Neisseria gonorrhea, E. coli, Proteus mirabilis, mixed bacterial flora.
If no systemic sx, can try conservative tx.
Warm vaginal baths and soaks.
If no relief or with systemic sx → antibiotic therapy and/or incision & drainage.
17
Q
Diseases of the Vulva- Vulvar Intraepithelial Neoplasia (VIN)
A
Noninvasive potential precursor of squamous cell carcinoma of vulva
18
Q
Disease of the Vulva- VIN
A
Graded according to degree of histologic changes:
VIN 1: low-grade or mild dysplasia.
VIN 2: intermediate-grade or moderate dysplasia.
VIN 3: high-grade or severe dysplasia – including carcinoma in situ.
19
Q
Disease of the Vulva 2 major types of VIN
A
Classic or bowenoid (undifferentiated) disease.
Associated with HPV virus - #16 most common
Occurs at any age; 30-40’s most common
Simplex (differentiated) disease.
Postmenopausal women.
Not associated with HPV.
Stronger association with invasive squamous cell carcinoma.
20
Q
Disease of the Vulva- VIN signs & symptoms
A
VIN – varied signs & symptoms
No single, specific clinical feature describes VIN lesions.
Color – white, gray-white, hyperpigmented, reddish.
Appearance – slightly elevated, roughened, crusted, ill-defined lesion.
21
Q
Diseases of the Vulva- VIN Symptoms
A
May be asymptomatic:
Lesions may be noted by HCP during routine exam.
Symptomatic women:
Pruritis – most common sx.
Other sx include – vulvar pain & swelling, soreness, warts, discoloration, vaginal discharge & vaginal bleeding.
22
Q
Disease of the Vulva- DX of VIN
A
Diagnosis of VIN
Suspicious lesions:
Punch biopsy.
Colposcopy.
23
Q
Diseases of the Vulva - Treatment of VIN
A
Treatment of VIN Aldara cream – effective in tx of some VIN. Usual tx: Surgical excision of lesion. Loop electroexcision. Laser ablation. Definitive tx: Partial or total vulvectomy.
24
Q
Diseases of the Vulva- NP Role in VIN Management
A
Thorough history & meticulous examination of genitalia.
Refer to MD for diagnosis & treatment.
Patient education:
Teach women to do vulvar self-examination.
Advise to contact HCP with
Any vulvar changes – discolorations, ulcerations or growths.
Sx – itching, burning, bleeding, discomfort
25
Diseases of the Vulva- Invasive Cancer of the Vulva
```
2009 projected cancer statistics:
3,580 new cases.
900 deaths.
Rarely occurs before age 40.
Associated diseases – diabetes, hypertension, CVD, obesity, STDs.
```
26
Diseases of the Vulva- Invasive Cancer of the Vulva
Most commonly found in labia majora & may involve clitoris & bartholin’s gland.
Sx:
May be asymptomatic.
Mass or growth may be present.
Pruritis, bleeding, or pain.
Dx made by biopsy.
Tx surgical – extent of surgery depends on the disease stage.
27
Diseases of the Cervix - Cogenital Abnormalities of the Cervix
Embryonic development → lack of fusion or incomplete fusion of the mullerian ducts or incomplete or absent development of one duct.
Cervix may be septate, double or incomplete (hemicervix)
Septate cervix → may be confined to cervix, more often continuous with a uterine or vaginal septum.
Double cervix may also exist with a longtitudinal vaginal septum.
28
Diseases of the Cervix - Structural abnormalities seen after in utero DES exposure:
Cockscomb → raised ridge usually on anterior cervix.
Collar → flat rim involving part to all of circumference of cervix.
Hypoplastic cervix → diameter > 1.5 cm.
29
Diseases of the Cervix - Benign Disorders of Cervix- Cysts
Nabothian cyst
Obstructed endocervical cell that becomes distended with mucus.
Slightly raised blue or yellow nodules on surface of cervix.
1-3mm diameter.
Not clinically significant, needs no treatment.
30
Diseases of the Cervix- Polyps
Most common tumors of cervix.
Most often found in women in menstruating years.
Soft, red lesions, usually pedunculated.
Often protrude from os.
Vary from several mm to 2cm diameter.
Usually asymptomatic → may cause bleeding especially postcoital.
Dx made by inspection.
Refer for removal, polyp should be sent for biospy to r/o rare cases of malignancy.
31
Disease of the Cervix - Cervicitis
Inflammation of cervix.
Causes: infection, injury, irritation.
1st sx → usually a vaginal discharge that becomes more pronounced immediately after menses.
Other sx → pain, bleeding, dysuria, may be asymptomatic.
Cervix may be edematous & erythematous; friable, reddened areas around os.
Diagnosis:
Std screening, wet mount, colposcopy for suspicious lesions, biopsy as indicated.
32
Diseases of the Cervix- Cervicitis Treatment
Treat identified organisms appropriately.
Nonspecific bacterial infections:
Sulfa vaginal cream.
Acid douches or jellies to readjust acid/alkaline balance.
Topical estrogens for postmenopausal women.
Chronic cervicitis
May do procedure to destroy abnormal cells on surface of cervix:
Cautery.
Cryosurgery.
Laser treatment.
33
Diseases of the Cervix- Cervical Cancer statistics
Worldwide Statistics:
2nd most common cancer in women.
Approximately 500,000 cases of cervical cancer are diagnosed each year.
About 80% of cervical cancer cases occur in developing countries.
Leading cause of cancer-related death in women in undeveloped countries → lack of screening.
34
Diseases of the Cervix- Cervical Cancer - U.S. stats
Estimated new cases 2009 – 11,270
Estimated deaths 2009 – 4,070
14th most common cancer in women.
Incidence and mortality rates dramatically in the US Pap screening.
35
Diseases of the Cervix - Human Papillomavirus (HPV)
Recognized as the main cause of cervical cancer.
Nearly 100% of women with cervical cancer have evidence of cervical infection with HPV.
Estimated that 75% of sexually active men and women have been exposed to HPV at some point in their lives.
Malignant cervical lesions most frequently associated with HPV 16 & 18.
36
Diseases of the Cervix - HPV Signs & Symptoms
Early cervical cancer often asymptomatic.
In women who receive regular screening first sign of disease is usually an abnormal pap test result.
Symptoms usually do not appear until abnormal cervical cells become cancerous and invade nearby tissue.
Most common symptom is abnormal vaginal bleeding
37
Diseases of the Cervix - HPV Prevention
Regular pap screening
No effective antiviral drugs have been developed to slow the progression of HPV.
Detection of advanced premalignant lesions by pap testing, followed by effective treatment, prevents invasive cancer.
38
Diseases of the Cervix- HPV Vaccines
Gardasil® (quadrivalant HPV vaccine - HPV4)
HPV types 6, 11, 16, 18.
Indicated for girls & young women 9 to 26 years of age.
May be given to boys & men - 9-26 years of age to prevent genital warts
Cervarix® (bivalent HPV vaccine – HPV2)
HPV types 16 & 18
Indicated for girls & young women – 9-26 years of age.
39
Diseases of the Cervix- Cervical Cancer Prognosis
```
Stage I
Cancer is confined to the cervix.
5 year survival rate – 80-90%.
Stage II
Cancer extends beyond the cervix.
5 year survival rate – 50-60%.
Stage III
Cancer extends to the pelvic wall.
5 year survival rate – 25-35%.
Stage IV
Cancer extends beyond the pelvic area.
5 year survival rate – 0-15%.
```
40
Diseases of the Cervix- Cervical Cancer Treatment preinvasive
Treatment
Cervical cancer treatments are dependent on the location & staging of the cancer.
```
Preinvasive stage – treatment may include:
Conization
Laser surgery
LEEP
Cryosurgery
```
41
Diseases of the Cervix- Cervical Cancer Treatment Invasive
Invasive stage – treatment may include:
Hysterectomy
Simple hysterectomy – removal of the cancer, the cervix, and the uterus.
Radical hysterectomy – removal of the cervix, uterus, part of the vagina, & lymph nodes in the area.
Radiation
Chemotherapy
42
Diseases of the Cervix- Cervical Cancer Treatment -Radical trachelectomy
Radical trachelectomy
Can be done with early-stage cervical cancer
Women may be able to preserve their fertility.
Involves removal of cervix & lower part of uterus. Lymph nodes in the pelvis are also removed to determine whether cancer has spread.
Enough of the uterus is left in place so that the woman may be able to carry a child.
43
Diseases of the Uterus
| Cogential Abnormalities
Septate Uterus
Complete /Incomplete – limited to fundus
Uterus grossly normal on pelvic exam.
Woman usually presents with c/o 2 or more second trimester losses not explainable by other causes.
Treated only when a term pregnancy cannot be achieved.
Surgical correction.
44
Diseases of the Uterus - Bicornate Uterus
Result from incomplete or absent fusion of mullerian ducts.
2 separate uterine cavities.
Bimanual exam – uterus may be palpated as large & heart-shaped.
Associated with prematurity, abnormal fetal presentation, & late second trimester SAB
45
Diseases of the Uterus- Myomas (leiomyomata)
Most common tumors of the female pelvis.
Called ‘fibroids’ → but arise from muscle cells.
Almost always benign.
Etiology unknown – estrogen, growth hormone, human placental lactogen → may cause tumor growth.
Arise from proliferation of smooth muscle cells.
All begin in the same part of the uterus → the central area of the myometrium.
Myomas identified by name according to location at time of diagnosis.
46
Diseases of the Uterus - Myomas identified as
Interstitial (intramural) – stays within uterine wall as it grows. Most common form.
Submucosal – protruding into uterine cavity; @ 5% of myomas.
Subserosal (subperitoneal) – bulging through outer uterine wall.
Intraligamentous – within the broad ligament.
Pedunculated – any myoma that has developed a thin pedicle attachment to a uterine base.
Parasitic – completely extruding from the uterus with a developed accessory blood supply.
47
Diseases of the Uterus Myomas Incidence in U.S.
```
4-11% of all women.
20% of women over 35.
↓ prevalence in postmenopausal women.
Preexisting myomas often regress.
New myomas do not develop.
3-9 times higher among African-Americans
```
48
Diseases of the Uterus - Myomas Signs and Symptoms
Majority are asymptomatic – noted on pelvic exam.
AUB – most common sx. → heavy periods; often painful.
Suprapubic discomfort, urinary frequency.
Low back pain.
Edema & varicosities of lower extremities from large tumors.
49
Diseases of the Uterus - Myomas Signs and Symptoms
Pain may result form twisted, pedunculated myomas or degenerating, hemorrhagic, or infected myomas.
Infertility → submucous myomas or with distortion of the uterus.
Rapid growth – especially in peri- or post-menopausal females may indicate sarcoma
50
Diseases of the Uterus - Myomas Management
History – ‘red flags’ for myomas:
Pelvic or bladder pressure.
Heavy or prolonged bleeding with menses.
Physical examination
Bimanual pelvic exam – uterine irregularity and/or enlargement; unusually firm, mobile, nontender, smooth nodules.
51
Diseases of the Uterus - Myomas Lab/Diagnostic Tests
Pregnancy test – enlarged uterus.
CBC
r/o infectious process.
Assess for anemia from prolonged blood loss.
U/A, urine C&S – bladder pressure.
Ultrasound with baseline measurement & remeasurement in 3-4 months.
Hysteroscopy – confirm & visualize myomas in uterine cavity.
52
Diseases of the Uterus - Myomas Treatment
Most women can be followed conservatively.
Should be seen 3 months after initial visit & then every 6 months – evaluate growth of myomas & change in symptoms.
Document: when myoma appeared; how long has it been followed; how rapidly is it growing.
Management based on severity of sx & plans for childbearing or contraception.
Anemia should be corrected.
53
Disease of the uterus - myomas treatment
Treatment
GnRH analogs
Use to induce ‘pseudomenopause’.
May be used to shrink myomas prior to surgery.
Myomas usually grow back when tx is stopped.
Myomectomy
Treatment of choice if potential for childbearing is to be preserved.
15% have recurrence of sx; 15-30% require reoperation.
Hysterectomy
54
Diseases of the uterus - myomas- uterine fibroid embolization
Use of angiographic methods to place a catheter in each of the 2 uterine arteries & small particles are injected to block the arterial branches that supply blood to the myomas.
The tissue dies, myomas shrink & in most cases sx are relieved.
Done under local anesthesia by interventional radiologist.
55
Diseases of the Uterus - Uterine Corpus Cancer
Uterine Cancer:
Endometrial cancer - @ 95% of all cases.
Uterine sarcomas - @ 2-4% of all cases.
US statistics 2009 – Uterine Corpus Cancers
Estimated new cases – 42,160
Estimated deaths – 7,780
56
Diseases of the Uterus - Endometrial Cancer stats
95% of all uterine corpus cancers.
@ 70% of all cases occur in women age 45 → 74.
@ 8% occur in younger women.
Chance of being diagnosed cancer during any woman’s lifetime → 1 in 40.
40% more common in white women, however, black women are nearly twice as likely to die from it.
57
Diseases of the Uterus- endometrial cancer Risk Factors- related to increased levels of estrogen
```
- Factors related to exposure to increased level of estrogen:
Age.
Obesity.
Certain types of estrogen replacement therapy.
Treatment with Tamoxifen.
Infertility.
Menstrual periods before age 12.
Menopause after age 52.
```
58
Diseases of the Uterus Risk Factors
Ovarian diseases that increase estrogen.
Family history:
Tends to run in some families with hereditary nonpolyposis colon cancer.
As many as ½ of women with this inherited disease will develop endometrial cancer.
Consider genetic counseling & testing → women with colon cancer or endometrial cancer in several family members.
Breast or ovarian cancer.
Prior pelvic radiation therapy
59
Diseases of the Uterus - Endomentrial Cancer Signs & Symptoms
No useful screening test → most women are diagnosed because they have symptoms.
Unusual bleeding, spotting, or other discharge:
Any postmenopausal bleeding.
Irregular vaginal bleeding.
Any abnormal vaginal discharge:
Does not have to be blood-tinged.
@ 10% discharge is white.
60
Diseases of the Uterus - Endomentrial cancer testing
Endometrial biopsy.
D&C.
Blood test – CA125 tumor marker:
Not all endometrial cancers release this tumor marker.
Very high CA125 levels – cancer has probably spread beyond the uterus.
Imaging tests → transvaginal ultrasound, CT scan, MRI
61
Diseases of the Uterus - Endomentrial cancer prognosis
```
Prognosis:
Five year survival rate:
Stage I – 90-95%
Stage II – 75%
Stage III – 60%
Stage IV – 15-26%
@ ¾ of patients are either stage I or II
```
62
Diseases of the Uterus - Endomentrial Cancer Treatment
```
Treatment:
Many times treatment modalities are combined.
Surgery:
Total hysterectomy.
Testing/removal of lymph nodes.
Radiation therapy.
Chemotherapy.
Hormone therapy:
Progesterone – slows growth of endometrial cells
```
63
Diseases of the Ovary Ovarian Tumors
Tumors or neoplasms of the ovary are classified according to cell type & whether or not the growth is cystic.
Most ovarian tumors are seen during the reproductive years & most common among women in their 40’s.
Malignant ovarian tumors → children & postmenopausal women.
64
Diseases of the Ovary Ovarian Tumors Symptoms
Most asymptomatic.
Tend to occur late in tumor’s development & not specific to particular type of tumor.
Pressure
Large tumor – feeling of heaviness or generalized pressure in pelvic area.
May press on bladder → urinary frequency or incontinence.
65
Diseases of the Ovary Ovarian Tumors Symptoms
Increased girth
May be only symptom of a large tumor.
May be obscured in obese women.
Pain
Rare sx.
When it occurs, it is usually associated with:
Tumor rupture.
Torsion of pedicle.
Rapid distention – possibly from hemorrhage.
Pain of ovarian origin → “constant aching”.
66
Diseases of the Ovary Ovarian Tumors Symptoms GI & Menstrual
GI symptoms
Sx nonspecific & may not appear to be of ovarian origin.
Mild nausea.
Epigastric discomfort.
Anorexia.
Menstrual abnormalities
Especially with tumors that are hormone secreting.
Oligomenorrhea or amenorrhea followed by irregular, heavy, or long menstrual periods.
67
Diseases of the Ovary Specific Benign Ovarian Cysts/Tumors
| Follicular cyst
Follicular cyst
Most frequent type of ovarian cyst.
Formed during the 1st half of menstrual cycle if dominant follicle fails to ovulate & continues to grow or if other follicles fail to undergo atresia.
Most are small, can grow to about size of lemon.
Most undergo spontaneous resorption.
68
Diseases of the Ovary Specific Benign Ovarian Cysts/Tumors
| Follicular cyst Symptoms
No sx specific to follicular cysts but can have some effects on menses.
Large cyst → can have pelvic heaviness, congestion, & aching on affected side.
69
Diseases of the Ovary Specific Benign Ovarian Cysts/Tumors
| Follicular cyst Management
Expectant management – will usually disappear within 8 weeks.
Reexamine in 6-10 weeks → if adenexal mass still present or larger → refer for surgical evaluation.
70
Diseases of the Ovary Lutein (Corpus Luteum) Cysts
Lutein (Corpus Luteum) Cysts
Formed by a hematoma or unusual growth of the corpus luteum.
Form in later half of menstrual cycle.
SX:
Can produce menstrual irregularities → usually a delay in onset of next menses – 3-4 weeks – up to 6 months.
Ovarian distention → crampy pain, usually unilateral & dull.
Ruptured cyst occurs either late in cycle or during or after delayed menses causing severe abdominal pain.
Can mimic ruptured ectopic pregnancy.
71
Diseases of the Ovary Lutein (Corpus Luteum) Cysts Management
Pelvic exam → small tender swelling on affected side of pelvis.
Labs → r/o pregnancy – IUP or ectopic.
Treatment:
Observation & expectant management – most will resolve spontaneously.
Large hemorrhagic cysts or evidence of active intraperitoneal bleeding → needs excision.
Ruptured cyst with subsequent hemoperitoneum → laparotomy & hemostasis.
Before removal of cyst – must consider possibility of early pregnancy → want to preserve corpus luteum if possible.
72
Diseases of the Ovary Dermoid Cyst
Benign cystic teratoma.
18-25% of all ovarian tumors.
Most frequently encountered type of ovarian tumor in women less than 20 years of age.
Consists of tissue from all 3 embryonic germ cell layers – ectoderm, mesoderm, & endoderm.
Contains sweat, apocrine, & sebaceous glands.
May have cartilage, nervous tissue, hair.
Most notable content is teeth.
73
Diseases of the Ovary Ovarian Cancer
| Stats
US Statistics:
2009:
Estimated new cases – 21,550
Estimated deaths – 14,600
Fifth most common cancer among women. (excluding non-melanoma skin cancers)
74
Diseases of the Ovary Ovarian Cancer Survival Rates:
@ 79% - survive one year after diagnosis.
More than 50% survive 5 years after diagnosis.
If diagnosed & treated while the cancer has not spread outside the ovary – 5 year survival rate is 95%.
Only 25% of all ovarian cancers are found at this stage.
Older women with ovarian cancer tend to have a poorer prognosis than younger women:
64% younger than 65 – 5 year survival rate.
30% older than 65 – 5 year survival rate.
75
Diseases of the Ovary Ovarian Cancer Risk Factors
```
Age
½ found in women over 63.
Personal history of breast cancer.
High fat diet.
Obesity.
Perineal talc use.
```
76
Diseases of the Ovary Ovarian Cancer Risk Factors
Reproductive history → possibly a relationship between the number of menstrual cycles in a woman’s lifetime & risk of developing ovarian cancer.
Menarche before age 12.
Nulliparous or 1st child after age 30.
Menopause after age 50.
Fertility drugs:
Prolonged use of clomiphene citrate, especially without achieving pregnancy may increase risk.
77
Diseases of the Ovary Ovarian Cancer Risk Factors
Family history of ovarian cancer, breast cancer, or colorectal cancer:
Risk ↑ if mother, sister, or daughter have, or have had ovarian cancer, especially developed at an early age.
50% ↑ risk – 2 first-degree relatives with ovarian cancer.
78
Diseases of the Ovary Ovarian Cancer Risk Factors
About 10% of ovarian cancers result from an inherited tendency to develop the disease.
Mother’s or father’s side of family. Many cases of familial epithelial ovarian cancer are caused by inherited gene mutations that can be identified by genetic testing.
Very high risk of ovarian cancer if there is family history of cancer due to an inherited mutation of the breast cancer gene BRCA1 or BRCA2.
A mutation leading to inherited colorectal cancer can lead to ovarian cancer.
79
Diseases of the Ovary - Ovarian Cancer Prevention
Oral contraceptives – especially when used long-term.
Tubal ligation.
When performed after childbearing – may reduce the chance of developing ovarian cancer by 67%.
Hysterectomy – may decrease risk.
80
Diseases of the Ovary - Ovarian Cancer Sign & Symptoms
In more than 75% women, disease is spread throughout the peritoneal cavity before noticeable symptoms occur.
Pelvic exam:
Mass that is bilateral, irregular, solid, or fixed – suspicious for malignancy.
81
Diseases of the Ovary - Ovarian Cancer Signs & Symptoms
Early cancers tend to cause symptoms that are relatively mild:
Abdominal swelling.
Unusual vaginal bleeding.
Pelvic pressure.
Back pain.
Leg pain.
Digestive problems – gas, bloating, indigestion, long-term stomach pain.
82
Diseases of the Ovary- Ovarian Cancer Testing Screening
Screening tests:
Transvaginal ultrasound – will find ovarian mass but not distinguish benign from malignant mass.
CA-125:
Elevated in many women with ovarian cancer.
Some benign diseases of the ovaries can also elevate CA-125.
Some ovarian cancers may not produce enough CA-125 to cause a positive test.
83
Diseases of the Ovary - Ovarian Cancer Testing Diagnostic
Imaging studies – ultrasound, CT scans, MRI.
Laparoscopy:
Provides view of ovaries.
Can help in planning treatments or more extensive surgery.
Can confirm stage of cancer.
Can obtain small tissue samples.
Biopsy – only way to determine if growth is cancerous.
84
Disease of the Ovary - Ovarian Cancer Prognosis
Rarely diagnosed in early stages.
Usually quite advanced by time diagnosis is made.
Outcome often poor.
5 year survival rate for all stages is only 35-38%.
If diagnosis made early in disease, 5 year survival rates can reach 90-98%.
85
Diseases of the Ovary - Ovarian Cancer Treatment
```
Surgery:
Total hysterectomy.
Unilateral or bilateral oophorectomy.
Cytoreduction or debulking – removal of as much of a tumor as possible.
Chemotherapy
Systemic.
Intraperitoneal
Radiation therapy.
```
86
Endometriosis
Benign, progressive disease.
Presence & growth of the glands & stroma of endometrial tissue in aberrant location.
Etiology unknown – many theories.
Natural history of the disease remains a mystery – difficult to predict the course of disease.
87
Endometriosis Exact incidence unknown:
Many cases of mild endometriosis → diagnosed incidentally during laparoscopy for other indications.
Age-specific incidence or prevalence of endometriosis unknown.
Accounts for:
20% women with chronic pelvic pain.
30-40% women with infertility.
88
endometriosis Aberrant endometrial tissue grows under the cyclic influence of ovarian hormone:
Most common during the reproductive years.
5% diagnosed after menopause
usually stimulated by exogenous estrogen.
Teens with endometriosis evaluate for obstructive reproductive tract abnormalities that increase the amount of retrograde menstruation.
89
Endometriosis - Typical patient
```
Mid 30’s.
Nulliparous.
Involuntarily infertile.
Symptoms of secondary dysmenorrhea.
Classic symptom – pelvic pain.
```
90
endometriosis
| Amount of ectopic endometrial growth does not always correlate with degree of symptoms:
Many large endometriomas – can be asymptomatic.
Minimal disease – can have severe pain.
Women with deep infiltrating endometriosis usually experience severe pain.
91
Endometriosis - Pathology
Majority of endometrial implants are located in the dependent portions of the female pelvis:
Ovaries – most common site, usually bilateral.
Other common sites uterus, the anterior & posterior cul-de-sac, & the uterosacral, round, & broad ligaments.
30% pelvic lymph nodes involved.
Cervix, vagina, vulva – possible pelvic locations.
10-15% with advanced disease lesions in rectosigmoid.
Rare sites – umbilicus, bladder, kidney, lung, arm, legs. Has been found in the male urinary tract.
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endometriosis
Gross appearance of the endometrial implant depends on the site, activity, relationship to day of menstrual cycle, & chronicity of the area involved
New lesions – small, bleb-like implants less than 1cm diameter.
Red, blood-filled lesions – most active phase of disease.
With time, the areas of endometriosis become larger & assume a light or dark brown color.
‘powder burn’ areas or ‘chocolate cysts’.
Individual areas of endometriosis vary – can range from 1mm to chocolate cysts greater than 8cm in diameter.
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Endometriosis - clinical diagnosis- symptoms
Many different clinical presentations.
‘Classic symptoms’:
Cyclic pelvic pain
& infertility.
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endometriosis
| Pelvic pain presents as secondary dysmenorrhea and/or dyspareunia:
Dysmenorrhea usually begins 36-48 hours prior to the onset of menses.
Pain is related to the sequential swelling & extravasation of blood & menstrual debris into the surrounding tissue believed to be caused by prostaglandins.
Pain is constant – varies from a dull ache to severe pelvic pain.
Patient complains of ‘pelvic heaviness’ or a perception of their internal organs being swollen.
Pain may last for many days, including the entire duration of the menstrual flow.
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endometriosis
| Dyspareunia – described as ‘deep pain in the pelvis
Etiology of dyspareunia – immobility of the pelvic organs during coital activity or direct pressure on areas of endometriosis in the uterosacral ligaments or the cul-de-sac of Douglass.
Pain occurs during deep penetration & may continue for several hours following intercourse.
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Endometriosis Facts
15-20% - have abnormal bleeding, usually premenstrual spotting & menorrhagia.
15% - have coincidental anovulation.
GI & urinary tract symptoms less common but can include:
Cyclic abdominal pain, intermittent constipation, diarrhea.
Urinary frequency, dysuria, hematuria.
Bowel obstruction & hydronephrosis may occur
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Endometriosis- physical manifestations
Endometriosis produces:
Tenderness of the pelvic structures.
Scarring that restricts movement of the pelvic organs.
Classic pelvic finding:
Fixed retroverted uterus with scarring & tenderness posterior to the uterus.
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Endometriosis - Diagnosis
Diagnosis confirmed by direct laparoscopic visualization of endometriosis.
Ultrasound shows no specific pattern for pelvic endometriosis:
May be helpful in differentiating solid from cystic lesions.
May be useful for additional & confirmatory information.
Cannot be used for primary screening.
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Endometriosis management
Variety of treatments based on:
Wide spectrum of clinical symptoms.
Differences in the extent of disease in each individual patient.
Choice of therapy depends on:
Patient’s age.
Future reproductive plans.
Location & extent of the disease.
Treatment can be medical, surgical, or a combination of both.
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Endometriosis - medical therapy
Effective while the patient is taking medication symptoms often recur several months after discontinuation of treatment.
Primary goal of hormonal treatment is induction of amenorrhea.
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Endometriosis - medical therapy - Danazol
Orally active attenuated androgen.
Produces a hypoestrogenic & hyperandrogenic effect of steroid-sensitive end organs.
Dosages of 800mg daily produce amenorrhea & inhibition of ovulation within 4-6 weeks after the onset of treatment.
Standard dosage – 400-800mg day.
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Endometriosis - medical therapy- Danazol
Started on fifth day after onset of menses.
Need to use barrier contraception for 1st month.
Danazol proven to produce pseudohermaphoditism in developing fetus.
Standard length of treatment 6-9 months.
Side effects can include:
Menopausal hot flashes & atrophic vaginitis.
Emotional lability.
Weight gain 8-10 pounds.
Migraine headaches.
Depression.
Oily skin,facial hair, & deepening of the voice.
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endometriosis - medical therapy - Danazol
Side effects encountered by 80%.
Virtually all symptoms disappear when drug therapy is stopped.
3 in 4 patients significant improvement in symptoms.
Corrected fertility rate 40%.
15-30% will have recurrence of symptoms within 2 years following therapy.
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Endometriosis - medical therapy - GnRh Agonists
Suppresses gonadotropin secretion shuts down ovarian function.
Cannot be given orally.
IV, IM, SQ, intravaginal or intranasal.
Medications frequently used:
Leuprolide acetate (Lupron) – injectible.
Nafarelin acetate (Synarel) – intranasal.
Goserelin acetate (Zoladex) – subcutaneous implant.
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Endometriosis - medical therapy - GnRh Agonists
Chronic use produces a ‘medical oophorectomy’.
Does not produce the androgenic side effects seen in Danazol therapy.
Side effects – associated with estrogen deprivation; most common are:
Hot flushes.
Vaginal dryness.
Insomnia.
Decrease in bone mineral content of the lumbar spine.
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Endometriosis - medical therapy - GnRh Agonists
75-90% achieve symptom relief with therapy.
Ovarian function will return to normal in 6-12 weeks following 6 months of therapy.
Primary advantage of GnRh agonist therapy over Danazol better patient compliance, side effects more tolerable.
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Endometriosis - medical therapy - Oral Contraceptives
```
Present low-dose coc’s, specifically the ones with a relatively high progestin potency, are equally effective. Examples (high progestational activity):
Ortho-Cept
Loestrin 1.5/30
Demulen 1/35
Yasmin
```
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Endometriosis - medical therapy - Oral Contraceptives
Regimen:
Single daily monophasic oc, started on 3rd day of the menses.
Pills taken continuously until BTB occurs.
Then dose is doubled to relieve the BTB.
After 5 days on double dose, most patients can go back to 1pill/day.
Amenorrhea is desired goal.
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Endometriosis - medical therapy - Oral Contraceptives
Most patients able to maintain amenorrhea for 6-9 months.
OC’s must be taken continuously – no placebo weeks!
Most common side effects – weight gain & breast tenderness.
80% - achieve in endometriosis symptoms.
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Endometriosis - medical therapy - other Hormonal Treatments
Provera 30mg po daily or Depo-Provera 150mg IM every 3 months.
Useful for women who cannot tolerate high estrogen levels or have contraindication to estrogen use.
Most common side effects:
Breakthrough bleeding or spotting.
Irritability, mood swings, depression.
Clinical results similar to those of coc therapy.
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Endometriosis - Surgical therapy
Only option when medical treatment has failed.
Treatment for women with moderate or severe endometriosis when the disease involves organs other than the pelvic genital tract.
Laparoscopy
Uses laser or electrocautery.
Lesions are coagulated, vaporized, and/or resected
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Endometriosis - Laparotomy
Goal removal of all macroscopic, visible areas of endometriosis with preservation of ovarian function.
More conservative approach – follows principles of microsurgery & plastic surgery:
Minimal & gentle handling of tissues.
Avoiding hypoxia of peritoneum.
Attempting to restore the pelvic anatomy to normal.
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Endometriosis - surgical therapy
Total abdominal hysterectomy with ovarian preservation of one or both ovaries.
Useful for women who have completed their childbearing but are in late 20’s & 30’s.
Definitive surgery
Patients with far advanced disease.
TAH & bilateral salpingo-oophorectomy with removal of all visible endometriosis.
