Disorders of the Adnexa

Question 1

What are the Adnexa?

Answer 1

Fallopian tubes and uterus

Question 2

When the corpus luteum does not involute after ovulation, but instead continues to enlarge

Answer 2

Corpus luteum syst

Question 3

Enlarged tender adnexae. US shows smooth, thin walled unilocular mass

Answer 3

Follicular cyst, occurs when follicle fails to rupture and ovulation does not occur

Question 4

Pt presents w/ Oligomenorrhea, acne and what appears to be excess body hair. What labs do you start w/? Imaging?

Answer 4

PCOS:
Labs: HcG, Thyroid, FSH, serum insulin level +…
Imaging: Pelvic US

Question 5

What criteria is used to dx PCOS?

Answer 5

Rotterdam Criteria: 2 of 3

• Oligomenorrhea and or anovulation
• Hyperandrogensim
• Polycistic ovaries on US

Question 6

Tx for pt w/ Hirsutism?

Answer 6

OCP: ethinyl estriadiol 30-35mcg / norethindrone 1-1.5

- Spironolactone 50-100 MG bid

Question 7

Most effective tx for infertility related to PCOS?

Answer 7

Weight loss

Question 8

Pt presents w/ temperature of 38 C, in acute abdominal pain, w/ nausea, breast tenderness and mild spotting (vaginal bleeding). How do you confirm your ddx? What will change in your next best step if pt is cool, pale, diaphoretic?

Answer 8

Ectopic Pregnancy: Hcg + Transvaginal US

Unstable pt: Immediate culdocentesis will confirm hematoperitoneum. Immediate surgical intervention. Medical emergency!

Question 9

Pt presents with pelvic pain, dysmenorrhea, dyspreunia. PE shows enlarged ovary, US shows complex mass. Top 3 ddx? Tx?

Answer 9

Cystadenoma, Endometrioma, Mature cycstic teratoma (dermoid cyst) - All are benign ovarian neoplasms
Tx: surgical removal

Question 10

Pt presents w/ vague GI sx, PE shows ascites, pleural effusion, and groin lymphadenopathy. Next best step?

Answer 10

Pelvic US.

If complex adnexal mass accompanied by ascites = Suspect Malignant Ovarian Neoplasm

Question 11

When do sx present for pts w/ malignant ovarian neoplasms?

Answer 11

Time of metastasis to other abdominal organs. 70% present w/ advance dz at time of dx. Rarely symptomatic in early treatable stage.

Question 12

Strongest RF for ovarian cancer?

Answer 12

Family hx in 10-15% of cases

Question 13

Ovarian CA tx?

Answer 13

Stage IA + IB : TAH +BSO w/ omentectomy if well differentiated tumor

Later stages: systemic chemotherapy

Question 14

What is a TAH +BSO?

Answer 14

Total abdominal hysterectomy-bilateral salpingo-oophorectomy

Question 15

6 causes of increased CA - 125

Answer 15

1) Endometreiosis
2) Uterine Leiomyoma
3) Cirrhosis
4) PID
5) Cancers of endometrium, breast, lung, or pancreas
6) Pleural or Peritoneal fluid

Question 16

Screening for Low risk vs High risk pt for ovarian carcinoma

Answer 16

Low risk (isolated family member w/o hereditary pattern): refer to genetic counselor + post menopausal annual screening of CA 125
High Risk family hx (suspect Hereditary): Genetic testing + prophylactic oophrectomy

Question 17

A 26-year old woman with a 2-year history of increased acne, abnormal hair growth, menstrual abnormalities presents to her obstetrician for an infertility workup. A pelvic ultrasound reveals enlarged cystic ovaries. She desires to become pregnant. What is the first line treatment?

Answer 17

Weight reduction

Question 18

A 32-year-old woman presents with fever and lower abdominal pain. She has a history of pelvic inflammatory disease. Her vitals are T 38.4°C, HR 133, and BP 101/60. On examination, the patient is toxic appearing and has marked lower abdominal tenderness to palpation with rebound and guarding. Pelvic examination reveals cervical motion tenderness, scant discharge, and left adnexal tenderness. The patient’s urine beta-hCG is negative. A transvaginal ultrasound is performed and reveals a complex cystic, thick-walled, well-defined mass in the left adnexa. Which of the following is the most appropriate next step in management?

Answer 18

Begin intravenous antibiotics and admit for possible drainage.

A tubo-ovarian abscess (TOA) typically results as a complication of pelvic inflammatory disease (PID) and is most commonly seen in sexually active women. Since it is a complication of PID, patients typically present with lower abdominal and pelvic pain, fever, vaginal discharge, and cervical motion or adnexal tenderness. Pelvic exam may reveal a palpable mass in the adnexa. Ultrasound is the test of choice for suspected TOA

Question 19

Which of the following is the greatest risk factor for an ectopic pregnancy?

Answer 19

Previous ectopic pregnancy