Disorders of the female genital tract 2: Uterus and ovaries Flashcards by Alice Spencer

What is endometriosis?

Get ectopic endometrium which bleeds into tissues resulting in fibrosis

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25% of women with endometriosis are asymptomatic, what 6 symptoms do some report?

1) Dysmenorrhoea
2) Dyspareunia (difficult or painful sexual intercourse)
3) Pelvic pain
4) Subfertility
5) Pain on passing stool
6) Dysuria

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What investigation is carried out in suspected endometriosis?

Laparoscopy (a surgical procedure in which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen)

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There is both medical and surgical treatment for endometriosis, what is the medical treatment? 3

1) COCP (combined oral contraceptive pill)
2) GnRH agonist.antagonist (lower FSH and LH)
3) Progesterone antagonist

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What is the possible surgical treatment for endometrosis?

1) Ablation

2) TAH-BSO (Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy)

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What 3 other conditions has endometriosis been linked with?

1) Ectopic pregnancy
2) Ovarian cancer
3) IBD

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What is endometritis and what 2 types can occur?

Inflammation of the endometrium

Can be acute or chronic

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Give 2 causes of acute endometritis?

1) Retained POC/placenta

2) Complicated labour

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What cell appears histologically in acute endometritis?

Neutrophils

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Give 4 causes of chronic endometritis?

1) PID (pelvic inflammatory disease)
2) Retained gestational tissue
3) Endometrial TB
4) IUCD (intrauterine contraceptive device) infection

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What cells appear histologically in chronic endometritis?

Lymphocytes and plasma cells

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What are the 5 common symptoms of endometritis?

1) Abdominal/ pelvic pain
2) Pyrexia
3) Discharge
4) Dysuria
5) Abnormal vaginal bleeding

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What are the 2 investigations in suspected endometriosis?

1) Biochemistry/ microbiology

2) USS

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What are the 3 therapies for endometritis?

1) Analgesia
2) Abx
3) Remove cause

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What are endometrial polyps?

Sessile/ polypoid oestrogen-dependent uterine overgrowths

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Endometrial polyps are often asymptomatic but can cause what 4 symptoms?

1) Intermenstrual bleeding
2) Post menopausal bleeding
3) Menorrhagia
4) Dysmenorrhoea

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What are the 2 main investigations in suspected endometrial polyps?

1) USS

2) Hysteroscopy (hysterscope inserted into vagina to examine cervix and inside of uterus)

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What is the medical treatment for endometrial polyps?

Progesterone/ Gonadotropin agonists

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What is the surgical treatment for endometrial polyps?

Curettage (scraping or scooping)

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Can endometrial polyps be malignant?

Yes, but less than 1% are malignant

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What is leiomyomata (uterine fibroids)?

Benign myometrial (smooth muscle) tumours with oestrogen/progesterone dependent growth

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What are the 5 risk factors for developing leiomyomata?

1) Genetics
2) Nulliparity (never having children)
3) Obesity
4) PCOS (polycystic ovarian syndrome)
5) HTN (hypertension)

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Leiomyomata is often asymptomatic, but what 3 symptoms are sometimes reported?

1) Menometrorrhagia (heavy, painful bleeding) - thus get Fe def anaemia
2) Subfertility/ pregnancy problems
3) Pressure symptoms

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What are the 2 investigations in suspected leiomyomata?

1) Bimanual examination

2) USS

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What are the 5 medical therapies for leiomyomata?

1) IUS 2) NSAIDs 3) OCP (oral contraceptive pill) 4) Progesterone 5) Iron

What are the 3 non medical therapies for leiomyomata?

1) Artery embolization 2) Ablation (surgical removal of body tissue) 3) TAH - total abdominal hysterectomy

What 2 things can leiomyomata lead to?

1) menopausal regression | 2) malignancy risk 0.1%

What is endometrial hyperplasia?

Excessive endometrial proliferation (increased oestrogen and decreased progesterone)

What are the 6 risk factors for endometrial hyperplasia?

1) Obesity 2) Exogenous oestrogen 3) PCOS 4) Oestrogen producing tumours 5) Tamoxifen 6) HNPCC (PTEN mutations) - hereditary non polypoidal colorectal cancer

What are the 2 types of endometrial hyperplasia according to the WHO classification, how likely is each to become malignant?

1) Non-atypical hyperplasia (1-3% progress) | 2) Atypical hyperplasia (23-48% are carcinoma on hysterectomy)

What is the main symptom of endometrial hyperplasia?

Abnormal bleeding (inter menstrual bleeding, post coital bleeding, post menopausal bleeding)

What are the 2 main investigations in suspected endometrial hyperplasia?

1) USS | 2) Hysterectomy +/- biopsy

What are the 2 medical treatments for endometrial hyperplasia?

1) IUS | 2) Progesterone

What is the surgical treatment for endometrial hyperplasia?

TAH - total abdominal hysterectomy

What type of cancer can endometrial hyperplasia progress to?

Endometroid adenocarcinoma

What are the 4 stages in the malignant progression of hyperplasia?

1) Normal 2) Non atypical hyperplasia 3) Atypical hyperplasia 4) Endometroid carcinoma

What is the most common cancer of the female genital tract?

Endometrial carcinoma

What are the 2 main symptoms of endometrial carcinoma?

1) Intermenstrual bleeding/ Post menopausal bleeding | 2) Pain if late

What are the 3 investigations in suspected endometrial carcinoma?

1) USS 2) Biopsy 3) Hysteroscopy

What staging system is used for endometrial carcinoma?

FIGO staging system

What are the 3 treatments for endometrial carcinoma?

1) Medical (progesterone) 2) Surgery - TAH 3) Adjuvant therapy - chemo/radio

What is the 5 year survival for stage 1 endometrial carcinoma?

90%

What is the 5 year survival for Stage 2/3 endometrial carcinoma?

What are the 2 main types of endometrial carcinoma?

1) Endometroid | 2) Serous

What is the difference in age of incidence of endometroid and serous endometrial carcinoma?

Endometroid - Pre-/perimenopausal | Serous - post menopausal

What is the pre existing state for endometroid and serous endometrial carcinoma?

Endometroid - Endometrial hyperplasia | Serous - Endometrial atrophy

What 2 mutations are found in endometroid and 1 is found in serous endometrial carcinoma?

Endometroid - PTEN, Kras | Serous - P53

What is the oestrogen status in endometroid and serous endometrial carcinoma?

Endometroid - Oestrogen positive | Serous - Oestrogen negative

What grades are there for serous and endometroid endometrial carcinoma?

Endometroid - stages 1-3 | Serous - always stage 3

What is polycystic ovarian syndrome?

Complex endocrine disorder made up of hyperandrogenism, menstrual abnormalities and polycystic ovaries

What are the 3 investigations in suspected PCOS?

1) USS 2) Fasting biochemical screen (decreased FSH, raised LH, testosterone and DHEAS) 3) OGTT (oral glucose tolerance test)

What is the Rotterdam criteria for the diagnosis of PCOS?

2 out of 3 of: 1) Polycystic ovaries 2) Hyperandrogenism (hirsuitism/ biochemical) 3) Irregular periods (>35 days)

What are the 3 treatments for PCOS?

1) Lifestyle - weight loss 2) medical - Metformin, OCP, clomiphene 3) Surgical - ovarian drilling

What 2 other conditions has PCOS been linked to?

1) Infertility | 2) Endometrial hyperplasia/ adenocarcinoma

What are the 2 types of gonadal failure?

1) Hypergonadotrophic hypogonadism (primary failure of the gonads) 2) Hypogonadotrophic hypogonadism (hypothalamic/ pituitary failure leading to secondary failure of the gonads)

What are the 2 congenital causes of primary hypogonadism?

1) Turner syndrome (XO) | 2) Klinefelter syndrome (XXY)

What are the 4 acquired causes of primary hypogonadism?

1) Infection 2) Surgery 3) Chemo-radiotherapy 4) Toxins/ drugs

What are the 5 causes of secondary hypogonadism?

1) Sheehan's syndrome 2) Pituitary tumours 3) Brain injury 4) Empty sella syndrome 5) PCOS

What are the 3 factors to the presentation of gonadal failure?

1) Amenorrhoea/ absent menarche 2) Delayed puberty 3) reduced sex hormone levels, +/- increased LH and FSH levels

What are the 2 investigations necessary in suspected gonadal failure?

1) Hormonal profiling | 2) Karyotyping

What is the treatment for gonadal failure?

It is difficult - often address the cause if possible and use HRT

What are the 3 types of ovarian neoplasms?

1) Surface epithelial stromal tumours (derived from the surface epithelium of the ovaries) 2) Germ cell tumours (come from the germ cells themselves) 3) Sex-cord stromal tumours (coming from the stroma of the ovary)

What is the most common type of ovarian neoplasms (accounting for 90%)?

Surface epithelial stromal tumours

What are the 3 major histological types of epithelial tumours?

1) Serous 2) Mucinous 3) Endometroid (each type contains benign/ borderline /malignant variants)

Benign ovarian epithelial tumours can be sub classified based on components, what are the 3 types?

1) Cystic (cystadenomas) 2) Fibrous (Adenofibromas) 3) Cystic and fibrous (cystadenofibromas)

What is the term for a malignant ovarian epithelial tumours?

Cystadenocarcinoma

Germ cell tumours account for what percentage of all ovarian tumours?

15-20% of all ovarian tumours

What are the 2 main types of ovarian germ cell tumours?

1) Germinomatous | 2) Non-germinomatous

Name the 1 type of germinomatous and 3 types of non-germinomatous ovarian germ cell tumours?

Germinomatous: dysgerminomas | Non-germinomatous: teratomas, yolk sac tumours, choriocarcinomas

What is a dysgerminoma, can it be treated?

Differentiation towards oogonia, malignant but responsive to chemo

What is a teratoma?

Differentiation towards multiple germ layers

What are the 2 types of teratomas?

1) Mature - benign, dermoid cyst (1% malignant transformation) 2) Immature - malignant, often contain embryonal/foetal tissue

What are yolk sac tumours, can they be treated?

Differentiation towards extraembryonic yolk sac, malignant but responsive to chemo

What are choriocarcinomas?

Differentiation towards placenta, malignant and often unresponsive to treatment

What is the therapy for ovarian germ cell tumours?

Surgical +/- chemo +/- radio

What are sex cord stromal tumours, where do they arise from, what is particularly unusual about it?

Rare - arise from ovarian stroma which was derived from the sex cord of embryonic gonad - can generate cells from the opposite sex

What are the 3 types of sex cord stromal tumours, are they malignant or benign and what hormones does each produce?

1) Thecoma/ fibrothecoma/ fibroma - all benign, thecomas and fibrothecomas produce oestrogen, fribromas are hormonally inactive 2) Granulosa cell tumours are low grade malignant and produce oestrogen 3) Sertoli-Leydig cell tumours - 10-25% are malignant and they produce androgens

What is the second commonest gynae cancer?

Ovarian

What 3 things make up Meig's syndrome?

1) Ovarian tumour 2) Right sided hydrothorax 3) Ascites

What are the 8 risk factors for ovarian cancer?

1) FH 2) Increasing age 3) PMH breast cancer 4) Smoking 5) Oestrogen only HRT 6) Lynch II syndrome 7) Obesity 8) Nulliparity (having no children)

What are 3 protective factors against ovarian cancer?

1) OCP 2) breastfeeding 3) Hysterectomy

What are the 6 commonest symptoms of ovarian cancer?

(Non specific symptoms) 1) Pain 2) Bloating 3) Weight loss 4) PV bleeding 5) Urinary frequency 6) Anorexia

What staging system is used in ovarian cancer?

FIGO staging system

What is the treatment for sensitive germ cell ovarian tumours?

Chemo only

What is the treatment for Stage

1) TAH/BSO 2) Omentectomy (Removal of some of omentum) 3) Appendectomy 4) Lymphadenectomy 5) Adjuvant chemotherapy

What is the overall 5 year survival for ovarian cancer?

43%

What are the 4 most common ovarian metastatic mullerian tumours?

1) Uterus 2) Fallopian tube 3) Pelvic peritoneum 4) Contralateral ovary

What are the 2 most common ovarian metastatic extra mullerian tumours which spread by direct extension?

1) Bladder | 2) rectal

What are the 5 most common ovarian metastatic extra mullerian tumours which spread by lymphatic/haematogenous spread?

1) GI tract - large bowel, stomach 2) Krukenburg tumour - pancreatobiliary 3) Breast 4) Melanoma 5) Less commonly kidney and lung

How are metastatic ovarian tumours confirmed, what is the prognosis?

They are confirmed histologically, prognosis is typically poor