Disorders of the female genital tract 2: Uterus and Ovaries Flashcards
What is endometriosis?
Get ectopic endometrium which bleeds into tissues resulting in fibrosis
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
3
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)
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
What is the possible surgical treatment for endometrosis?
1) Ablation
2) TAH-BSO (Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy)
What 3 other conditions has endometriosis been linked with?
1) Ectopic pregnancy
2) Ovarian cancer
3) IBD
What is endometritis and what 2 types can occur?
Inflammation of the endometrium
Can be acute or chronic
Give 2 causes of acute endometritis?
1) Retained POC/placenta
2) Complicated labour
What cell appears histologically in acute endometritis?
Neutrophils
Give 4 causes of chronic endometritis?
1) PID (pelvic inflammatory disease)
2) Retained gestational tissue
3) Endometrial TB
4) IUCD (intrauterine contraceptive device) infection
What cells appear histologically in chronic endometritis?
Lymphocytes and plasma cells
What are the 5 common symptoms of endometritis?
1) Abdominal/ pelvic pain
2) Pyrexia
3) Discharge
4) Dysuria
5) Abnormal vaginal bleeding
What are the 2 investigations in suspected endometriosis?
1) Biochemistry/ microbiology
2) USS
What are the 3 therapies for endometritis?
1) Analgesia
2) Abx
3) Remove cause
What are endometrial polyps?
Sessile/ polypoid oestrogen-dependent uterine overgrowths
Endometrial polyps are often asymptomatic but can cause what 4 symptoms?
1) Intermenstrual bleeding
2) Post menopausal bleeding
3) Menorrhagia
4) Dysmenorrhoe
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)
What is the medical treatment for endometrial polyps?
Progesterone/ Gonadotropin agonists
What is the surgical treatment for endometrial polyps?
Curettage (scraping or scooping)
Can endometrial polyps be malignant?
Yes, but less than 1% are malignant
What is leiomyomata (uterine fibroids)?
Benign myometrial (smooth muscle) tumours with oestrogen/progesterone dependent growth
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)
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
What are the 2 investigations in suspected leiomyomata?
1) Bimanual examination
2) USS
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?
-add-
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?
) 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
