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Clin Med Final Material- Semester 2 > Disorders of the Ovaries and Fallopian tubes: Ross > Flashcards

Disorders of the Ovaries and Fallopian tubes: Ross Flashcards

1
Q

MOST adnexal masses are discovered _______

A

incidentally

**Clinical Challenge is distinguishing benign vs. malignant

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2
Q

disorders of the ovaries and oviducts (Fallopian tubes):
Consider age groups->

young women:

A
  • majority of ovarian cysts benign; hemorrhagic corpus luteum, follicular cysts, and dermoid cysts
  • Tubal abnormalities including ectopic pregnancy and tubal infection
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3
Q

disorders of the ovaries and oviducts (Fallopian tubes):
Consider age groups->

Postmenopausal:

A

when majority of ovarian or tubal cancers occur

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4
Q

Evaluation of adnexal mass: includes?

A

-History: Age, Previous Hx, Acute/chronic, Family hx

-Physical exam:
Tenderness, peritoneal signs

  • Labs: CBC, Tumor Markers
  • Imaging: U/S, CT, MRI
  • Final dx–> bx
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5
Q

DDx of adnexal mass

-benign:

A

ectopic pregnancy, pyosalpinx, ovarian cyst, tuboovarian abscesses, adnexal torsion

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6
Q

DDx of adnexal mass

- Cancers:

A

epithelial ovarian cancer, germ cell cancers and stromal cell cancers

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7
Q

Because hard to distinguish these masses should be evaluated with:

A

Hx, PE and imaging typically **US first

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8
Q

Benign adnexal masses are common in women during ________

A

*reproductive age and are caused by physiologic cysts

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9
Q

A 25 year old woman presents to you for routine annual WWE. She has had two routine vaginal deliveries and is otherwise healthy. She smokes 1 pk/day, has no GYN complaints. LMP 3 weeks ago.
PE: Left ovary enlarged to 5cm in diameter.
Which of the following is the best recommendation to this patient?

A. Order CA-125 testing

B. Order outpatient diagnostic laparoscopy

C. Order ultrasound

D. Order a CT scan of the pelvis
Admit to the hospital for exploratory laparotomy

A

C. Order ultrasound

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10
Q

Functional Cysts:

-normally the ovaries grow _____ each month

A

follicles

–*Follicles produce the hormones estrogen and progesterone

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11
Q

Follicles release an ____

A

egg when you ovulate

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12
Q

Sometimes a normal monthly follicle keeps growing, When that happens, it is known as a _______

A

**functional cyst

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13
Q

There are two types of functional cysts:

list

A
  • Follicular Cyst: failure of ovulation

- Corpus Luteum Cyst

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14
Q

Which type of functional cyst is MC?

A

**Follicular cyst=Failure in Ovulation– most likely 2/2 disturbances in the release of pituitary gonadotropins.

  • **Common
  • Failure to Ovulate and fluid fails to be reabsorbed
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15
Q

Follicular cyst:

  • Diameter ?
  • Histologically they are lined by an inner layer of ______
A
  • vary in diameter, 3-8cm

- granulosa cells and an outer layer of theca interna cells

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16
Q

Follicular Cyst:

-Sx?

A
  • Typically, asymptomatic

- Large cysts may cause aching pelvic pain, dyspareunia, and occasional abnormal uterine bleeding

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17
Q

Follicular Cyst:

-complications?

A

**ovarian torsion and bleeding

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18
Q

Follicular cysts:

-tx?

A
  • Watch and Wait
  • Usually Disappear spontaneously in 60 days without tx
  • Reevaluate in 6 weeks by US
  • Benign vs. Malignant
  • Surgical evaluation
  • OCPs often recommended to help establish normal rhythm, but more recent studies show may not produce more rapid resolution than expectant management
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19
Q

Corpus luteum cyst= thin walled _______ cysts that forms after ______

A
  • **unilocular

- ovulation when corpus luteum fails to regress

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20
Q

Corpus luteum cyst:

  • average size?
  • how common?
A
  • 3-11 cm in size (considered a cyst >3cm)

- Much less common

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21
Q

Corpus luteum cyst:

  • Sx?
  • associated with either _______ or _______
A
  • Persistent corpus luteum cyst may cause local pain or tenderness
  • **amenorrhea or delayed menstruation and can mimic clinical picture of ectopic
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22
Q

Corpus luteum cyst:

-complications?

A

torsion of ovary, rupture and bleed may cause severe pain and patient will present with peritoneal signs and acute abdomen

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23
Q

Corpus luteum cyst:

-S/Sx?

A
  • Localized pain, tenderness

- Amenorrhea or delayed menstruation

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24
Q

Corpus luteum cyst:

-Tx?

A
  • Watch and Wait, usually regress in 1-2 months
  • OCPs have been recommended but questionable benefit
  • *Laparoscopy or laparotomy is usually required to control hemorrhage or to perform detorsion of ovary
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25
Q

Polycystic ovarian syndrome aka ________ syndrome

A

**STEIN LEVENTHAL SYNDROME

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26
Q

Polycystic ovarian syndrome:

-characterized by ?

A

-Persistent anovulation and hyperandrogenism
-Oligomenorrhea/amenorrhea
Hirsutism
Obesity
Enlarged polycystic ovaries
infertility
-5-10% prevalence with variance among races/ethnicities

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27
Q

Polycystic ovarian syndrome: Clinical features

  • ___% of Pts are Hirsute
  • ____% of Pts are obese
A
  • 50%

- 30-75%

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28
Q

*A presumptive diagnosis of PCOS can be made based on history and ____

A

PE

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29
Q

PCOS dx can be made if at least 2 of the following conditions are diagnosed: (list)

A
  • Oligomenorrhea or amenorrhea
  • Hyperandrogenism
  • **Polycystic ovaries on US
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30
Q

PCOS:

-Labs: 4 things**

A
  • elevated serum androgen levels–> Testosterone/DHEA-S
  • Increased ratio of LH/FSH – 3:1
  • Lipid abnormalities
  • Insulin Resistance – HbA1c
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31
Q

PCOS:

Anovulation is identified in women with (4 things)

A
  • Persistent high concentration of LH
  • Low concentration of FSH
  • Low day 21 progesterone level
  • Sonographic follicular monitoring
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32
Q

PCOS: management
–Thought to be related to Hypothalamic pituitary dysfunction and insulin resistance
SO………….

  • For all women with PCOS
  • For women seeking pregnancy
  • For women not seeking pregnancy

Tx of PCOS:

A

-Lifestyle changes:
–Weight loss – (2-7%)–> Improves ovulatory function,
Makes contraception easier and pregnancy safer,
and Lowers risk of diabetes

  • Contraceptives - OCPs
  • Metformin
  • Infertility Treatments: **Clomiphene CITRATE (Clomid)= an ovulation stimulant
  • Hirsutism Treatments
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33
Q

List Ex’s of hirsutism tx’s

A

Shaving/Laser, Spironolactone – Do not give to women wanting to get pregnant because can cause abnormal genitalia development in males

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34
Q

Treatment:
As patients with PCOS are chronically anovulatory, the endometrium is stimulated by estrogen alone. Endometrial hyperplasia and _____ are more frequent in patients with PCOS.

A

carcinoma

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35
Q

PCOS:

If endometrial hyperplasia occurs, can be treated with ______

A

**progesterone – Refer to GYN

  • Repeat u/s
  • **Mandatory endometrial biopsy to ensure no malignancy develops
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36
Q

A 26 year old woman who has not had any pregnancies comes to your office with a CC of being too hairy. She reports that her menses started at age 13 and have always been irregular. Her cycles are every 2-6 mo. She has acne and sees a dermatologist. She is otherwise healthy. Surgery – appendectomy at age 8

Vitals: Ht 5’5” Wt 180 BP: 100/60,

PE: sparse hair around nipples, chin and upper lip. No galactorrhea, thyromegaly or temporal balding.

Pelvic exam: no evidence of clitoromegaly, NTTP, no uterine or adnexal enlargement.

Which of the following likely explains her problem?

Adrenal tumor

Polycystic ovarian syndrome

Late onset congenital adrenal hyperplasia

Sertoli-Leydig cell tumor of ovary

A

Polycystic ovarian syndrome

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37
Q

Pheochromocytoma high bp, low potassium=

A

adrenal tumor

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38
Q

Ovarian Cancer Statistics:

  • Early stage:
  • Late stage:
  • majority of women present w early or late stage disease?
A

-ovarian cancer presents with vague symptoms
VS
-Late stage disease presents with abdominal pain, bloating, early satiety, and or urinary urgency/frequency

-Majority–> late stage disease (deadliest GYN Cancer

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39
Q

Ovarian Cancer Statistics:
-Risk increases with age, mean age of diagnosis is mid ___

-Lifetime risk of ovarian cancer in general population is ___%

A
  • 50’s

- 1.7%

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40
Q

Ovarian CA:

  • causes?
  • majority of adnexal cancers arise from:
  • ____ is shown to be protective
A
  • Hereditary causes of ovarian cancer
  • arise from: the surface epithelial cells of the ovary

-**Oral contraceptive pills shown to be protective

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41
Q

Ovarian Cancer Risk Factors (list)

A

-Age of menses early or late onset menopause

Genetic factors:
- BRCA1 and BRCA2 tumor gene

  • Family History of ovarian cancer puts you at risk
  • Obesity
  • Nulliparity
  • Personal hx of breast, endometrial, or colon cancer

-Smoking

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42
Q

Ovarian Cancer: Clinical Features

A
  • None
  • Abdominal distention
  • Ascites
  • Pain
  • Early satiety
  • Urinary or GI symptoms
  • Vaginal bleeding
  • Estrogenic/androgenic Sx
  • Complication can have rupture or torsion
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43
Q

Pt with Ovarian CA:

- Pelvic Exam will reveal ______

A

**solid, fixed, irregular, adnexal mass

44
Q

Ovarian CA:

-Screening test of choice?

A

No good screening test, patients often present with advanced disease

45
Q

Ovarian Cancer: Dx

-Labs:

A
  • **CA-125 (but normal CA-125 level DOES NOT exclude Ovarian CA dx)
  • Pregnancy test
  • CBC (check for anemia)
  • **AFP and LDH may be markers for malignant germ cell tumor
46
Q

Ovarian CA: imaging?

  • pelvic US: _____
  • other imaging tests?
A

-**Pelvic US – solid mass, nodular or papillary, septations, and ascites,
Doppler can show increased blood flow to mass

  • CT or MRI
  • Chest x-ray for mets
  • Screening mammogram
47
Q

Ovarian CA:

Tx?

A

Surgical removal of tumor

48
Q

Ovarian CA: prognostic factors (list 6)

A
  1. Stage
  2. Grade
  3. Histologic Type
  4. Size
  5. Age
  6. Residual Tumor
49
Q

Staging of Ovarian Cancer (I-IV) Describe

A

I. Tumor limited to one or both ovaries

II. Tumor involves one or both ovaries w/ pelvic extension

III. Tumor involves one or both ovaries with confirmed peritoneal metastasis outside pelvis and/or regional lymph node metastasis

IV. Distant metastasis (excludes peritoneal cavity)

50
Q

Ovarian CA:

-Divided into Epithelial ovarian cancers: (3 kinds)

A
  • Surface epithelium stroma
  • Sex cord stroma
  • Germ cells
51
Q

Epithelial ovarian Cancers (EOC) ____% of all malignant ovarian tumors

A

**80%

52
Q

Epithelial Ovarian CA:

Describe the classic theory

A

Classic theory comes from repair to the ovarian epithelium during normal ovulation with subsequent genetic alterations and malignant transformation

53
Q

Epithelial Ovarian CA:

-Describe the Secondary theory

A

high serum concentration of gonadotropins lead to epithelial proliferation and subsequent transformation

54
Q

Epithelial Ovarian CA:

-describe the third theory

A

based on molecular findings is that these cancers are derived from the fallopian tube and endometrium

55
Q

What is the BEST characterized marker for ovarian CA?

A

**CA-125= a glycoprotein

56
Q

CA-125:

–seen in what other malignancies ?

A
  • Cut off is somewhat arbitrary
  • Seen in other malignancy such as pancreas, colon, breast, fallopian and endometrial
  • Useful adjunct in postmenopausal
  • **Normal CA-125 does not exclude a diagnosis of cancer
57
Q

______ is a protein whose gene is overexpressed in a patient with serous and endometrioid ovarian cancers

A

**Human epididymis protein: (HE4)

KNOW!

58
Q

Adolescents with adnexal mass should have which labs tested?**

A

**AFP, LDH and hCG given the greater likelihood of a malignant germ cell tumor

59
Q

_____ Tumors account for majority of the epithelial ovarian cancers:

A

*Serous

60
Q

Serous tumors:

  • Develop from?
  • May grow how large?
A
  • These tumors/cysts develop from ovarian tissue and may be filled with a watery liquid or a mucous material
  • May grow large enough to fill abdominal cavity, but usually smaller than mucinous tumor
61
Q

Serous tumors:
-account for ___% of ALL epithelial ovarian neoplasms
-Ages 20-30 usually ______
vs
-perimenopausal and postmenopausal– more likely to be _______

A
  • **75-85%
  • Low grade neoplasms

-**cancer

62
Q

Mucinous Ovarian Tumor:

-often they are ___ in origin and metastasize to ____

A
  • GI (appendix)

- MET to ovary**

63
Q

Mucinous Ovarian Tumor:

  • Filled with ______
  • Size: ?
  • malignant or benign?
A

opaque, thick, mucoid material

  • LARGEST tumors
  • 75-85% are benign, favorable prognosis
64
Q

Mucinous Ovarian Tumor:

  • demographic?
  • ___% are bilateral
A
  • Most between 30-50 yo

- 8-10% are bilateral

65
Q

Endometrioid tumors contain glandular material with a ______ ______ pattern resembling endometrial glands

A

**histological glandular pattern

66
Q

Endometrioid tumors:

are termed “_______ cysts”

A

**chocolate

67
Q

Endometrioid tumors can be seen in association with _____

-benign or malignant?

A
  • *endometriosis

- Benign “tumor like” condition rather than a true neoplasm

68
Q

Epithelial Tumors of the Ovary:

-Other tumors (list Ex’s)

A
  • Clear cell tumors

- Transitional cell tumors (Brenner Tumor)

69
Q

Epithelial Tumors of the Ovary::

tx?

A

**Surgical removal and forward to pathology

70
Q

SEX CORD-STROMAL TUMORS:are rare about ___% of ovarian cancers, that secrete ____ ______ such as estrogen

A

1-2%

-sex steroids

71
Q

Granulosa cell accounts for ___% of Sex cord-stromal tumors

-Granulosa cell tumors produce ______

A

70%**

-estrogen

72
Q

Granulosa cell tumor:

2 types=

A
  • juvenile
  • adult

-*May present in juvenile as precocious puberty due to estrogen

73
Q

Sex cord-stromal tumors:
Thecoma

  • filled with:
  • prroduces:
  • Sx?
  • have presented w/:
A
  • Filled with lipid containing cells
  • Produces Estrogen
  • Sx: postmenopausal bleeding
  • adenocarcinoma of endometrium from estrogen
74
Q 
Sex cord-stromal tumors:
Thecoma
-Size: 
-bilateral or unilateral?
-malignant?
A

Size: **non-palpable to >20cm

  • Rarely bilateral
  • Rarely malignant
75
Q

Sex cord-stromal tumors:
Thecoma
tx?

A

ranges depending on age from hysterectomy with bilateral salpingo-oophorectomy to ovarian cystectomy

76
Q

Sex cord-stromal tumors:
Sertoli-Leydig Tumor

  • Sx?
  • Secretes: ?
A
  • hirsutism, virilzation, menstrual irregularities, clitoromegaly
  • Excess testosterone secreted by tumor
77
Q

Sex cord-stromal tumors:
Sertoli-Leydig Tumor
-How common?

A
  • Rare tumor that occurs in teens/young women
  • -Hilus Cell Tumor is a Subset of Leydig cell tumor
  • Originate from ovarian hilum
  • Rarely attains a palpable size
78
Q

Germ Cell tumors: Teratoma (dermoid cyst)

  • ____% of all benign ovarian tumors
  • Describe this tumor
A

-40-50%

=**Well differentiated tissue from 3 germ cell layers, including hair and teeth

79
Q

Germ Cell tumors: Teratoma (dermoid cyst)

  • demographic?
  • Sx?
  • Dx image of choice=
A
  • Reproductive age women
  • Usually asymptomatic
  • *Ultrasound very accurate
80
Q

Struma Ovarii= subset of monodermal teratoma

  • It’s composed of _____
  • accounts for __% of teratomas
  • __% will produce Sx of thyroidtoxicosis
A
  • almost entirely thyroid tissue
  • 3%
  • 5%
81
Q 
Other Gynecological Tumors:
ie Fibroma
-Produces hormones?
-Demographic?
Size?
A
  • Do NOT produce hormones
  • close to menopausal age
  • Size: incidental finding to >20cm
82
Q

Fibroma:

  • nodules?
  • Found as part of _____ syndrome**
A
  • *Multinodular

- Found as part of Meig’s syndrome

83
Q

Meig’s Syndrome:

Triad of Sx=

A

triad of benign ovarian tumor, ascites, and pleural effusion

84
Q

Ovarian torsion may occur 2/2 _____

-pain?

A

enlarged ovary by a mass (cyst)

-**Causes Severe abdominal pain

85
Q

Ovarian torsion:

  • S/Sx=
  • dx?
A

Acute severe abdominal or pelvic pain, usually localized to one side
Nausea/Vomiting

dx: good History, PE and imaging–>**Ultrasound with Doppler is imaging of choice

86
Q

Ovarian torsion:

managment/treatment?

A

**Surgical Emergency*

admit them!!!

87
Q

Complications of ovarian cancer are due to:

A
  • metastases esp to abdomen

- Increased risk of venous thrombosis

88
Q

Benign lesions of the fallopian tubes are routinely _______

-Size?

A

asymptomatic

  • Rarely large enough to be palpable
  • ->Exception is paratubal or paraovarian cyst
  • Dx is incidental finding during imaging or during surgery
89
Q

Hydatid cysts of Morgagni= ____ tumor found on ________ end of ovary

A
  • cystic

- fimbriated end

90
Q

Serous tumors are often paratubal OR _______

A

*paraovarian especially in the broad ligament, low malignancy potential

91
Q

Adenomatoid Tumors:

  • how common?
  • Found where?
A

**MC benign tumor found in the fallopian tube

92
Q

Hydrosalpinx=

A

Distally blocked fallopian tube filled with fluid

-*Blocked tube may become distended giving it a “sausage appearance”

93
Q

Hematosalpinx=

A

fallopian tube filled with blood

94
Q

**Pyosalpinx=

A

fallopian tube filled with pus

95
Q

Hydrosalpinx:
-Sx:
Causes?

A

Sx can vary – asymptomatic, pelvic pain, or abdominal pain, common cause of infertility

-Causes may be recent injury, PID, endometriosis, abdominal surgery, ruptured appendicitis

96
Q

Hydrosalpinx:

-imaging?

A

May be seen by Ultrasound, hysterosalpingogram, laparoscopy

97
Q

Pelvic Inflammatory Disease (PID)= an infection of ______

-usually _______ etiology, common complication of ___

A

*female reproductive organs

  • **polymicrobial, complication of G/C
  • usually from ascending infection
98
Q

PID:

often diagnosed clinically based on _____

A

**presence of Cervical Motion Tenderness or uterine/adnexal tenderness

99
Q

PID May result in scarring and ______

A

infertility

100
Q

PID: Sx

A
  • Pain in lower abdomen or pelvis
  • Fever
  • Vaginal discharge
  • Pain and/or bleeding with intercourse
  • Nausea and/or vomiting
  • Pelvic pressure or back pain
  • Adnexal tenderness
  • **Cervical motion tenderness
101
Q

“chandelier sign” =

A

**PID
=severe pain elicited during pelvic examination of patients with pelvic inflammatory disease, in which the patient responds by reaching upward toward the ceiling for relief

102
Q

PID: how to make the dx

A

dx can be made clinically and empiric treatment started in sexually active young women and other women at risk for STiS if they have pelvic or lower abd pain and no cause for illness other than PID can be identified with 1 or more of the following minimum criteria present on pelvic exam:

  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness
103
Q

PID dx:

  • labs?
  • imaging?
A 
Wet prep may show abundant white cells
CBC may show leukocytosis
ESR and CRP may be elevated
Swabs/URINE may be positive for G/C
All tests may also be normal
Transvaginal US or MRI may show thickening or fluid filled tubes 
Diagnostic laparoscopy
104
Q

PID Complications:
-If diagnosed/treated early, complications can be ____

-List complications

A
  • prevented
  • Formation of scar tissue both outside and inside the fallopian tubes that can lead to tubal blockage
  • Ectopic pregnancy
  • Infertility
  • Long-term pelvic/abdominal pain
  • Peritonitis/bacteremia
  • Intestinal Obstruction due to adhesion
105
Q

PID: tx

A

-Ceftriaxone 250mg IM x 1 dose Plus
Doxycycline 100mg BID x 14 days with or without
Metronidazole 500 mg BID x 14 days

-May need to be hospitalized for IV antibiotics
–Cefotetan 2 g IV every 12 hours Plus
Doxycycline 100mg IV every 12 hours

Clin Med Final Material- Semester 2 (22 decks)

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