E2: Vulvar And Ovarian Disease Flashcards
What is the clinical presentation of lichen sclerosis?
- seen mostly in postmenopausal women
- pruritis is the most common symptom
- pain
- usually begins periclitorally with spread to the perineal skin
- Not usually seen at keratinized, hair bearing labia
On PE, you see sharply and well demarcated white plaques on the vulva. The plaques demonstrate “cellophane paper” appearance. What should you be suspicious of?
Lichen sclerosus
What is the hallmark of disease of lichen sclerosus?
Fragility: purpura, erosions, and fissures
What are patients with lichen sclerosus at increased risk for?
-Squamous cell carcinoma occurs in 5% of women with untreated lichen sclerosus (risk factors are elderly and hyperkeratoic lesions)
How is lichen sclerosus definitively diagnosed?
Vulvar punch biopsy
What is the treatment of lichen sclerosis?
- Topical ultra potent steroid ointment, first line is Temovate 0.05% ointment applied twice daily until texture is normal, then 1-3x per week for maintenance
- topical estrogen
What are the possible side effects of temovate?
Atrophy, dermatitis, rosacea
What is the pathophysiology of bartholin cysts?
-Cysts form as a result of ductal obstruction due to trauma or non-specific inflammation. Abscess formation results from an infected cyst or primary gland infection
What is the clinical presentation of a bartholin cyst?
- Acute painful unilateral labial swelling
- dyspareunia
- pain with sitting or walking
What is the treatment of a bartholin cyst?
- incision and drainage with insertion of word catheter
- culture purulent material
- possible and therapy with keflex or doxy
- sitz baths for 2-3 days
- no intercourse until catheter is removed
What is the clinical presentation of vulvodynia?
- vulvar discomfort described as a burning sensation
- introital pain with intercourse
- On PE, pain is limited to the vestibule
What is the treatment of vulvodynia?
- avoid scented products, tight clothing, vigorous exercise, and pads
- Sitz baths BID followed by a thin film of petroleum jelly
- topical vaginal estrogen 0.03% with testosterone 0.1%
- Nortriptyline OR Gabapentin
- Couples counseling
What is vulvar intraepithelial neoplasia (VIN)?
- Neoplasticism cells confined to squamous epithelium
- Classified as VIN 1, 2, or 3
Which types of VIN are precursors to vulvar CA?
VIN 2 and 3
VINU is associated with HPV type ** and **.
16 and 18
How is VINU diagnosed?
- Vulvar colposcopy with 3-5% acetic acid and allow to sit for 3-5 minutes. Reapply often.
- Lesions are raised or flat and range in color from gray to whit or red to black
What is the presentation of VINU usual type?
- Most are asymptomatic
- vulvar burning and pruritis in 50% of cases
- Associated with high grade CIN therefore colposcopy of the cervix is mandatory
- Biopsy all pigmented lesions
What is the pharmacologic treatment of VINU?
- None provide a guaranteed cure
- All medical therapies are off-label use
- 5FU cream
- Interferon
- Imiquimod 5% cream
What is the standard of care for VINU?
- Surgical treate=meant with CO2 laser vaporization, which causes destruction of entire thickness of epithelium and do no perform if invasion is suspected
- local wide excision
- vulvectomy
What is VIND (differentiated)?
- Unrelated to HPV and do no demonstrate same risk factors as VINU
- Seen in older women
- Involves the lower 1/3 of the epithelium
What is VIND commonly associated with?
Associated with squamous cell hyperplasia (lichen sclerosus, lichen simplex chronicus)
How can VIND be prevented?
Proper treatment of underlying condition
How is VIND treated?
Surgical excision
What is the recommended follow up for VINU and VIND?
- Gardasil vaccination up to age 45 (especially VINU)
- Should be considered at risk for recurrent throughout their lifetime
- post treatment follow up includes colposcopic vulvar inspection at 6 and 12 months and then annually
What is he 4th most common malignancy of the female genital tract?
Vulvar cancer
What is the bimodal peaks of vulvar cancer?
- Women 20-40 years is HPV related
- women 60-70 years is due to chronic irritation and poorly understood factors
What is the clinical presentation of vulvar cancer?
- asymptomatic
- pruritus is the most common symptom
- vulvar bleeding and pain
What is the appearance of squamous cell carcinoma of the vulva?
-varies in appearance from large, exophytic cauliflower like lesion to small ulcerative lesions with surrounding hyperkeratosis
What is the appearance of basal cell carcinoma of th vulva?
-Raised lesions with an ulcerated center and rolled border
What is the appearance of malignant melanoma of the vulva?
Seen at the labia minors and clitoris, raised and darkly pigmented lesion
What is the treatment of vulvar cancer?
- Primary treatment is complete surgical removal of tumor with inguinal node dissection
- Radiation therapy indicated with lymph node spread
- Staging based on FIGO
What has to be present for Vaginal intraepithelial neoplasia (VAIN)?
HPV infection
What are the risk factors for VAIN?
- Same as CIN (Smoking, multiple sex partners, and early onset of sexual activity)
- History of CIN III
What is the pathogenesis of VAIN?
- HPV exposure
- frequency of VAIN is not as high as CIN since vaginal epithelium is different than cervical
- Most lesions are located in the upper 1/3 of the vagina
What are the 3 classifications of VAIN?
VAIN 1: benign viral proliferation
VAIN 2: intermediate risk
VAIN 3: True precursor to vaginal cancer
How is VAIN diagnosed?
- Detection is via Pap smear
- Colposcopy
What is the management of VAIN 1?
- Observation is justified in younger women
- cytology/HPV/Colposcopy every 6 months
What is the management of VAIN 2 and 3?
Surgical intervention vs chemotherapy
What are the options for VAIN management?
- Vaginectomy (90% success rate)
- laser vaporization
- total chemotherapy/ 5FU
What is the most common cause of vaginal cancer?
Metastasis from endometrium, ovary, or cervix
What is the most common type of vaginal cancer?
Squamous cell
What is the clinical presentation of vaginal cancer?
- Aymptomatic
- Leukorrhea
- vaginal odor
- post-coital bleeding
- Abnormal PAP
What is the treatment of vaginal cancer?
- Since occurrence is so rare there is no standardized treatment
- combination of vaginectomy and radiation
- 5 year survival rate is 61%
What is the pathophysiology behind PCOS?
- Abnormal androgen and estrogen metabolism
- control of androgen production is unregulated
- Insulin resistance and hyperinsulinemia
- decreased adiponectin
- Increased LH stimulates theca cells
- FSH production is depressed
- increased circulating insulin stimulates the ovary to produce more androgens
What is the clinical presentation of PCOS?
- Infertility
- Oligomenorrhea/amenorrhea
- Obesity
- acne
- hirsutism
- male pattern baldness
How is PCOS diagnosed?
- NIH criteria
- The following must be present: Oligomenorrhea and hyperandrogenism
- The following causes must be excluded: hyperprolactinemia, CAH, Cushing syndrome
What is the Rotterdam criteria for PCOS?
-Two of the three must be present after exclusion of related disorders: oligomenorrhea, clinical or biochemical signs of hyperandrogenism, and polycystic ovaries
On pelvic US, you see a “string of pearls” on the ovaries. What should you suspect?
- PCOS
- No evidence of dominant follicle/corpus luteum
What is the treatment of PCOS?
- weight loss
- Metformin (only in patients with hyperinsulinemia and combin with Clomid for infertility)
- COCs
- Provera 10mgQD for endometrial protection
If you see a thin walled adnexal mass that is <3cm in a premenopausal woman or <1cm in a postmenopausal woman, what should you suspect?
Simple adnexal cyst
You see a hyperechoic nodule with distal acoustic shadowing of the adnexa. What should you suspect?
Teratoma
What findings should you make you suspicious of a malignant adnexal mass?
- Thick septations >2mm
- Solid component appears nodular or papillary
- blood flow to the solid component
What US findings should make you thing of a hemorrhagic adnexal cyst?
Network of linear or curvilinear pattern
What is the most common type of ovarian cyst?
Follicular
What causes follicular ovarian cysts?
- Failure of the mature follicle to rupture
- Failure of the non-dominant follicles to undergo atresia in the presence of the mature follicle
What causes corpus luteum ovarian cysts?
- Following ovulation, blood accumulates within the cavity of the corpus luteum which stimulates resorption. If resorption doesn’t occur and the corpus luteum is greater than 3cm it is considered a cyst
- Usually resolves in 1-2 menstrual cycles
What lab is often elevated with theca lutein cysts?
Elevated chorionic gonadotropin levels
What is the pathophysiology of mature teratomas?
- Benign neoplasms
- originate from primordial germ cells, teratomas are found along the migration pathway of germ cells from yolk sac to gonads
- Composed of well differentiated tissue derived from any of the 3 germ layers
What is the most common origin of mature teratoma?
Ectoderm also germ (hair, teeth)
What is the clinical presentation of mature teratomas?
- Asymptomatic
- Pelvic pain
- Urinary frequency or urgency
- Back pain
What labs should be ordered for a mature teratoma?
- Transvaginal US
- CEA, CA-125, AFP, and beta HCG (all tumor markers that should be within normal limits)
What is the treatment of a mature teratoma?
- Laparotomy vs laparoscopy
- Ovarian cystectomy vs oophorectomy
What are serous/mucinous cystadenoma?
- Benign neoplasms
- lined with columnar epithelium, secretes a thick gelatinous mucin
- May be uni or mulitlocular
What is the treatment of serous/mucinous cystadenoma?
Surgical excision and ensure benign pathology
What is the second most common gynecologic cancer?
Ovarian cancer
What is the most common cause of GYN cancer death in the US?
Ovarian cancer
What are the risk factors for ovarian cancer?
- Nulliparity
- early menarche
- late menopause (increased menses= increased risk)
What are the 4 types of ovarian cancer?
- Epithelial
- germ cell
- Sex cord and stromal
- neoplasms metastatic to the ovary
What is the most common type of ovarian cancer?
Epithelial cancer
What kind of ovarian cancer is associated with high grade serous papillary cancer?
Fallopian tube epithelial ovarian cancer
What are the 4 types of ovarian cancer epithelial neoplasms?
- high grade serous carcinoma (Fallopian tube, most common)
- Endometrioid carcinoma (ovary)
- Clear cell carcinoma (Ovary)
- Mucinous carcinoma (Ovary)
Does epithelial or germ cell ovarian cancer occur in younger women?
Germ cell, highest incidence at 20-30 years old
What are the 5 types of germ cell ovarian cancer?
- Dysgerminoma (Most common, unilateral)
- Yolk sac tumor (unilateral)
- Immature teratoma (unilateral)
- Embryonal carcinoma (mixed germ cell tumors
- Choriocarcinoma (mixed germ call tumors)
What are the two types of sex-cord stromal tumors?
- Granulosa cell (most common, causes hyperestrogenism and precocious puberty)
- Sertoli stromal cell (rare, causes hyperandrogenism)
If CA-125 is elevated, what should you be suspicious of?
Epithelial ovarian cancer
If hCG, AFP, or LDH is elevated, what ovarian cancer should you be suspicious of?
Germ cell tumors because they produce high levels of these hormones
