Female reporductive Flashcards
Space of Rezius. How is bladder displaced with a mass in this space?
Extraperitoneal potential space b/w pubic symphysis and bladder. Mass in space will displace bladder posteriorly. Pelvic/abdominal mass will displace bladder inferiorly/anteriorly.
How are cervix and bladder attached
Cervix attached to posterior edge of bladder by the parametrium.
True and false pelvis seperatied by:
Linea terminalis (bony landmark) which is a composite of the arcuate line of the ilium, iliopectinal line, and pubic crest
What organs are in true pelvis and false pelvis?
True pelvis usally has uterus, ovaries, and body of bladder. Dome of bladder is in false pelvis.
Gynecologic cysts (4)
Nabothian. Gartner duct cyst (anterior vagina). Bartholin gland cyst (posterior (Bartholin near Butthole). Skene gland cyst (anterior)
Associations w/ unilateral kidney (women)
Unicornuate uterus +/- rudimentary horn.
Explain etiology of bicornuate uterus vs. septate uterus
Bicorneaute uterus, the 2 uterus halves fail to fuse correctly. In sepatate uterus, they fuse correctly, but the septum doesn t cleave completely
Bicornea uterus vs. septate uterus differentiation
look at fundus of uterus. Bicornuate is more heart shaped. Septate is just normal shaped.
Didelphys uterus vs. bicorneate
Didelphys is complete failure of fusion. Bicorneate is partial failure of of fusion.
Fertility issues in bicronuate uterus and septate uterus
Bicornuate uterus has no fertility issues (because its all endometium in there). Septate uterus has fertility issues (because septum is not endometrium)
American Fertility society classification of mullerian duct abnormalities (Class 1-7)
- uterine agenesis/hypoplasia. 2. unicornuate uterus. 3. Didelphys. 4. Bicornuate. 5. Septate. 6. Arcuate (normal variant). 7. Diethylstilbestrol (DES) uterus (hypoplastic/T-shaped.
HSG contraindications
contrast allergy, infection,pregnancy.
Salpingitis isthmica Nodosa (SIN) (aunt Minnie).
Nodular scarring of fallopian tubes, likely post inflammatory/infectious, a/w infertility and ectopic pregnancy.
Uterine anatomy on T2 MR (intensity of 3 layers)
Endometrial stripe; T2 hyperintense. Junctional zone; very T2 hypointense. Outer myometrium; mildly T2 hypointense
Benign (2) and malignant (1) uterine disease
Adenomyosis, leiomyoma. Endometrial cancer.
Cyclical endometrial thickness
1-4 (menstrual phase) <4mm. 5-9 Early proliferative; 4-8mm. 10-14 later proliferative; 6-10mm. 15-18 (secretopy phase); 7-14mm.
Hormonal dominance by phase of menstrual cycle
Proliferative phase: estrogen. Secretory phase: progesterone.
Causes for thickened endometrium (3)
Endometrial polyp, tamoxifen effect, endometrial cancer/postmenopausal thickness.
Endometrial polyp. What is a more definitve test for diagnosis? How large is too large?
Sonohystogram is helpful for diagnosis. If over 1.5, concerning for malignancy.
Tamoxifen changes. How thick can it get? How often to screen for cancer?
Tamoxifen is estrogen agonist no uterus. Causes endometrial hyperplasia, metaplasia, and carcinoma. Subendometrial cysts and endometrial polyps. Tamoxifen changes can be as thick as 8mm. Ulstrasound screening every 6 mont.s
Endometrial cancer - 2 demographic peaks
- Perimenopausal (estrogen dependent, better prognosis). 2. Older(70 s), spontaneous froma trophic changes. Bad prognosisl
Endometrial cancer staging
1.A endometrium 1.A.. Myometrium less than 50%. 1B. Myometrium More than 50%. 2. Cervix. 3. Outside Uterus. 4. Bladder/Rectum.
Endometiral staging - critical stage
Stage 1B; More than 50% of myometrium. At this stage, patients are more likely to have a Positive lymph node. Will get lymph node dissection, and possible Pelvic radiation.
Risk factors for endometrial cancer
Nullparity, hormone replacement, tamoxifen.
Endometrial thickness that necessicatates biopsy in post-menopausal woman with bleeding and without.
With bleeding; >4mm = biopsy. W/0 bleeding: >8mm = biopsy.
Myometial masses
Leyomyoma, leiomyosarcoma
Leiomyoma MR appearance
T2 hypointense with distinct margins. However if cystic/myxoid degeneration, then it may be heterogenously T2 hyperintense. If there is cavernous or hemorrhageic degeneration, it may be T1 hyperintense.
Leiomyoma MR mimic
Uterine contraction.
Leiomyoma on u/s.
Heterogenous, hypoechoic uterine mass w/ linear bands of shadowing.
Leiomyoma Locations in uterus
Intramural, submucosal, subserosal, cervical
Variant of leiomyoma w/ fat
Lipoleiomyoma.
Leiomyosarcoma features
Rare. Difficult to diagnose on MRI or u/s unless there is clear malginant behavior is seen (invasion of structures)
Ddx ectopic endometrium
Endometriosis, adenomyosis.
adenomyosis. Demographics. Appearance on MR. Classic MR feature
endometrial tissue in myometrium. Multiparous women of reproductive age. Enlarged uterus. Favors posterior wall. Most classic feature = thickening of junctional zone >12mm with small foci of T2 hyperintensity.
Adenomyosis on u/s
Heterogenous myometrium, poor differentiation of endometrial-myometrial border.
Misc uterine disease on u/s (5)
Endometrial fluid, uterine infections, IUD, AVM, Post-C-sectioncomplications.
Causes for endometrial fluid in pre and postmenopausal women.
Premenopausal women: bleeding from menses or spontanious abortion. Post-menopausal; cervical stenosis, possibly from cervical malignancu.
Uterine infections (2)
Endometritis (commonly seen post-partum), pyometa (pus in uterus, should evaluate for outflow obstructionand cervical malignancy
Risks of IUD
infection, ectopic, uterine perf (very rare)
C-section complications
Bladder flap hematoma (hematoma in vesicouterine space). Subfascial hematoma. Extraperitoneal hemorrhage w/in prevesical space.
Uterine AVM. Etiology. Doppler finding.
Can be congenital or acquired. Recent miscarriage or C-section. Dopplor shows low reistance high velocity pattern.
Normal T2 cervix anatomy
Endocervical canal: T2 hyperintense due to mucin. Cervical mucosa: Intermediate T2 signal intensity. Inner cervical stroma: very hypointense.
Cervical cancer, critical staging
Stage2A (spread beyond cervix) and under = surgery. Stage 2B and above, you get chemo/radiation. 2B. Spread into lower 1/3 of vagina or parametrial involvement.
Cervical cancer general staging
- confined to cervic. 2A spread to vagina w/ no parametrial invasion. 2B. Parametrial invasion (critical stage). 3. Spread to lower vagina, siedwall, hydronephrosis, or nodes. 4. bladder/rectum.
Ovaries on PET
can be hot in premenopausal patient. (thats why you should do PET in 1st week of menstrual cycle.). Ovaries should not be hot in post-menopausal patient.
What is the dual blood supply to the ovary?
Ovarian artery (lateral). Branch of internal iliac artery (medial)
4 Segments of fallopian tube
Interstitial/intramural, isthmus, ampulla, infundibulum
ovarian cysts (5), Adnexal cysts (3)
- Physiologic simple cyst (in premenopausal patient), postmenopausal simple cyst, functional cyst, OHSS, PCOS. 2. Paraovarian cyst, peritoneal inclusion cyst, dilated fallopian tube
Simple cyst f/u in premenopausal patient
<3cm, no mention. 3-5, mention as benign. 5-7 usually benign, but follow annually. >7cm, need MRI or surgery.
Postmenopausal simple ovarian cyst
<1cm, no mention. 1-7cm, usually benign, but should be followed up w/ ultrasound annually. >7cm MRI or surgery.
Functional ovarian cysts (4)
Follicular cyst (simple cyst >2.5cm), corpus luteal cyst, theca-lutein cysts, hemorrhagic cysts.
Ovarian hyperstimulation syndrome. Etiology. Criteria for dx.
Complication of fertility treatment, thought to be due to VEGF dysregulation causing capillary leak. Criteria is enlarged ovary (>5cm), presence of either ascites or hydrothorax, or a clinical symptom inluding increased hematocrit, WBC, LFts, renal failure, or dypnea. OHSS increases risk of torsion and ectopic.
Theca Lutein cysts
Related to overstimulation of B-HCG. Large cysts (2-3cm). Multilocular cystic “spokewheel”
People w/ high HCG (who can get theca lutein cysts). (3)
Multifetal pregnancy, gestational trophoblastic disease, ovarian hyperstimulation syndrome.
PCOS ovary. Clinical syndrome.
10 or more small peripheral simple cysts. String of pearls. Ovaries are typically enlarged (>10cc). Obesity, insulin resistance, anovulation, hirsutism, increased LH.
Paraovarian cyst
Simple cyst, separate from ovary, developmental in origin (wolfian duct remnants). Normal if <5cm.
Peritoneal inclusion cyst
septated fluid collection formed by adhesions from prior surgery. Should not recommend further surgery. Main differential is cystadenoma, which has thick septations and mass effect.
Dilated fallopian tube (3)
Hydrosalpinx (incomplete septation sign), hematosalpinx (setting of ectopic or endometriosis), pyosalpinx (in setting of PID).
Adnexal torsion; epideminology. Classic presentation and u/s appearance
Reproductive age women, commonly in pregnancy or with dermoid. More commonly on right side, due to position of sigmoid. Ultrasound shows enlarged ovary, often in unusual position, free fluid. There can be lack of flow, or intermittent/normal flow (due to dual blood supply.
Dermoid. Demographic. u/s and MR appearance.
Most common in young patients. Hyperechoic Rokitansky nodule, “tip of iceberg” or “dot-dash pattern. T1 Bright, Fat Sats out.
Dermoid malignant potential
Rarely can turn to SCC (Moreso in older patients w/ big tumor
What is Rokitansky nodule
Solid nodule projecting into cyst cavity, fromwhich hair or teeth may arise.
Endometrioma on u/s. On MR
Homogenous w/ low level echoes. On MR, it is T1 bright and T2 shading/gradient (T2 Shaded = “shading sign” of endometrioma).
ovarian Hemorrhagic cyst on u/s
“Lacy” fishnet appearance.
How to differentiate hemorrhagic cyst from endometrioma?
f/u ultrasound in 6 weeks
Ruptured endometrioma on MR
fluid that is hyperintense on T1 and T2
How to tell apart endometrioma from dermoid on MR
Dermoid should supress on fat sat. Endometioma should have T2 shading.
Rare cancer transfomrations of dermoid and endometrioma
Dermoid:SCC, Endometrioma: Clear cell
Role of MR in ovarian cancer
Characterize intermediate lesions. Look for peritoneal implants in pouch of douglas, paracollic gutters, bowel durface, greater omentum, liver surface.
Ultrasound findings suggestive of a malignant mass (6)
Mural nodule, thick/irregular walls/septae, solid components, high flow, ascites, papillary projections.
Ovarian neoplasms (4).
Epithelial (3 subtypes) 67%. Germ cell 25%. Sex cord-stroma, metastatic.
Epithelial ovarian tumors? (3 + a rare one)
Serous. Mucinous. Endometrioid. Clear-cell. Brenn (rare).
Serous epithelial ovarian tumor features
75% benign (large unilocular cyst). Malignant (solid masses, nodular walls, contrast enhancement).
Mucinous epithelial ovarian tumors features.
95% benign (large multilocular cystic mass). Pseudomyxoma peritonei.
Subtype of teratoma that is composed of mature thyroid tissue
Struma Ovarii
Sex cord stromal tumors (3). Meig s syndrome
Fibroma, thecoma, fibrothecoma. Meig s syndrome is triad of benign ovarian fibroma, ascites, and right pleural effusion.
Metastases to ovary (name 3-4)
Breast and Krukenberg tumors (mucinous adenoCA from stomach or colon). Endometrial.
What time and hCG should you normally see gestational sac. What are signs of gestational sac.
5 weeks, 1500 hCG. First signs are intradecidual sign and double decisual sign
