Gynae Flashcards
History of lower abdominal pain.
Distorted fallopian tube, no normal tube present, distended and filled with thin fluid. NO PUS. The wall has become paper thin and the fimbrae are not visible as they have become embedded within the blocked tube.
hydrosalpinx
Where does the fluid come from in a hydrosalpinx?
The ends of the tube are blocked, and as a result, the tube becomes filled with the thin fluid secretions from the tubal epithelial cells.
What is PID?
Pelvic inflammatory disease. Includes infection and inflammation of the upper female genital tract: endometritis, salpingitis, oophoritis
Cause of hydrosalpinx
Normally follows PID, more specifically acute salpingitis
Who gets PID?
- 1 in 50 sexually active women in UK/year
- typically women under the age of 25 yrs
Causes of PID
- commonly a result of ascending infection within the genital tract (STI)
- medical/surgical intervention e.g. hysteroscopy, and certain organisms are associated with the presence of an IUCD (Actinomycetes)
- TB (spreads via the haematogenous route to the fallopian tubes)
- Chlamydia trachomatis
- Neisseria gonorrhoea
IUCD
Intrauterine Contraceptive Device
What’s the most common sexually transmitted infection in England?
Chlamydia trachomatis
How does a hydrosalpinx develop after an acute infection?
- formation of a pyosalpinx during the acute infection
- The fimbrial end of the tube is blocked due to inflammation, hence the pus cannot escape.
- inflammation resolves, the pus is reabsorbed, but the tube remains blocked and a hydrosalpinx develops.
What is a pyosalpinx?
a tube distended with pus
Complications of PID
- development of a tubo-ovarian abscess in the acute stages, which may rupture
Longer term they may develop chronic PID with pelvic pain, and this may be complicated by further episodes of acute salpingitis. Serious long term complications are ectopic pregnancy, and tubal infertility:
1 episode of acute salpingitis increases the risk of ectopic pregnancy 7-10 times.
Infertility occurs in approximately 10% patients after 1 episode of PID, but the rate reaches 40 - 75% after 3 episodes.
Presentation of acute salpingitis
vague lower abdominal/pelvic pain, often with purulent vaginal discharge, and with or without fever and systemic features of inflammation. However, it is often a silent disease that presents with complications
What’s the problem with acute salpingitis?
Often silent presentation so you don’t treat with antibiotics.
Therefore preventative measures include:
- barrier contraception is important
- National Chlamydia Screening Programme in the UK, that offers opportunistic non-invasive (urine or vulvo-vaginal swab) chlamydia testing to men and women under the age of 25 yrs.
35-year-old female who presents with acute severe right iliac fossa pain, and vaginal bleeding. History of 8 weeks of amenorrhoea. Cystic structure within the ovary. Tube is distended with a blood clot
A tubal ectopic pregnancy
Cystic structure is the corpus luteum
What proportion of pregnancies are ectopic?
1%
What is an ectopic pregnancy?
Ectopic pregnancy refers to the implantation of the fertilised ovum anywhere other than the uterus.
Common sites for ectopic pregnancies
- 90% of cases fallopian tube
- ovary
- uterine cornu (site at which fallopian tube enters the uterus)
- cervix
- abdominal cavity (if the fertilised ovum drops out of the fimbrial end of the tube)
What causes a haematosalpinx?
The fertilised ovum implants into the wall of the fallopian tube. The developing placenta implants onto the wall of the tube and gradually invades through the wall, as there is no decidua between the placenta and the wall of the tube. The result is haemorrhage into the tube (due to rupture of vessels in the wall) which is referred to as haematosalpinx.
How might an ectopic pregnancy be fatal?
Ruptured ectopic pregnancy
How could you confirm a diagnosis of a tube ectopic pregnancy prior to surgery?
- Amenorrhoea suggests pregnancy
- pregnancy test or serum βHCG would have confirmed this
- distended tube would have been visible on ultrasound scan (abdominal or transvaginal)
Risk factors for ectopic pregnancies
Anything that prevents the fertlised ovum entering the uterus, or that impairs implantation.
However, half of affected women have no predisposing factors.
Risk factors include:
- Previous salpingitis and PID
- tubal structural anomalies (which may follow surgery to the tube, pelvic adhesions e.g. secondary to endometriosis (distorting the tube)
- some fertility drugs
- uterine abnormalities that prevent passage of ovum into uterus, e.g. distortion by fibroids
- IUCD (specifically the progesterone releasing IUD, although if pregnancy occurs with a traditional IUD it is more likely to be ectopic)
- increasing maternal age
What does the corpus luteum do during pregnancy?
It is the source of oestrogen and progesterone secretion during the first 12 weeks of pregnancy, under the influence of HCG secreted by the developing placenta (after the 12th week, the placenta takes over the function of the corpus luteum, which then regresses). The oestrogen and progesterone maintain the endometrial lining of the uterus.
Differential diagnosis of acute severe lower abdominal pain (in a woman of reproductive age) are:
- Acute salpingitis
- Torted ovary and fallopian tube
- Endometriosis (but not usually acute in onset). May have rupture of an endometriotic cyst.
- Mittelschmerz (pain associated with ovulation - can be severe)
- And non-gynaecological causes such as: (this list is not exhaustive)
Cystitis, ureteric stone, acute appendicitis, diverticulitis
Even in the absence of the history of amenorrhoea, any women of child-bearing age who presents with abdominal pain of this nature should have a pregnancy test to exclude ectopic pregnancy.
What could cause a fallopian tube and ovary that are dark brown/black in colour? Associated with severe lower abdo pain
A torted ovary and fallopian tube.
Dark colour due to haemorrhage and infarction (with necrosis) of the tissue. The blockage of venous return due to rotation of the tube and ovary around the broad ligament has resulted in ischaemia and infarction. The structures are also swollen due to oedema.
Which side is it more common to get a torted ovary?
Right as the left side is less mobile in the presence of the sigmoid colon.
Risk factors for tortion
Enlargement of the ovary regardless of cause:
Tumour (benign or malignant) - involved in 50-60% of cases of torsion
Most commonly a dermoid cyst. Malignant tumours may be associated with adhesions that reduce the likelihood of torsion.
Cyst - of any type, including tumour (see above)
Torsion of the ovary during pregnancy may be due to a corpus luteal cyst or to increased mobility of the ovaries due to general laxity of the ligaments
Developmental abnormality
Torsion of the ovary may be seen in a child. This usually occurs with a normal ovary in association with an abnormality of the fallopian tube (e.g. excessively long tube)
Types of ovarian cysts
Ovarian cysts can be functional, endometriotic, or neoplastic. The neoplastic cysts may be benign or malignant (or of borderline malignant potential if epithelial in origin). The more common examples of each are:
Functional cysts: follicular, corpus luteal cysts
Endometriotic (chocolate) cyst: associated with endometriosis
Neoplastic cysts:
Benign: epithelial - mucinous and serous cystadenoma
germ cell tumour - dermoid cyst (cystic teratoma)
Malignant: epithelial - mucinous and serous cystadenocarcinoma
(malignant germ cell tumours are often solid)
Ovaries from female, early twenties, vague abdominal pain with a palpable adnexal mass on examination, cyst wall is smooth and shiny on the outer surface (peritoneal/serosal surface). The lining of the cyst is slightly roughened in areas, noules in the wall, a small amount of hair, and several teeth, cyst is unilocular.
mature cystic teratoma aka a dermatoid cyst
What cells do teratomas arise from?
Post meiotic germ cells which are totipotential, which means that they have the ability to differentiate along all 3 cell lines (i.e. ectodermal, endodermal, or mesodermal).
What’s the most common germ cell tumour of the ovary, representing around 25% of ovarian neoplasms?
Mature cystic teratoma
Who gets teratomas?
They are most commonly diagnosed during reproductive life (peak age 20-29 years), and are usually unilateral.
Why are teratomas also known as dermatoid cysts?
Almost all teratomas have ectodermal differentiation, and often they contain tissues from the other cell lineages. Commonly, the cysts are lined by skin with its appendages, such as hair follicles and sebaceous glands. It is for this reason that these tumors are sometimes referred to as dermoid cysts.
Prognosis for patients with teratomas
These tumours are benign. As such they are confined to the ovary, and once removed the patient is cured. They may undergo torsion (17% of cases) which often results in acute presentation.
Very occasionally (1%), a malignancy may arise within a mature teratoma. This is most often a squamous cell carcinoma arising in the skin component of the tumour.
Less common are the immature teratomas. These are solid tumours, and are considered to be malignant. Mature tissue elements may be seen, but these tumors contain immature tissues, usually ectodermal and mesodermal in origin. The tissues do not have the organised structure that is seen in mature teratomas. The immature neural component is particularly significant.
Types of ovarian tumours
Epithelial tumours
Germ cell tumours
Sex cord/ Stromal tumours
Metastatic tumours
What are the epithelial tumours that occur in the ovary?
Serous and mucinous ovarian tumours
The surface epithelium undergoes metaplasia (under conditions of repeated damage with ovulation) to give rise to serous and mucinous ovarian tumours. These are often cystic, and they can be benign (cystadenoma; the majority) or malignant (cystadenocarcinoma).
There is a 3rd group of epithelial tumours referred to as those of borderline malignant potential. These are less common, and behave as a low grade cancer.
Other epithelial tumours include endometrioid-type, clear cell (both usually malignant), and Brenner tumour (with urothelial differentiation, and mostly benign).
What’s the most common type of ovanian tumour?
Epithelial tumours
Serous tumours representing 30% ovarian tumours.
Mucinous tumours represent 25% of ovarian tumours.
Endometrioid tumours represent 25% of ovarian tumours.
What’s a Brenner tumour?
urothelial differentiation, and mostly benign
Second most common ovarian tumours
Germ cell tumours
Of these, the teratoma is the most common
Malignant germ germ cell tumours
DECY
dysgerminoma
embryonal carcinoma
choriocarcinoma
yolk sac tumour (endodermal sinus carcinoma)
Are sex cord/stromal tumours benign or malignant?
Most benign
Most common Sex cord/stromal tumour
Fibroma/thecoma.
The thecoma component can be hormone (oestrogen) secreting, and may give rise to endometrial abnormalities.
Which sex cord/stromal tumours may secrete androgens or oestrogens?
Granulosa cell tumour, and Sertoli-Leydig tumour
Small cysts are known as
Locules
Pathology of mucinous and serous tumours
With repeated ovulation during reproductive life, the surface of the ovary becomes scarred, and with time the epithelium becomes embedded in the ovarian cortex in the form of small cysts. The lining of these cysts can undergo metaplasia, most commonly to serous or mucinous type, to give rise to serous and mucinous ovarian tumours respectively. This is thought to be due to increased susceptibility to genetic mutations during repeated episodes of epithelial damage and repair.
Term for benign cyst tumours
Cystadenomas
Term for malignant cyst tumours
Cystadenocarcinomas
What are borderline malignant tumours?
These are less common than mucinous/serous epithelial tumours
Generally behave as a low grade cancer, and some may have peritoneal involvement.
Malignant epithelial tumours
endometrioid-type,
clear cell
Features of benign mucinous tumours
- smooth serosal surface over the ovary
- intact capsule
What are fibroids also known as?
Leiomyomas (leiomyosarcomas if malignant)
They are tumours of smooth muscle which commonly arise in the myometrium.
What’s the 4th most common malignancy in UK females?
Ovarian cancer (after breast, bowel, and lung).
Most common cell type of malignant ovarian tumours
epithelial in origin
Who gets ovarian tumours and what’s the prognosis?
rarely diagnosed in women <40yrs old.
These tumours have a relatively poor prognosis in comparison with other malignancies of the female genital tract simply because they usually present late due to non-specific clinical features.
Benign or malignant?
Solid areas on the surface of the ovary which have a cauliflower-like appearance which is referred to as ‘papillary’. There are several cysts present which have been sliced to reveal thick tan greasy (mucinous) contents.
On the surface= malignant
Risk factors for ovarian cancer
Increased age: most malignant ovarian tumours occur in post-menopausal women
Positive family history: 1 in 20 ovarian malignancies is seen in a patient who has a positive family history. In some of these cases the tumours will have arisen in association with an inherited gene mutation, such as BRCA 1, or HNPCC (hereditary non polyposis colon cancer syndrome). These tumours usually occur at a younger age (those patients with known inherited mutation in BRCA 1 may be screened for the development of ovarian cancer).
Early menarche/late menopause, nulliparity: related to the number of ovulatory cycles (during pregnancy there is no ovulation).
Protective factors: Breast feeding and the oral contraceptive (both by suppressing ovulation).