Gynaecology Flashcards

Question

What are the aetiolgies of intermenstrual bleeding and post-coital bleeding?

Answer 1

* Cervical cancer * Cervical ectropian * Cervical polyps * Cervicitis * Genital prolapse (including urethral) * Bengin vascular neoplasms * Haemangioma * Lymphangioma * AV malformations * Lower genital tract infections

Answer 2

Mentruation occuring every 35 days to 6 months.

Answer 3

* Primary * genetic or chromosomal abnormalities * Abnormalities of the reproductive organs * Secondary * PCOS * ovarian insufficiency (early menopause) * Hypothalamic amenorrhea: hypothalamus slows or stops releasing gonadotropin-releasing hormone (GnRH) * Prolactin-secreting tumour * Ovarian and adrenal neoplasms * Cushing's syndrome

Answer 4

* 2 of 3 to make diagnosis: * oligomenorrhea/irregular menses for 6 mo * clinical or lab evidence of hyperandrogenism * polycystic ovaries on U/S

Answer 5

* Hyperlipidemia * Adult-onset DM * Endometrial hyperplasia * Infertility * Obesity * Sleep apnea

Answer 6

* average age 15-35 yr at presentation * in adolescents, wait at least 1-2 yr to make diagnosis * abnormal/irregular uterine bleeding, hirsutism, infertility, obesity, virilization * insulin resistance occurs in both lean and obese patients * acanthosis nigricans: browning of skin folds in intertriginous zones (indicative of insulin resistance) * family history of DM

Answer 7

* goal of investigations is to identify hyperandrogenism or chronic anovulation; and rule out specific pituitary or adrenal disease as the cause * laboratory * prolactin, 17-hydroxyprogesterone, free testosterone, DHEA-S, TSH, free T4 , androstenedione, SHBG * LH:FSH \>2:1; LH is chronically high with FSH mid-range or low (low sensitivity and specificity) * increased DHEA-S, androstenedione and free testosterone (most sensitive), decreased SHBG * transvaginal or transabdominal U/S: polycystic-appearing ovaries (“string of pearls” – 12 or more small follicles 2-9 mm, or increased ovarian volume) * tests for insulin resistance or glucose tolerance * fasting glucose:insulin ratio \<4.5 is consistent with insulin resistance (U.S. units) * 75 g OGTT yearly (particularly if obese) * laparoscopy * not required for diagnosis * most common to see white, smooth, sclerotic ovaries with a thick capsule; multiple follicular cysts in various stages of atresia; hyperplastic theca and stroma * rule out other causes of abnormal bleeding

Answer 8

* Lifestyle modifications: conparable to or better than medical treatment. * Weight loss * Increase exercise * Diet * cycle control * lifestyle modification (decrease BMI, increase exercise) to decrease peripheral estrone formation * OCP monthly or cyclic Provera® to prevent endometrial hyperplasia due to unopposed estrogen * oral hypoglycemic (e.g. metformin) if type 2 diabetic or if trying to become pregnant * tranexamic acid (Cyklokapron®) for menorrhagia only * infertility * medical induction of ovulation: clomiphene citrate, human menopausal gonadotropins (HMG [Pergonal®]), LHRH, recombinant FSH, and metformin * metformin may be used alone or in conjuction with clomiphene citrate for ovulation induction * ovarian drilling (perforate the stroma), wedge resection of the ovary * bromocriptine (if hyperprolactinemia) * hirsutism * any OCP can be used * Androcur® (cyproterone acetate): antiandrogenic * Yasmin® (drospirenone and ethinyl estradiol): spironolactone analogue (inhibits steroid receptors) * mechanical removal of hair * finasteride (5-α reductase inhibitor) * flutamide (androgen reuptake inhibitor) * spironolactone: androgen receptor inhibitor

Answer 9

* Hirsutism * Virilisation * Defeminisation

Answer 10

48-55 years 51.4 years

Answer 11

* associated with estrogen deficiency * vasomotor instability (tends to dissipate with time) * hot flushes/flashes, night sweats, sleep disturbances, formication, nausea, palpitations * urogenital atrophy involving vagina, urethra, bladder * dyspareunia, pruritus, vaginal dryness, bleeding, urinary frequency, urgency, incontinence * skeletal * osteoporosis, joint and muscle pain, back pain * skin and soft tissue * decreased breast size, skin thinning/loss of elasticity * psychological * mood disturbance, irritability, fatigue, decreased libido, memory loss

Answer 12

Lack of menses for 1 yr

Answer 13

* physiological; average age 51 yr (follicular atresia) * premature ovarian failure; before age 40 (autoimmune disorder, infection, Turner’s syndrome) * iatrogenic (surgical/radiation/chemotherapy)

Answer 14

* increased levels of FSH (\>35 IU/L) on day 3 of cycle (if still cycling) and LH (FSH\>LH) * FSH level not always predictive due to monthly variation; use absence of menses for 1 yr to diagnose * decreased levels of estradiol (later)

Answer 15

* goal is for individual symptom management * vasomotor instability * HRT (first line), SSRIs, venlafaxine, gabapentin, propranolol, clonidine * acupuncture * vaginal atrophy * local estrogen: cream (Premarin®), vaginal suppository (VagiFem®), ring (Estring®) * lubricants * urogenital health * lifestyle changes (weight loss, bladder re-training), local estrogen replacement, surgery * osteoporosis * 1,000-1,500 mg calcium OD, 800-1,000 IU vitamin D, weight-bearing exercise, smoking cessation * bisphosphonates (e.g. alendronate) * selective estrogen receptor modifiers (SERMs): raloxifene (Evista®) – mimics estrogen effects on bone, avoids estrogen-like action on breast and uterine cancer; does not help hot flashes * HRT: second-line treatment (unless for vasomotor instability as well) * decreased libido * vaginal lubrication, counseling, androgen replacement (testosterone cream or the oral form Android®) * cardiovascular disease * management of cardiovascular risk factors * mood and memory * antidepressants (first line), HRT (augments effect) * alternative choices (not evidence-based, safety not established) * black cohosh, phytoestrogens, St. John’s wort, gingko biloba, valerian, evening primrose oil, ginseng, Don Quai

Answer 16

Degenerating theca cells fail to react to endogenous gonadotropins (FSH, LH) → Less estrogen is produced → Decreased negative feedback on hypothalamic-pituitary-adrenal axis → Increased FSH and LH → Stromal cells continue to produce androgens as a result of increased LH stimulation

Answer 17

* **A**cute liver disease * Undiagnosed vaginal **B**leeding * **C**ancer: Breast/uterine, **C**ardiovascular disease * **D**VT (thromboembolic disease)

Answer 18

* Oestrogen * oral or transdermal (e.g. patch, gel) * transdermal preferred for women with hypertriglyceridemia or impaired hepatic function, smokers, and women who suffer from headaches associated with oral HRT * low-dose (preferred dose: 0.3 mg Premarin®/25 µg Estradot® patch, can increase if necessary) * Progestin * given in combination with estrogen for women with an intact uterus to prevent development of endometrial hyperplasia/cancer

Answer 19

* abnormal uterine bleeding * mastodynia – breast tenderness * oedema, bloating, heartburn, nausea * mood changes (progesterone) * can be worse in progesterone phase of combined therapy

Answer 20

* absolute * acute liver disease * undiagnosed vaginal bleedin * known or suspected uterine cancer/breast cancer * acute vascular thrombosis or history of severe thrombophlebitis or thromboembolic disease * cardiovascular disease * relative * pre-existing uncontrolled HTN * uterine fibroids and endometriosis * familial hyperlipidemias * migraine headaches * family history of estrogen-dependent cancer * chronic thrombophlebitis * DM (with vascular disease) * gallbladder disease, hypertriglyceridemia, impaired liver function (consider transdermal oestrogen) * fibrocystic disease of the breasts

Answer 21

* common viral STD in the United States * \>200 subtypes, of which \>30 are genital subtypes * HPV types 6 and 11 are classically associated with anogenital warts/condylomata acuminata * HPV types 16 and 18 are the most oncogenic (classically associated with cervical HSIL) * types 16, 18, 31, 33, 35, 36, 45 (and others) associated with increased incidence of cervical and vulvar intraepithelial hyperplasia and carcinoma

Answer 22

* latent infection * no visible lesions, asymptomatic * only detected by DNA hybridization tests * subclinical infection * visible lesion found during colposcopy or on Pap test * clinical infection * visible wart-like lesion without magnification * hyperkeratotic, verrucous or flat, macular lesions * vulvar oedema

Answer 23

* cytology * koilocytosis: nuclear enlargement and atypia with perinuclear halo * biopsy of lesions at colposcopy * detection of HPV DNA subtype using nucleic acid probes (not routinely done but can be done in presence of abnormal Pap test to guide treatment)

Answer 24

* patient administered * imiquimod 5% cream topically (apply to each wart), 3 times weekly on alternate days at bedtime (wash off after 6 to 10 hours) until warts resolve (usually 8 to 16 weeks) * podophyllotoxin 0.15% cream or 0.5% paint topically (apply to each wart), twice daily for 3 days followed by a 4-day break; repeat weekly for 4 to 6 cycles until warts resolve. * provider administered * cryotherapy with liquid nitrogen: repeat q1-2wk * surgical removal/laser

Answer 25

* vaccination: Gardasil® * condoms may not fully protect (areas not covered, must be used every time throughout entire sexual act)

Answer 26

90% are HSV-2, 10% are HSV-1

Answer 27

* may be asymptomatic * initial symptoms: present 2-21 d following contact * prodromal symptoms: tingling, burning, pruritus * multiple, painful, shallow ulcerations with small vesicles appear 7-10 d after initial infection (absent in many infected persons); lesions are infectious * inguinal lymphadenopathy, malaise, and fever often with first infection * dysuria and urinary retention if urethral mucosa affected * recurrent infections: less severe, less frequent and shorter in duration (especially with HSV-1)

Answer 28

* viral culture preferred in patients with ulcer present, however decreased sensitivity as lesions heal * cytologic smear (Tzanck smear) * multinucleated giant cells, acidophilic intranuclear inclusion bodies * type specific serologic tests for antibodies to HSV-1 and HSV-2

Answer 29

* first episode * acyclovir, famciclovir, or valacyclovir * recurrent episode * acyclovir, or acyclovir; famciclovir and valacyclovir may also be used * daily suppressive therapy * consider if more than 6 recurrences per yr or one every 2 mo * acyclovir or famciclovir or valacyclovir * severe disease * IV therapy: acyclovir followed by oral antiviral therapy to complete at least 10 d * education regarding transmission * avoid contact from onset of prodrome until lesions have cleared * use barrier contraception

Answer 30

* Antiviral suppression of women with first episode or history of HSV infections from 36 wk GA onward * C-section should be performed on women who have active genital lesions at time of delivery * Treatment: acyclovir 400 mg PO tid

Answer 31

* primary syphilis * 3-4 wk after exposure * painless chancre on vulva, vagina, or cervix * painless inguinal lymphadenopathy * serological tests usually negative, local infection only * secondary syphilis (can resolve spontaneously) * 2-6 mo after initial infection * nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy * generalized maculopapular rash: palms, soles, trunk, limbs * condylomata lata: anogenital, broad-based fleshy gray lesions * serological tests usually positive * latent syphilis * no clinical manifestations; detected by serology only * tertiary syphilis * may involve any organ system * neurological: tabes dorsalis, general paresis * cardiovascular: aortic aneurysm, dilated aortic root * vulvar gumma: nodules that enlarge, ulcerate and become necrotic (rare) * congenital syphilis * may cause fetal anomalies, stillbirths, or neonatal death

Answer 32

* aspiration of ulcer serum or node * darkfield microscopy (most sensitive and specific diagnostic test for syphilis) * spirochetes * non-treponemal screening tests (VDRL, RPR); nonreactive after treatment, can be positive with other conditions * specific anti-treponemal antibody tests (FTA-ABS, MHA-TP, TP-PA) * confirmatory tests; remain reactive for life (even after adequate treatment)

Answer 33

* treatment of primary, secondary, latent syphilis of \<1 yr duration * benzathine penicillin G IM single dose * treat partners, reportable disease * treatment of latent syphilis \>1 yr duration * benzathine penicillin G * treatment of neurosyphilis * IV aqueous penicillin G * screening * high risk groups * in pregnancy

Answer 34

* subepithelial fat becomes diminished; labia become thin, atrophic, with membrane-like epithelium and labial fusion * pruritus, dyspareunia, burning * ‘figure of 8’ distribution * most common in postmenopausal women but can occur at any age * treatment: ultrapotent topical steroid 0.05% clobetasol x 2-4 wk then taper down

Answer 35

* Clinical Presentation * well-defined plaque(s) of lichenified skin with decreased skin markings ± excoriations * common sites: neck, scalp, lower extremeties, urogenital area * often seen in patients with atopy * Pathophysiology * skin hyperexcitable to itch, continued rubbing/scratching of skin results * eventually lichenification occurs * Investigations * if patient has generalized pruritus, rule out systemic cause: FBC with differential count, transaminases, renal and thyroid function tests * CXR if lymphoma suspected * Management * treat pruritus to break the itch-scratch cycle: antipruritics (e. g. antihistamines, topical or intralesional glucocorticoids, Unna boot)

Answer 36

* Purple * Pruritic * Polygonal * Peripheral * Papules * Penis (i.e. mucosa)

Answer 37

* topical or intralesional corticosteroids * short courses of oral prednisone (rarely) * phototherapy for generalized or resistant cases * oral retinoids for erosive lichen planus in mouth * oral metronidazole or systemic immunosuppressants (e.g. azathioprine, methotrexate, cyclosporine)

Answer 38

* 5% of genital tract malignancies * 90% SCC; remainder melanomas, basal cell carcinoma, Paget’s disease, Bartholin’s gland carcinoma * Type I disease: HPV-related (50-70%) * more likely in younger women * 90% of VIN contain HPV DNA (usually types 16, 18) * Type II disease: not HPV-related, associated with current or previous vulvar dystrophy * usually postmenopausal women

Answer 39

* HPV infection * VIN: precancerous change which presents as multicentric white or pigmented plaques on vulva (may only be visible at colposcopy) * progression to cancer rarely occurs with appropriate management * treatment: local excision (i.e. superficial vulvectomy ± split thickness skin grafting to cover defects if required) vs. ablative therapy (i.e. laser, cauterization) vs. local immunotherapy (imiquimod)

Answer 40

* many patients asymptomatic at diagnosis (many also deny or minimize symptoms) * most lesions occur on the labia majora, followed by the labia minora (less commonly on the clitoris or perineum) * localized pruritus or lesion most common * less common: raised red, white or pigmented plaque, ulcer, bleeding, discharge, pain, dysuria * patterns of spread * local * groin lymph nodes (usually inguinal → pelvic nodes) * haematogenous

Answer 41

* ovarian and testicular malignancy * hepatoma * pregnancy * choriocarcinoma

Answer 42

* relaxation, weakness, or defect in the cardinal and uterosacral ligaments which normally maintain the uterus in an anteflexed position and prevent it from descending through the urogenital diaphragm (i.e. levator ani muscles) * related to * vaginal childbirth * aging * decreased estrogen (post-menopause) * following pelvic surgery * increased intra-abdominal pressure (obesity, chronic cough, constipation, ascites, heavy lifting) * congenital (rarely) * ethnicity (Caucasian women \> Asian or African women) * collagen disorders

Answer 43

* Protrusion of cervix and uterus into vagina * Clinical features: * Groin/back pain (stretching of uterosacral ligaments) * Feeling of heaviness/pressure in the pelvis * Worse with standing, lifting * Worse at the end of the day * Relieved by lying down * Ulceration/bleeding (particularly if hypoestrogenic) * ± urinary incontinence

Answer 44

* General conservative treatment * Vaginal hysterectomy ± surgical prevention of vault prolapse * Consider additional surgical procedures if urinarym incontinence, cystocele, rectocele, and/or enterocele are present

Answer 45

* Kegel exercises * local vaginal estrogen therapy * vaginal pessary (intravaginal suspension disc)

Answer 46

* protrusion of apex of vaginal vault into vagina, post-hysterectomy. * Clinical features: * Groin/back pain (stretching of uterosacral ligaments) * Feeling of heaviness/pressure in the pelvis * Worse with standing, lifting * Worse at the end of the day * Relieved by lying down * Ulceration/bleeding (particularly if hypoestrogenic) * ± urinary incontinence

Answer 47

* is a term sometimes used to describe urinary incontinence as a complication of urinary retention. * use of the term if used it should be accompanied by the associated pathophysiology (e.g. BPH with overflow incontinence)

Answer 48

* General conservative measures * Sacralcolpopexy (vaginal vault suspension), sacrospinous fixation, or uterosacral ligament suspension

Answer 49

* protrusion of bladder into the anterior vaginal wall. * Clinical features: * Frequency, urgency, nocturia * Stress incontinence * Incomplete bladder emptying ± associated increased incidence of urinary tract infections – may lead to renal impairment

Answer 50

* General conservative treatment * Anterior colporrhaphy (“anterior repair”) * Consider additional/alternative surgical procedure if documented urinary stress incontinence

Answer 51

* protrusion of rectum into posterior vaginal wall. * Clinical features: * Straining/digitation to evacuate stool * Constipation

Answer 52

* General conervative treatment * Also laxatives and stool softeners * Posterior colporrhaphy (“posterior repair”), plication of endopelvic fascia and perineal muscles approximated in midline to support rectum and perineum (can result in dyspareunia)

Answer 53

* Similar to hernia repair * Contents reduced, neck of peritoneal sac ligated, uterosacral ligaments, and levator ani muscles approximated

Answer 54

* 0 = no descent during straining * 1 = distal portion of prolapse \>1 cm above level of hymen * 2 = distal portion of prolapse ≤1 cm above or below level of hymen * 3 = distal portion of prolapse \>1 cm below level of hymen but without complete vaginal eversion * 4 = complete eversion of total length of lower genital tract * Procidentia: failure of genital supports and complete protrusion of uterus through the vagina

Answer 55

Involuntary loss of urine with increased intra-abdominal pressure (coughing, laughing, sneezing, walking, running)

Answer 56

involuntary leakage of urine

Answer 57

* detrusor overactivity * CNS lesion, inflammation/infection (cystitis, stone, tumor), bladder neck obstruction (tumor, stone), BPH, idiopathic. * decreased compliance of bladder wall (inability to store urine) * CNS lesion, fibrosis * sphincter/urethral problem

Answer 58

* common in women; seen in men after prostate cancer treatment or pelvic operations * urethral hypermobility * weakened pelvic floor and musculofascial urethral and vaginal supporting mechanisms allows bladder neck and urethra to descend with increased intra-abdominal pressure * urethra is pulled open by greater motion of posterior wall of outlet relative to anterior wall * associated with childbirth, pelvic surgery, aging, levator muscle weakness, obesity * intrinsic sphincter deficiency (ISD): weakness of the urethra and associated smooth and striated muscle elements * pelvic surgery, neurologic problem, aging and hypoestrogen state * ISD and urethral hypermobility can co-exist

Answer 59

combination of stress and urgency incontinence

Answer 60

* variable prevalence in women: 25-45% * F:M = 2:1 * more frequent in the elderly, affecting 5-15% of those living in the community and 50% of nursing home residents

Answer 61

* pelvic prolapse * pelvic surgery * vaginal delivery * hypoestrogenic state (post-menopause) * age * smoking * neurological/pulmonary disease

Answer 62

* General conservative treatment * surgical * tension-free vaginal tape (TVT), tension-free obturator tape (TOT), prosthetic/fascial slings or retropubic bladder suspension (Burch or Marshall-Marchetti-Krantz procedures)

Answer 63

* urine loss associated with an abrupt, sudden urge to void * “overactive bladder” * diagnosed based on symptoms

Answer 64

* idiopathic (90%) * detrusor muscle overactivity (“detrusor instability”)

Answer 65

* frequency, urgency, nocturia, leakage

Answer 66

* behavior modification (reduce caffeine/liquid, smoking cessation, regular voiding schedule) * Kegel exercises * medications * anticholinergics: oxybutinin, tolterodine, solifenacin * tricyclic antidepressants: imipramine

Answer 67

* Dysmennohea: painful periods * Dyspareunia: painful sex * Dyschezia: constipation associated with a defective reflex for defecation

Answer 68

* Neural control of the bladder and urethra * Voiding reflex * Controlled at the level of the pons * Afferent fibres respond to distention of the bladder wall and pass to the spinal cord * Efferent parasympathetic fibres pass back to the detrusor muscle and cause contraction, and also enable opening of the bladder neck * Efferent sympathetic fibres to the detrusor muscle are inhibited * Continence * Dependent on the pressure in the urethra being greater than the bladder * Urethral pressure influenced by urethral muscle tone, pelvic floor and intra-abdominal pressure * Detrusor muscle is expandable, and so as the bladder fills there is no increase in pressure * Micturition * Results when bladder pressure exceeds urethral pressure * Achieved voluntarily by simultaneous drop in urethral pressure (partly due to pelvic floor reaction) and an increase in bladder pressure due to detrusor muscle contraction

Answer 69

* Ovulatory suppression through inhibition of LH and FSH * Decidualization of endometrium * Thickening of cervical mucus resulting in decreased sperm penetration

Answer 70

* Highly effective * Reversible * Cycle regulation * Decreased dysmenorrhea and menorrhagia (less anemia) * Decreased benign breast disease and ovarian cyst development * Decreased risk of ovarian and endometrial cancer * Increased cervical mucus which may lower risk of STDs * Decreased PMS symptoms * Improved acne * Osteoporosis protection (possibly)

Answer 71

* Nausea * Breast changes (tenderness, enlargement) * Fluid retention/bloating/edema * Weight gain (rare) * Migraine, headaches * Thromboembolic events * Liver adenoma (rare) * Breakthrough bleeding (low estradiol levels)

Answer 72

* Amenorrhea/breakthrough bleeding * Headaches * Breast tenderness * Increased appetite * Decreased libido * Mood changes * HTN * Acne/oily skin\* * Hirsutism\*

Answer 73

* Known/suspected pregnancy * Undiagnosed abnormal vaginal bleeding * Prior thromboembolic events, thromboembolic disorders (Factor V Leiden mutation; protein C or S, or antithrombin III deficiency), active thrombophlebitis * Cerebrovascular or coronary artery disease * Oestrogen-dependent tumors (breast, uterus) * Impaired liver function associated with acute liver disease * Congenital hypertriglyceridemia * Smoker age \>35 yr * Migraines with focal neurological symptoms (excluding aura) * Uncontrolled HTN

Answer 74

* Migraines (non-focal with aura \<1 h) * DM complicated by vascular disease * SLE * Controlled HTN * Hyperlipidemia * Sickle cell anemia * Gallbladder disease

Answer 75

* Progestin prevents LH surge * Thickening of cervical mucus * Decrease tubal motility * Endometrial decidualization * Ovulation suppression – oral progestins (not IM) do not consistently suppress compared to combined OCPs

Answer 76

* Suitable for postpartum women (does not affect breast milk supply) * Women with contraindications to combined OCP (e.g. thromboembolic or myocardial disease) * Women intolerant of estrogenic side effects of combined OCPs

Answer 77

* Copper-containing IUD: mild foreign body reaction in endometrium toxic to sperm and alters sperm motility * Progesterone-releasing IUD (Mirena®): decidualization of endometrium and thickening of cervical mucus; minimal effecton ovulation * Highly effective (95-99%); failurerate 0-1.2% * Contraceptive effects last 5 yr * Reversible, private, convenient * May be used in women with contraindications to OCPs or wanting long-term contraception

Answer 78

* Both Copper and Progesterone IUD * Breakthrough bleeding * Expulsion (5% in the 1st yr, greatest in 1st mo and in nulliparous women) * Uterine wall perforation (1/1,000) on insertion * If pregnancy occurs with an IUD, increased risk of ectopic * Increased risk of PID (within first 10 d of insertion only) * Copper IUD: increased blood loss and duration of menses, dysmenorrhea * Progesterone IUD: bloating, headache

Answer 79

* Both Copper and Progesterone IUD * Known or suspected pregnancy * Undiagnosed genital tract bleeding * Acute or chronic PID * Lifestyle risk for STDs\* * Copper IUD: * Known allergy to copper * Wilson’s disease

Answer 80

* Both Copper and Progesterone IUD * Valvular heart disease * Past history of PID or ectopic pregnancy * Presence of prosthesis * Abnormalities of uterine cavity, intracavitary fibroids * Cervical stenosis * Immunnosuppressed individuals (e.g. HIV) * Copper IUD: severe dysmenorrhea or menorrhagia

Answer 81

* _Endocervix:_ lined by columnar epithelium that secretes mucus; epithelium has complex infoldings that resemble glands or clefts on cross section; mucosa rests on inconspicuous layer of reserve cells * _Ectocervix (exocervix)_: covered by nonkeratinizing, stratified squamous epithelium, either native or metaplastic; has basal, midzone and superficial layers; after menopause is atrophic with mainly basal and parabasal cells with high N/C ratio that resembles dysplasia; prepubertal girls have similar appearing epithelium * _Squamocolumnar (SC) junction_: where squamous and columnar epithelium meets; lined by krt7+ non-stratified cuboidal cells; can migrate proximately as columnar epithelium is replaced by metaplastic squamous epithelium, due to increased estrogen production and growth of vaginal bacterial flora (new SC junction); recent studies support SC junction as site of “embryonic cell population”, involved in cervical remodeling (metaplasia and microglandular hyperplasia), and as cell of origin for cervical cancer and its precursors. * _Transformation zone:_ also called ectropion, area between original SC junction and new SC junction due to regenerative metaplastic response; site of \> 90% of squamous cell carcinomas and dysplasia

Answer 82

* Ovary * Tube * Cervix * Endometrium * Sperm

Answer 83

Inability to conceive or carry to term a pregnancy after 1 yr of regular, unprotected intercourse

Answer 84

* Primary infertility: infertility in the context of no prior pregnancies * Secondary infertility: infertility in the context of a prior conception

Answer 85

* Most are well differentiated and mimic proliferative endometrial glands. * Typically arise in the setting of endometrial hyperplasia, and like endometrial hyperplasia they are associated with: * Obesity * DM (found in more than 60%) * HTN * infertility * Unopposed oestrogen stimulation * Needs to develop alterations in tumour suppressor genes and oncogenes. * PTEN mutation develops forming hyperplasia of the endometrium. * Further development of mutations in PI3K/AKT pathway which is a hallmark of this particular tumour → this augments expression of oestrogen receptor-dependent target genes in endometrial cells. Individual tumours may harnour multiple mutations that increase PI3K/AKT signalling which include: * PIK3CA * ARID1A * KRAS

Answer 86

* Arise in the setting of endometrial atrophy, 10 years later than those with type I. * Poorly differentiated * Serous carcinoma is the most common subtype, others include clear cell and malignant mixed mullerian. * Mutations in the tumour suppressor TP53 are present in at least 90% of serous endometrial carcinoma. The majority are missense mutations that result in an accumulation of the altered protein. * Poorer prognosis than type I.

Answer 87

* Cancer: * Uterus, endometrial, uterine sarcoma * cervix or vagina * Endometrial atropgy or vaginal atrophy * uterine fibroids or polyps * INfection * Medictions: HRT, tamoxifen * Pelvic trauma * Bleeding from rectum or urinary tract * Endometrial hyperplasia

Answer 88

* Type I: excess estrogen (estrogen unopposed by progesterone) * obesity * PCOS * unbalanced HRT (balanced HRT is protective) * nulliparity * late menopause * oestrogen-producing ovarian tumors (e.g. granulosa cell tumors) * HNPCC (hereditary non-polyposis colorectal cancer)/Lynch II syndrome * tamoxifen * Type II: not estrogen-related * possibly tamoxifen

Answer 89

* Type I (well-differentiated endometrioid adenocarcinoma) ~80% of cases: * postmenopausal bleeding in majority, abnormal uterine bleeding in majority of affected pre-menopausal women (menorrhagia, intermenstrual bleeding) * Type II (serous, clear cell carcinoma, grade 3 endometrioid, undifferentiated, carcinosarcoma) _~15% of cases: * may not present with bleeding in early stage, more likely to present with advanced stage disease with symptoms like ovarian cancer (i.e. bloating, bowel dysfunction, pelvic pressure).

Answer 90

* Physical exam: * Vaginal including bimanual * Cardio * Lymph nodes * Blood tests: Rule out other causes of bleeding * FBC, UEC, LFTs, * endometrial sampling * office endometrial biopsy * D&C ± hysteroscopy * ± pelvic ultrasound (in women where adequate endometrial sampling not feasible without invasive methods) * not acceptable as alternative to pelvic exam or endometrial sampling to rule out cancer

Answer 91

* Macroscopic: * These tumors are often called "dermoid cysts" because they are mostly cystic and mostly contain ectodermal elements, typically resulting in the abundant hair. * Microscopic: * this teratoma is seen to have cartilage as well as adipose tissue and even intestinal glands at the right, while at the left are a lot of thyroid follicles. The presence of abundant thyroid tissue within a mature teratoma can be termed struma ovarii. Rarely, a struma ovarii can even be a cause for hyperthyroidism.

Answer 92

* Type I: * Endometrioid microscopic pattern with glandular, cribriform, and papillary features. * Type II: * Serous microscopic pattern with papillary features with glands having irregular luminal borders; high mitotic rate.

Answer 93

* Exam: * Pelvic * Vaginal + spectulum: PAP smear + high vaginal swab * Laboratory: * FBC, UEC, LFT * ß-HCG * CA-125 * Urinalysis: MCS * Imaging: * US: pelvic, transvaginal ± Biopsy or FNA * CT/MRI (if pregnant)

Answer 94

* Functional tumours (all benign) * Follicular cyst * Lutein cyst * Theca-Lutein cyst * Endometrioma * PCOS * Benign germ-cell tumours * Benign cystic teratoma (dermoid) * Malignant germ cell tumours * Dysgerminoma * Immature teratoma * Gonadoblastoma * Epithelial ovarian tumours (malignant or borderline) * Serous

Answer 95

* Elements of all 3 cell lines: ectoderm, mesoderm, endoderm. * Contains dermal appendages (sweat and sebaceous glands, hair follicles, teeth)

Answer 96

* excess oestrogen * nulliparity * early menarche/late menopause * age * family history of breast, colon, endometrial, ovarian cancer * race: Caucasian

Answer 97

* OCP: likely due to ovulation suppression (significant reduction in risk even after 1 yr of use) * pregnancy/breastfeeding * tubal ligation (recently questioned) * hysterectomy (without removal of ovaries) * BSO (prophylactic surgery performed for this reason in high risk women – i.e. BRCA mutation carriers)

Answer 98

* Do nothing * Do something: * Medical: * Chemotherapy * Monitor with CA-125 * Surgical: * Tumour resection

Answer 99

* depends on certainty of the diagnosis, severity of symptoms, extent of disease, desire for future fertility, and impact to GI/GU systems (e.g. intestinal obstruction) * medical * NSAIDs * pseudopregnancy * cyclic/continuous oestrogen-progestin (OCP) * medroxyprogesterone (Depo-Provera®) * dienogest (Natazia®) * pseudomenopause * 2nd line: only short-term (\<6 mo) due to osteoporotic potential with prolonged use, unless combined with add-back therapy (e.g. oestrogen/progesterone or SERM); if long-term use required, add-back estrogen+progesterone * danazol (Danocrine®): weak androgen – side effects: weight gain, fluid retention, acne, hirsutism, voice change * leuprolide (Lupron®): GnRH agonist (suppresses pituitary) – side effects: hot flashes, vaginal dryness, reduced libido – can use ≥12 mo with add-back progestin or oestrogen * surgical * conservative laparoscopy using laser, electrocautery ± laparotomy * ablation/resection of implants, lysis of adhesions, ovarian cystectomy of endometriomas * definitive: bilateral salpingo-oophorectomy ± hysterectomy * ± follow-up with medical treatment for pain control not shown to impact on preservation of fertility * best time to become pregnant is immediately after conservative surgery