GYNE Benign Disorders of the Upper and Lower Genital Tract, Blueprints Flashcards
Most common cause of labial fusion
Exogenous androgen
Most common form of enzymatic deficiency
21-hydroxylase deficiency
21-hydroxylase deficiency: Associated condition
Congenital adrenal hyperplasia (CAH)
Congenital adrenal hyperplasia (CAH): Hormone elevated
17α-hydroxyprogesterone
Congenital adrenal hyperplasia (CAH): Serum cortisol, increased vs decreased
Decreased
Congenital adrenal hyperplasia (CAH): Treatment
Exogenous cortisol
Congenital adrenal hyperplasia (CAH): Mechanism of exogenous cortisol
Negative feedback on pituitary > decrease ACTH > inhibition of adrenal gland stimulation > decrease in androgens
Primary amenorrhea + cyclic pelvic pain: Condition
1) Imperforate hymen
2) Transverse vaginal septum
3) Vaginal atresia
Accumulation of menstrual flow behind the hymen in the vagina
Hematocolpos
The caudal portion of the Müllerian ducts develops into
Uterus and upper vagina
Structure that must be canalised for normal vagina to form
Mullerian tubercle
Failure of mullein tubercle to canalise results in
Transverse vaginal septum
Most common site of transverse vaginal septum
Between upper 1/3 and lower 2/3
Occurs when the lower vagina is replaced by fibrous tissue and on PE reveals a vaginal dimple
Vaginal atresia
Vaginal atresia, management
Vaginal pull-through
Congenital absence of vagina and absence or hypoplasia of all or part of the cervix, uterus, and fallopian tubes
Vaginal agenesis
Vaginal agenesis is aka
Meyer-Rokitansky-Kuster-Hauser syndrome
T/F Ovary is hypoplastic in vaginal agenesis
F, normal
Vaginal agenesis: T/F Normal external genitalia
T
Vaginal agenesis: T/F Normal secondary sexual characteristics (breast development, axillary, and pubic hair)
T
Vaginal agenesis: T/F Normal ovarian function
T
Vaginal agenesis: T/F Phenotypically female
T
Vaginal agenesis: T/F Genotypically female
T
Vaginal agenesis: Management
1) Non-surgical with the use of dilators
2) Surgical
Vaginal agenesis: Most common surgical procedure used
McIndoe procedure
Vaginal agenesis: T/F Will be unable to carry a pregnancy
T
Inflammatory dermatosis that is associated with a risk for vulvar skin Ca in postmenopausal women
Lichen sclerosis
Inflammatory dermatosis associated with vaginal adhesions and erosive vaginitis
Lichen planus
T/F Lichen planis carries a risk of vulvar skin cancer
T
Inflammatory dermatosis that generally occurs in women in their 50s and 60s
Lichen planus
Skin disorder of the vulva that leads to a scratch–itch cycle
Lichen simplex chronicus
Management of nonneoplastic epithelial disorders of vulva
1) Lifestyle
2) Topical steroids
High-potency topical steroids that can be used to treat lichen sclerosis or lichen planus, and severe lichen simplex chronicus
Clobetasol
T/F There is no role for topical estrogens or testosterone in the treatment of nonneoplastic epithelial disorders of vulva
T
Most common tumor found on the ulva
Epidermal inclusion cyst
T/F Epidermal inclusion cysts usually result from occlusion of a pilosebaceous duct or a blocked hair follicle
T
Symmetric white, thinned skin on labia, perineum, and perianal region; shrinkage and agglutination of labia minora
Lichen sclerosis
Multiple shiny, flat, red-purple papules, usually on the inner aspects of the labia minora and vestibule with lacy white changes; often erosive
Lichen planus
Red moist lesions on the vulva, sometimes scaly; usually asymptomatic but sometimes pruritic
Vulvar psoriasis
Sweat glands found throughout the mons pubis and labia majora
Apocrine sweat glands
An infrequently occurring chronic pruritic papular eruption in the vulva that localizes to areas where apocrine glands are found
Fox-Fordyce disease
Skin disease that most commonly affects areas bearing apocrine sweat glands or sebaceous glands
Hidradenitis suppurativa
Paraurethral glands are aka
Skene glands
Location of Bartholin glands
4 o’clock and 8 o’clock positions of vaginal orifice
Bartholin cyst affects which part of the gland
Duct, gland itself remains unchanged
Bartholin duct cyst, management: 2cm
Can be left untreated or managed with sitz baths
Bartholin duct cyst, management: >40 years old
Biopsy to rule out Bartholin gland Ca
Catheter that can be used to manage complicated or troublesome Bartholin duct cyst
Word catheter
Done for recurrent Bartholin’s duct cysts or abscesses
Marsupialization
Bartholin duct cyst: Adjunct antibiotic therapy is only recommended when
1) Drainage culture is positive for N. gonorrheae
2) Refractory to simple surgical treatment
Remnants of the mesonephric ducts of the Wolffian system found in the vagina
Gartner’s duct cysts
Gartner’s duct cysts: Found most commonly in
Anterior lateral aspects of upper vagina
Gartner’s duct cysts: T/F Most are asymptomatic
T
Gartner’s duct cysts: Management
Excision
Elevated soft red papules on the vulva tha contain an abnormal proliferation of blood vessels
Cherry hemangiomas aka Campbell de Morgan spots
T/F Isolated congenital anomalies of the cervix are rare
T
25% of women who were exposed in utero to ___have an associated cervical hypoplasia, cervical collars, cervical hoods, cock’s comb cervix, and pseudo polyps
DES
T/F DES exposure in utero are at increased risk of cervical insufficiency in pregnancy
T
T/F Clear cell adenocarcinoma of the cervix and vagina is common in women exposed to DES in utero
F, occurs in only 0.1%
Caused by intermittent blockage of an endocervical gland
Nabothian cyst
T/F Nabothian cyst expand to no more than 1 cm in diameter
T
T/F Nabothian cysts are more commonly found in postmenopausal women
F, menstruating
T/F Nabothian cysts are usually symptomatic
F, asymptomatic
T/F Nabothian cysts require no treatment
T
Remnants of the mesonephric ducts of the Wolffian system found in the cervix
Mesonephric cysts
Nabothian vs mesonephric cysts: Lie deeper in the cervical stroma and on the external surface of the cervix
Mesonephric cysts
Red or purple lesion on the cervix associated with cyclic pelvic pain and dyspareunia
Endometriosis
T/F Cervical polyps are often asymptomatic
T
Cervical polyps: Most common symptom
Intermenstrual or postcoital spotting
T/F Cervical polyps are not usually considered a premalignant condition
T
Cervical polyps: Management
Removed to decrease the likelihood of masking irregular bleeding from another source
Leiomyomas are aka
Myomas or fibroids
T/F Leiomyomas may arise in the cervix
T
Leiomyoma of cervix: T/F Can cause intermenstrual bleeding
T
T/F When evaluating an asymptomatic cervical fibroid, the possibility of cervical cancer should be ruled out
T
Management for symptomatic fibroid
Hysterectomy > myomectomy
T/F Cervical stenosis is typically asymptomatic
T
Cervical stenosis: Management
Cervical dilatation and catheter insertion to maintain patency
Lower vagina is derived from
Urogenital sinus
All reproductive structures arise from the müllerian system except
1) Ovaries (genital ridge)
2) Lower 1/3 of vagina (urogenital diaphragm)
Mullerian ducts are aka
Paramesonephric ducts
Most common congenital mullerian/uterine anomaly not related to drugs
Septate uterus
Septate uterus is brought about by
Malfusion of paramesonephric ducts
All reproductive structures arise from the müllerian system except
1) Ovaries (genital ridge)
2) Lower 1/3 of vagina (urogenital diaphragm)
Why septate uterus is related to recurrent ___trimester pregnancy loss
First
Why septate uterus is related to recurrent first-trimester pregnancy loss
Septa lack adequate blood supply
Pregnancy complications associated with bicornuate and unicornuate uteri
1) 2nd trimester pregnancy loss
2) Malpresentation
3) Preterm labor and delivery
Why bicornuate and unicornuate uteri are related to pregnancy complications
Limited size of uterine horn
Congenital anomaly associated with increased incidence of renal anomalies
Mullerian anomaly
Most infrequent Mullerian anomaly
Uterus didelphys with septate vagina
T/F Most uterine myomas cause no major symptoms and require no treatment
T
T/F Most uterine myomas cause no major symptoms and require no treatment
T
T/F Fibroids are also hormonally responsive to both estrogen and progesterone
T
Leiomyomas of uterus: Most common type
Intramural
Leiomyomas of uterus: Most commonly associated with heavy or prolonged bleeding
Submucosal
A pedunculated fibroid that becomes attached to the pelvic viscera or omentum and develops its own blood supply
Parasitic leiomyoma
T/F Pseudocapsule of leiomyoma has abundant blood vessels and lymphatics
F
T/F Pseudocapsule of leiomyoma has abundant blood vessels and lymphatics
F
T/F Leiomyomas enlarge, they can outgrow their blood supply, infarct, and degenerate, causing pain
T
T/F Leiomyosarcomas arise from leiomyomas
F
Risk factors for uterine leiomyoma
1) Non-smoker
2) Early menarche
3) Nulliparity
4) Perimenopause
5) Increased alcohol use
6) Htn
T/F The use of hormone replacement in postmenopausal women with fibroids is as- sociated with fibroid growth but typically does not result in clinical symptoms
T
T/F The risk of fibroids decreases with oral contraception use
T
Uterine leiomyoma: Most common symptom
AUB, heavy or prolonged bleeding
Uterine leiomyoma: Most common symptom
AUB
Increasingly heavy periods of longer duration
Menorrhagia
Bleeding between periods
Metrorrhagia
Heavy irregular bleeding
Menometrorrhagia
Uterine leiomyoma: Type that most commonly presents with pelvic pain
Subserosal pedunculated fibroid (due to vascular compromise)
T/F Leiomyomas enlarge, they can outgrow their blood supply, infarct, and degenerate, causing pain
T
T/F Leiomyosarcomas arise from leiomyomas
F
Fibroid characteristics that may contribute to increased rates of pregnancy complications
1) Multiple
2) Large, 5-10 cm
3) Located behind the placenta
T/F The use of hormone replacement in postmenopausal women with fibroids is as- sociated with fibroid growth but typically does not result in clinical symptoms
T
T/F The risk of fibroids decreases with oral contraception use
T
T/F The risk of fibroids decreases with injectable depot medroxyproges- terone acetate use
T
Uterine leiomyoma: Most common symptom
AUB
Increasingly heavy periods of longer duration
Menorrhagia
Bleeding between periods
Metrorrhagia
Uterine leiomyoma: Treatment that may be given prior to surgical treatment of uterine fibroids to shrink fibroid size, stop bleeding, and increase the hematocrit
GnRH agonists
Less invasive surgical approach for treating symptomatic fibroids that are large and pedunculated
Uterine artery embolization
Blood vessel catheterised to reach the uterine artery in uterine artery embolization
Femoral artery
Uterine leiomyoma: Type unlikely to affect conception or pregnancy loss
1) Subserous
2) Intramural
T/F Majority of women with fibroids are able to conceive without any difficulties
T
Fibroid characteristics that may contribute to increased rates of pregnancy complications
1) Multiple
2) Large, 5-10 cm
3) Located behind the placenta
Indications for Surgical Intervention for Uterine Leiomyomas
1) Abnormal uterine bleeding, causing anemia
2) Severe pelvic pain or secondary amenorrhea
3) Uterine size > 12 wk obscuring evaluation of adnexa
4) Urinary frequency, retention, or hydronephrosis
5) Growth after menopause
6) Recurrent miscarriage or infertility
7) Rapid increase in size
Uterine leiomyoma: Most common means of diagnosis
Pelvic ultrasound
Hysterectomy for leiomyoma: Age for which ovaries should be preserved
Younger than 45 years with normal- appearing ovaries
Diagnostic modality especially helpful in distinguishing fibroids from adenomyosis as well as for surgical planning
MRI
Actively growing fibroids should be monitored every
6 months
Uterine leiomyoma: Treatment associated with shrinkage of fibroids, decrease in bleeding, and increase in hct by decreasing circulating estrogen levels
GnRH agonists
Uterine leiomyoma: Treatment that may be given prior to surgical treatment of uterine fibroids to shrink fibroid size, stop bleeding, and increase the hematocrit
GnRH agonists
Less invasive surgical approach for treating symptomatic fibroids
Uterine artery embolization
Blood vessel catheterised to reach the uterine artery in uterine artery embolization
Femoral artery
T/F UAE should not be used in women who are planning to become pregnant after the procedure
T
New option for management of uterine fibroids typically reserved for premenopausal women who have completed childbearing and wish to retain their uterus
MRI-guided high-intensity ultrasound
Uterine leiomyoma: Primary disadvantage of myomectomy
1) Recurrence in more than 60% of patients in 5 years
2) Adhesions
Endometrial hyperplasia: Brought about by
Unopposed endogenous or exogenous estrogen
Definitive treatment for leiomyoma
Hysterectomy
Hysterectomy for leiomyoma: Age for which ovaries should be preserved
Younger than 45 years with normal- appearing ovaries
T/F Endometrial hyperplasia is the abnormal proliferation of only the glandular elements of the endometrium
F, glandular and stromal
Localized benign overgrowths of endo- metrial glands and stroma over a vascular core
Endometrial polyps
Endometrial polyps: Most common age group
40-50
Endometrial polyps: Risk factor/s
Tamoxifen
Endometrial polyps: Most common presentation
Abnormal vaginal bleeding
Endometrial polyps: Accounts for ___% of all causes of postmenopausal bleeding
25
Classification of endometrial hyperplasia: Carries a higher risk of progression to endometrial cancer and may have coexistent endometrial cancer
Atypical hyperplasia
Women 45 or older with abnormal bleeding from en- dometrial polyps should be evaluated with ___ prior to removal
Endometrial biopsy
Endometrial polyps: Can be malignant or premalignant
T
Endometrial hyperplasia: Brought about by
Unopposed estrogen
Most common exogenous source of estrogen
HRT w/o progesterone
Source of increased oestrogen in obese women
Peripheral conversion of androgens (androstenedione and testosterone) to estrogens (estrone and estradiol) by AROMATASE
Property of tamoxifen that increases the risk of endometrial hyperplasia
Weak estrogenic agonist activity
Endometrial hyperplasia: Only architectural changes are present
Simple or complex
Endometrial hyperplasia: When cytologic atypic is present
Atypical simple or atypical complex
Architectural changes vs cytologic atypia: Changes in complexity and crowding of the glandular components of the endometrium
Architectural changes
Architectural changes vs cytologic atypia: Changes in the cellular structure of the endometrial cells
Cytologic atypia
T/F Tissue diagnosis is required for the diagnosis of endometrial hyperplasia
T
Classification of endometrial hyperplasia: Carries a higher risk of progression to endometrial cancer and may have coexistent endometrial cancer
Atypical hyperplasia
Classification of endometrial hyperplasia: Abnormal proliferation of both the stromal and glandular endometrial elements
Simple hyperplasia
Classification of endometrial hyperplasia: Abnormal proliferation of the glandular endometrial elements without prolifera- tion of the stromal elements
Complex hyperplasia
Classification of endometrial hyperplasia: Cellular atypia and mitotic figures in addition to glandular crowding and complexity
Atypical hyperplasia
Classification of endometrial hyperplasia: Glands are crowded in a back-to-back fashion and are of varying shapes and sizes, but no cytologic atypia is present
Complex hyperplasia
Duration of progestin treatment for endometrial hyperplasia
3-6 months, then repeat EMB
Endometrial hyperplasia: Management after treatment to prevent recurrence
Regular cyclic or continuous progestin
Independent risk factors for endometrial hyperplasia
1) Htn
2) DM
Syndrome related to a 10-fold increased lifetime risk for endometrial hyperplasia and cancer
Lynch II syndrome (HNPCC)
Typical presentation of endometrial hyperplasia
Long periods of oligomenorrhea or amenorrhea followed by irregular or excessive uterine bleeding
Stigmata associated with chronic anovulation
1) Obesity
2) Acanthosis
3) Acne
4) Hirsutism
Duration of progestin treatment for endometrial hyperplasia that is predictive of failure
9 months
Method of choice for evaluation of abnormal uterine bleeding including that from endometrial hyperplasia
Endometrial biopsy
Indications for D&C in ruling out endometrial hyperplasia and cancer
1) Insufficient tissue
2) Patient discomfort
3) Cervical stenosis
4) Atypical complex hyperplasia on biopsy (coexistent endometrial Ca
Endometrial hyperplasia: Goal of treatment
1) Prevent progression of disease
2) Control abnormal bleeding
Treatment for simple and complex hyperplasia without atypia
Progestin
Progestin MOA for endometrial hyperplasia
Activation of progestin receptors, resulting in stromal decidualization and thinning of endometrium
Follicular cysts: Size that can lead to pelvic pain, ovarian torsion, and dyspareunia
> 4cm
Treatment of choice for women with endometrial hyperplasia with atypia who do not desire future fertility
Hysterectomy
Population of women most commonly with atypical complex hyperplasia
1) Perimenopausal
2) Postmenopausal
Management recommended for younger patients with atypical complex hyperplasia and chronic anovulation who wish to preserve fertility or if the patient is a poor surgical candidate
1) Longer-term progestin
2) Weight loss
When to repeat EMB after longer-term progestin and weight loss
3 months
Duration of progestin treatment for endometrial hyperplasia that is predictive of failure
9 months
T/F Functional cysts of the ovaries result from normal physiologic functioning of the ovaries
T
Cysts that can cause a amenorrhea or delay in menstruation and dull lower quadrant pain
Corpus luteum cysts
Condition: Acute pain and signs of hemoperitoneum late in the luteal phase
1) Ruptured corpus luteum cyst
2) Ovarian torsion
3) Hemorrhagic corpus luteum cyst
Follicular cysts: T/F Classically asymptomatic
T
Follicular cysts: T/F Usually bilateral
F, unilateral
Theca lutein cysts: Result from
Stimulation by abnormally high ß-human chorionic gonadotropin
Follicular cysts: T/F Most resolve spontaneously
T
Follicular cysts: Expected duration of resolution
60-90 days
Normal size of an ovarian follicle (physiologic cyst)
Less than 2.5 cm
2 types of functional ovarian cysts
1) Follicular cysts
2) Corpus luteum cysts
Increases the risk for functional cysts twofold
Smoking
Corpus luteum cysts: Arise from
Failure of corpus luteum to regress after 14 days and becomes enlarged to > 3cm or hemorrhagic
Cysts that can cause a delay in menstruation and dull lower quadrant pain
Corpus luteum cysts
Condition: Acute pain and signs of hemoperitoneum late in the luteal phase
Ruptured corpus luteum cyst
Large cysts filled with clear, straw-colored fluid
Theca lutein cysts
Theca lutein cysts: T/F Usually bilateral
T
Theca lutein cysts: Result from
Stimulation by abnormally high ß-human chorionic gonadotropin
Sources of high ß-human chorionic gonadotropin
1) Molar pregnancy
2) Choriocarcinoma
3) Ovulation induction therapy
Growth of ectopic endo- metrial tissue within the ovary
Endometerioma
Nonfunctional neoplasm vs functional cysts: Most common ovarian masses in women of reproductive age
Functional cysts
Functional ovarian cysts can be found most commonly in what age group
Between puberty and menopause
Increases the risk for functional cysts twofold
Smoking
Management of a cystic adnexal mass: Reproductive age, simple cyst more than 7 cm
Further imaging or surgical evaluation
Functional ovarian cysts: Generally larger (greater than 8 cm)
Lutein cysts
Functional ovarian cysts: T/F A ruptured cyst can cause pain on palpation, acute abdominal pain, and rebound tenderness
T
Classic presentation of ovarian torsion
1) Waxing and waning pain
2) Nausea and vomiting
Functional ovarian cysts: Tend to be simple or unilocular
Follicular
Primary diagnostic tool for the workup of ovarian cyst
Pelvic ultrasound
Diagnostic tool used to check for cyst resolution
Serial ultrasounds
CA-125: Screening/diagnosis vs response to treatment
Response to treatment
Management of a cystic adnexal mass: Premenarchal, more than 2 cm
Surgical evaluation
Management of a cystic adnexal mass: Reproductive age, simple cyst less than or equal to 5 cm
No follow-up necessary
Management of a cystic adnexal mass: Reproductive age, simple cyst more than 5 cm but less than 7 cm
Repeat ultrasound after 1 year
Management of a cystic adnexal mass: Reproductive age, simple cyst more than 7 cm
Further imaging or surgical evaluation
Management of a cystic adnexal mass: Reproductive age, hemorrhagic less than or equal to 5 cm
No follow up necessary
Management of a cystic adnexal mass: Reproductive age, hemorrhagic more than 5 cm
Repeat ultrasound in 6-12 weeks
Management of a cystic adnexal mass: Reproductive age, endometrioma
Repeat ultrasound in 6-12 weeks; surgically remove or follow yearly
Management for cysts that do not resolve within 60-90 days
Cystectomy or oophorectomy
Medical treatment options to shrink leiomyoma
1) Provera
2) Danazol
3) GnRH analogs
Management of a cystic adnexal mass: Postmenopausal, simple more than 1 but less than or equal to 7 cm
Repeat ultrasound in 1 year
Management of a cystic adnexal mass: Postmenopausal, more than 7 cm
Further imaging or surgical evaluation
Management of a cystic adnexal mass: Early postmenopausal, hemorrhagic
Repeat ultrasound in 6-12 weeks
Management of a cystic adnexal mass: Late menopause, hemorrhagic
Surgical evaluation
Management of a cystic adnexal mass: Postmenopausal, nodule without flow or multiple thin septations
Surgical evaluation or MRI
A palpable ovary or adnexal mass in a premenarchal or post- menopausal patient is suggestive of
Ovarian neoplasm > functional cyst
Reproductive-age women with cysts larger than 7 cm or that persist or that are solid or complex on ultrasound are suggestive of
Ovarian neoplasm > functional cyst
May be given to patients with follicular cysts during the 60-90-day observation period
OCPs
MOA of OCPs during the 60-90-day observation period for follicular cysts
Suppress ovulation to prevent formation of future cysts
Management for cysts that do not resolve within 60-90 days
Cystectomy or oophorectomy
Medical treatment options to shrink leiomyoma
1) Provera
2) Danazol
3) GnRH analogs
