Menstrual and Endocrine Disorders Flashcards
in what phase does PMS occur? how many days prior to menses? when does it resolve?
the luteal phase
a cyclic occurence; 5-7 days before menses and resolves within about 4 days after onset of menses
symptoms of PMS
-can range from mild to severe; occur cyclically in the luteal phase with a symptom-free period in the follicular phase
a. physical
-headache
-breast changes
-fluid retention
-swelling
-abdominal bloating
-N/V
-alterations in appetite
-food cravings
-lethargy/fatigue
-exacerbations of preexisting conditions, like asthma
symptoms of PMS
b. psychological
-irritability
-depression
-anxiety
-sleep alterations
-inability to concentrate
-anger
-violent behavior
-crying
-confusion
-changes in libido
DIFFERENTIAL DIAGNOSES for PMS
(many-13)
- a diagnosis of exclusion
- depression and or anxiety
- bipolar affect disorder
- alcohol or substance abuse
- personality disorder
- chronic fatigue syndrome
- fibromyalgia
- diabetes
- brain tumor
- thyroid disease
- hyperprolactinemia
- perimenopause
- premenstrual dysphoric disorder (PMDD)
what steps should you recommend to patients with suspected PMS?
write symptoms in diary fashion for 2 to 3 months to evaluate for symptom consistency with ovulation and menses
PMS management
1. nonmedical (first line therapy)
-self-help strategies first-line, but no quick cures
-Vitamin B continuous
-calcium carbonate supplementation of 1200-1600 mg/day
-chaste tree berry extract shown in placebo-controlled trial to reduce PMS symptoms
T/F restriction of salt and refined sugar or limiting caffeine have show to be helpful with PMS
FALSE
little evidence exists
T/F aerobic exercise 20 to 30 minutes at least four times a week can help PMS symptoms
TRUE
what can be prescribed to reduce swelling and bloating r/t PMS?
Spironolactone
T/F NSAIDs given before and during menstruation may reduce fluid retention, breast, lower back, abdominal, pelvic pain
true
other medical management of PMS suggestions
-COCs or POPs may decrease physical symptoms by suppressing ovulation and reducing menstrual bleeding and pain
-SSRIs alleviate severe PMS
-Danazol may improve PMS symptoms by suppressing ovulation; SIGNIFICANT androgen-related side effect
primary vs secondary dysmenorrhea definition and etiology
primary: dysmenorrhea unassociated with pelvic pathology; rarely begins AFTER age 20; associated with ovulatory cycles; from prostaglandins stimulating contractile response on smooth muscles
secondary: underlying pelvic pathologic condition thought to be the cause; may occur at any age
how do primary and secondary dysmenorrhea differ in their presenation
primary is often shortly before and early on in the menses; lasts no more than 2 days and is crampy spasmodic pain in lower abs, radiates to lower back and thighs
secondary is at any time in the cycle, unlikely to be relieved by OTC measures and symptoms persist longer than with primary
differential diagnoses for dysmenorrhea
-imperforate hymen
-endometriosis
-cervical stenosis
-uterine abnormalities
-pelvic infection
-ovarian cycts
-pelvic congestion
-adhesions
-infibulation
-STIs
-UTI
-vaginismus
-interstitial cystitis
what is infibulation
type of female genital cutting that includes narrowing of the vaginal orifice
management of primary and secondary dysmenorrhea
primary: NSAIDs are TOC and best begun 2 days prior to expected menses or at onset of menses and continuing for 48-72 hours
CHCs are good too; act by reducing prostaglandins and menstrual flow
progestin only may relieve symptoms by decreasing or eliminating menstrual bleeding (DMPA, nexplanon)
self help measures: regular exercise, warm heat, relaxation exercises
secondary: tx consistent with pathology found on u/s
primary vs secondary amenorrhea
- Primary: no menstruation by the age of 14 years in absence of secondary sex characteristics; no menstruation by age 16 years regardless of secondary sex characteristics
- secondary: absence of menses in previously menstruating women; no menses 3-6 months in women who has normal periods/3 cycles
Possible causes of amenorrhea
-pregnancy
-disorders of genital outflow tract
-endocrine disorders (hyper/hypothyroidism, hyperprolactinemia, hyperandrogenism, PCOS, ovarian failure)
-congenital and chromosomal abnormalities
-anorexia nervosa
-excessive exercise
-obesity
-malnutrition
-MEDICATIONS (birth control, antipsychotics, chemo)
-chronic illness (T1DM, TB)
-chronic or excessive stress
if a patient presents to you with absent menses and abnormal visual fields you should suspect and/or rule out a…
PITUITARY TUMOR
(think about HPO axis!!)
differential diagnoses for amenorrhea
- pregnancy
- menopause
- anorexia nervosa
- intensive physical training
- disorders of ovary, anterior pituitary, hypothalamus
- congenital or acquired anatomic disorders
- chronic illness
- medication effects
Amenorrhea workup
- pregnancy test
- serum prolactin levels
- TSH
if initial labs for amenorrhea workup are normal, may evaluate availability of estrogen with..
a progestin challenge test!!!
Progestin challenge test explained
a. progestin each day for 10 to 14 days- wait for bleeding, which should occur within 7 to 14 days; will indicate adequate estrogen production and stimulation as well as no problem with outflow tract
b. if no withdrawal bleed in 2 weeks, order FSH/LH
c. if FSH and LH are low, the case is likely hypothalamic or pituitary dysfunction
d. if FSH and LH are high, the cause is likely ovarian failure or menopause
management of primary amnorrhea
REFER TO ENDOCRINOLOGIST
if prolactin and TSH are normal and bleeding occurs after progestin challenge, initiate…
treatment for annovulation based on age, contraceptive needs, and lifestyle
CHCs or cyclic progestins may help too
infrequent menstrual bleeding definition and workup
infrequent uterine bleeding characterized by one or two bleeding episodes in a 90 day period; common in perimenopause
workup: pregnancy test, tests to evaluate thyroid, ovaries, pituitary, or hypothalamus `
heavy or prolonged menstrual bleeding definition (HMB or PMB)
HMB is characterized by monthly blood loss volume >80 mL; prolonged menstrual bleeding (PMB) is characterized by bleeding episodes lasting > 8 days; (previously known as menorrhagia)
etiology of HMP or PMB
- often occurs at extremes of reproductive ages- adolescence and perimenopause
- gynecologic causes: leiomyoma, adenomyosis, endometrial and endocervical polyps, endometrial hyperplasia, cervical cancers
- inherited and acquired bleeding disorders- von Willebrand disease, anemia
- disturbances of hypothalamic-pituitary-ovarian axis
- imbalance of prostaglandins favoring those that cause vasodilation
- systemic diseases
- medications
- other- physical trauma, extreme stress, obesity
- PALM COEIN
PALM- structural causes of AUB
P: Polyp! endometrial and endocervical; may cause intermenstural bleeding
A: Adenomyosis: may cause HMP and or PMB
L: Leiomyomas (fibroids): may cause HMP or PMB
M: Malignancy/hyperplasia: AUB is most common symptom of endometrial cancer, bleeding patterns are variable
Adenomyosis is…
when endometrial tissue grows inside muscular wall of uterus; displaced tissue continue to respond to hormones: thickening, breaking down, bleeding
COEIN- non structural causes of AUB
C: Coagulopathy!
O: Ovulatory dysfunction: PCOS, androgen excess, thyroid disorders, may have irregular menses, HMP, or PMB
E: Endometrial! likely due to vasoconstriction disorders, inflammation, infection, HMP associated with predictable ovulatory cycles
I: Iatrogenic! medication-related
N: not yet classified, for those poorly understood conditions and rare disorders
differential diagnosis of AUB
- pregnancy (ectopic or intrauterine)
- gynecologic disorders
- HPO disturbance
- bleeding disorder
- systemic diseases
- medication related
AUB workup includes
- pregnancy test
- pap test for cervical cancer if no recent normal test
- CBC
- FSH and LH to evaluate estrogen stimulation (RARELY indicated)
- TSH
- STI testing as indicated
- endometrial evaluation
- coagulation study if indicated
with AUB who is endometrial evaluation reserved for?
patients over 40: biopsy, TVUS
management/treatment of AUB
1. hormonal management
a. acute excessive bleeding
b. moderate bleeding, not currently bleeding, maintenance control
a. acute excessive bleeding: parenteral estrogen or high dose oral estrogen gradually tapered, then MPA added last 10 days to initiate withdrawal bleeding; high dose oral progestin therapy, gradually tapered
b. moderate bleeding, not currently bleeding, maintenance control: LNG-IUS is FDA approved for treatment of HMB; CHCs cyclic, extended or continuous regimens; DMPA; cyclic MPA
management/treatment of AUB
2. non hormonal
a. treat anemia
b. NSAIDS- start at onset of menses and continue for 5 days or until cessation of menstruation; increases ratio of vasoconstrictive prostaglandins to vasodilating prostaglandins
c. TXA (lysteda): antifibrinolytic agent that blocks lysis of fibrin clots; take up to the first 5 days of menses; decreases blood loss in women who have increased endometrial plasminogen activity
side effects of tranexamic acid
nausea, leg cramps, CI in women with history or at risk for thrombosis
surgical management of AUB to which you would refer include (3)
- endometrial ablation
- dilation and curettage is diagnostic and therapeutic
- hysterectomy
PCOS definition and etiology
-symptom complex associated with menstrual irregulariyt due to oligo-ovulaiton or annovulation and clinical or biochemical signs of hyperandrogegism with 25% having polycystic ovaries on u/s
-etiology not well understood; mix of genetic, endocrine, and metabolic factors
endocrine and metabolic factors seen in patients with PCOS
-endocrine: increased LH:FSH ratio, increased androgen concentrations, decreased SHBG with resultant increase in free testosterone
-metabolic factors: hyperinsulinemia associated with increased insulin resistance which can have significant impact on promoting or disrupting follicles
T/F women with PCOS are at increased risk for future development of endometrial cancer, diabetes mellitus, and heart disease
true!
symptoms of PCOS
-irregular menses (amenorrhea or infrequent menstrual bleeding)
-gradual onset of hirsutism around puberty or in early 20s
-other signs of androgen excess (acne, deep voice, male pattern baldness)
-infertility
physical findings of PCOS
-mostly normal physical findings
-ovaries no always palpable
-virilization: hirsutism, increased muscle mass, frontal balding, enlargement of clitoris, deepening of voice, decreased breast size
-abdominal obesity
-acne
-acanthosis nigricans (skin around neck darkened)
differential diagnoses for PCOS
- obesity
- hyperprolactinemia
- thyroid dysfunction
- Cushing’s disease
- adrenal or ovarian tumor
workup of patient with suspected PCOS (lots)
-TSH
-prolactin
-pregnancy test
-determinants of biochemical hyperandrogegism: serum total testosterone and SHBG/free testosterone (debatable if this is necessary)
-serum 17-OHP (greater than 800 dL with PCOS)
-endometrial biopsy to rule out hyperplasia if indicated
-assess ovaries with u/s
-glucose and lipid levels
Rotterdam criteria for diagnosis of PCOS includes (3)
at least two of three of the following in an adult female; all three present in adolescent female to include biochemical confirmation of hyperandrogenism:
1. oligo-ovulation/annovulation
2. clinical/biochemical hyperandrogenism
3. polycystic ovaries
management/treatment of PCOS
-overall goal?
to lower androgen levels, treat current clinical manifestations
if pregnancy is desired in PCOS patient, first line treatment is…
Letrozole
and if Letrozole is ineffective, refer to reproductive endocrinologist
if pregnancy is NOT desired in the PCOS patient and they want contraception….
*direct therapy toward preventing endometrial hyperplasia and pregnancy
a. low dose COC with low androgenicity- inhibits LH secretion and LH-dependent ovarian androgen production, increases SHBG binding of free T, regulates menstrual cycles, protects form endometrial cancer
b. progestin contraceptives- protect from endometrial cancer
if PCOS patient does not desire and is not at risk for pregnancy and does not want to use hormonal contraception, focus on…
*preventing endometrial hyperplasia (same goal)
a. endometrial biopsy may be indicated
b. MPA for 10 days of month induces withdrawal bleeding- can be used every month or every 2-3 months
what should we monitor for in the PCOS patient?
diabetes and hyperlipidemia (glucose test, lipid panel)
Endometriosis definition
presence of endometrial stroma and glands outside uterus
etiology not clearly understood (genetics, hormonal, retrograde menstruation)
typical endometriosis patient is usually…
20 to 30 years old, caucasian, nulliparous
but occurs in all races, majority has + family history
symptoms (wide range of clinical symptoms; severity does not correlate with extent of disease)
Most common:
-dysmenorrhea
-infertility
-premenstrual spotting
-menorrhagia
-pelvic pain
-dyspareunia
symptoms less often seen
-low back pain
-diarrhea
-dysuria
-hematuria
-difficult or painful defecation
-rectal bleeding
symptoms classically occur before or during menses
physical findings of endometriosis
-uterus postion
-adnexal
-uterosacral ligaments
-fixed, retroverted uterus
-bilateral, fixed, tender ovaries
-nodularity and tenderness of uterosacral ligaments and cul-de-sac
-lesions may be visible on laparoscopy
-CMT associated with menses
differential diagnoses for endometriosis
-chronic pelvic inflammatory infection
-acue salpingitis
-adenomyosis
-ectopic pregnancy
-benign or malignant ovarian neoplasma
diagnostic tests/findings for endometriosis
1: DIAGNOSTIC LAP reveals classic implants
2. u/s shows no specific pattern but can help distinguish adnexal abnormalities, solid vs cystic lesions
DO NOT: use CT or MRI, they only provide presumptive evidence
T/F CA-125 levels correlate with degree of disease and response to therapy in endometriosis
TRUE- BUT cannot be used for diagnosis
management/treatment of endometriosis
-no medical management provides universal cure; goal is to relieve pain, restore fertility, prevent progression
Medical
a. NSAIDs are first choice for analgesics
b. GnRH agonists and danazol induce regression of endometrial implants
c. progestins- subq 104 DMPA is FDA approved treatment; IM also effective
d. continuous use of COC pills produces atrophy of implants and acyclic hormone environment
e. hysterectomy with bilateral salpingoophorectomy is CURATIVE
T/F delayed childbirth may lead to development of endometriosis
TRUE
adenomyosis is most commonly diagnosed in what patient?
parous women between 40 to 50 years old
Adenomyosis definition and etioloty
benign condition in which ectopic endometrium is found within the myometrium
may be related to breakdown of endometrium during labor and delivery
symptoms of adenomyosis (2)
- increasingly severe dysmenorrhea and heavy bleeding during menses are common
- infertility
physical findings of adenomyosis (3)
- boggy, tender uterus
- diffuse, globular enlargements- may be 8-10 weeks gestation in size
- may see evidence of anemia
management of adenomyosis includes…
symptomatic relief!
hysterectomy may be indicated and is curative
NSAIDs for pain relief, hormone suppression
hyperprolactinemia, galactorrhea, and pituitary adenoma definitions
hyperprolactinemia: elevated levels of prolactin
galactorrhea: secretion of a non-physiologic, milky fluid from the breast, unrelated to pregnancy
pituitary adenoma:benign tumor of pituitary; most common type secretes prolactin
T/F most pituitary adenomas occur in women younger than 40 years old
true!
if a woman comes to you with complaints of amenorrhea and milky discharge from her breast, you must first rule out
a pituitary adenoma!!
one third of women with secondary amenorrhea have pituitary adenoma and one third of women with high levels of prolactin have galactorrhea
when should galactorrhea be elevated?
in a nulliparous women or in a non-breastfeeding parous women if 12 months has passed since last pregnancy
s/sx of hyperprolactinemia, galactorrhea, pituitary adenoma
-bilateral or unilateral breast secretions from ducts
-normal or irregular menses; secondary amenorrhea
-disturbances of vision and headaches may be present (if adenoma is cause)
s/sx of pituitary adenoma specifically
- breast secretions
- menstrual changes/secondary amenorrhea
- severe vascular headaches and blurred vision
diagnostic tests/work up for suspected hyperprolactinemia or pituitary adenoma
- TSH
- serum prolactin
- pregnancy test
- microscopy of breast secretions (milk indicated by fat globules)
- CT or MRI to r/o adenoma
what level of prolactin warrants referral to reproductive endocrinologist
> 20 ng/mL; if in 100-300 range adenoma highly suspicious
if prolactin is less than 20 and patient is having menses, ok to…
follow up with yearly prolactin levels
treatment of choice with hyperprolactinemia
dopamine agonist (bromocriptine- inhibits prolactin) is treatment of choice and has highest cure rate
Benign and Malignant Tumors/Neoplasms
to be continued…
Cervical polyps definition and etiology
pedunculated growths arising from the mucosal surface of the endocervix
etiology: inflammation, trauma, pregnancy, etc,
T/F cervical polyps are the most common benign neoplasm of the cervix
true!
most often seen in perimenopausal and multigravida women between 30-50 years old
symptoms of cervical polyps (3)
-asymptomatic
-leukorrhea
-abnormal vaginal bleeding (intermenstrual, postcoital)
diagnostic tests/findings for cervical polyps
- pap test to rule out premalignant cervical lesions or cancer
- histologic evaluation of removed polyp to rule out cancer
management/treatment of polyps
-removal or polyp is usually curative
-recur frequently
T/F its ok to remove cervical polyp in pregnancy
FALSE
do NOT touch!
Leiomyomata Uteri (Fibroid, myoma)
nodular, discrete tumors that are classified according to location:
-submucosal: protrudes into the uterine cavity
-subserosal: bulge through the outer uterine wall
-intraligamentous: within the broad ligament
-interstitial: stays within the uterine wall as it grows (most common)
-pedunculated: on a thin pedicle or stalk attached to the uterus
T/F fibroids occur more often in African American women than caucasian women
true!
increased incidence with family history
fibroid symptoms
-usually asymptomatic
-heavy or prolonged menstrual bleeding
-pelvic pain presents as dysmenorrhea, pelvic pressure, or dyspareunia
-large fibroids may cause constipation
fibroid physical findings
- abdominal enlargement
- enlarged, irregularly shaped, firm uterus
- tumors usually painless on palpation
- potential complications: spontaneous abortion, PML, anemia, infertility
diagnostic workup for suspected fibroid
-pap test
-pregnancy test
-CBC if anemia suspected
-occult blood test if rectal or colon symptoms
-EMB or D AND C when abnormal bleeding present
-u/s to confirm diagnosis
management/treatment of fibroids
-asymptomatic
-pharm (4)
-asymptomatic may require no treatment; periodic observation and follow up (in stable fibroids, follow up is usually 3-4 months)
PHARM
a. GnRH agonists results in 40-60% reduction in volume, may use to shrink size preoperatively (Lupron)
b. progestational agents such as MPA may decrease fibroid size and bleeding
c. progestin-containing intrauterine devices (IUDS) with 52 mg of levonorgestrel may reduce heavy bleeding and decrease dysmenorrhea but will NOT decrease fibroid size; NOT rec for submucosal fibroids
d. CHCs may help with heavy bleeding but will not decrease fibroid size
surgical interventions for fibroids
-when is surgery indicated? (5)
indicated if:
-abnormal bleeding
-rapid growth
-definitive diagnosis concerning mass if otherwise uncertain
-encroachment of organs
-symptoms not managed with pharm therapies
b. myomectomy
c. uterine artery embolization (fertility may not be preserved)
d. hysterectomy
Myfembree, a GnRH antagonist has also been used to treat…
heavy menstrual bleeding and endometriosis
Ovarian cysts
-functional vs dermoid
- functional: cysts that are secondary to hormonal stimulation
-follicular: occur in follicular phase, when continued hormonal stimulation prevents fluid resorption
-corpus luteum: occur in the luteal phase, when corpus luteum fails to degenerate - dermoid (benign cystic teratoma): most common ovarian germ cell tumor
in what number of cycles do most follicular cysts resolve?
in 2-3 menstrual cycles
corpus luteum cysts form following..
the failure of the corpus luteum to degenerate after 14 day
functional cysts symptoms
-usually asymptomatic
-may cause irregular menses
-acute pain if cyst ruptures or it torsion occurs
-large cysts may cause pelvic pressure, dull ache on affected side that may radiate to the lower back
dermoid (benign cystic teratom) symptoms
-usually asymptomatic
-may cause acute pain if twists or ruptures; may experience peritonitis
-may cause vague feelings of local pelvic pressure if large
signs of ruptured cyst include
severe, sudden abdominal pain; mimics ruptured ectopic
physical findings
-functional vs dermoid cyst size
functional cysts: usually less than 5 cm, cystic to firm, mobile, usually unilateral
dermoid: 5-10 cm, usually unilateral, firm to cystic, often anterior to uterus
differential diagnoses of suspected ovarian cysts
-pregnancy, ectopic pregnancy
-ovarian torsion
-uterine fibroid; endometrioma
-tubo-ovarian abscess
-diverticulitis
-distended bladded
diagnostic tests/findings for ovarian cysts
- pregnancy test
- TVUS
- ca-125 (ONLY in postmenopausal women)
management of a functional cyst less than 10 cm in diameter in a reproductive age women consists of…
examine after next menses and or serial u/s every 4 to 12 weeks (i think we do 2-3 month follow up)
when should we refer for ovarian mass?
when its greater than 10 cm, u/s findings of solid tumor or complex cyst
postmenopausal management
-when less than 10 cm
-Refer when…
- if less than 10 cm, u/s shows simple cyst, no concerning symptoms, or risk factors for ovarian cancer and CA-125 < 35, perform serial u/s every 4 to 12 weeks
- refer if
> 10 cm
u/s findings show solid or complex cyst
concerning symptoms or risk factors
persists greater than 12 weeks
Ca 125 > 35
gynecologic cancers include…
- cervical carcinoma
- endometrial carcinoma
- ovarian carcinoma
- vaginal carcinoma
- vulvar carcinoma
abnormal vaginal bleeding or discharge is a sign for which cancers?
-cervical
-ovarian
-uterine
-vaginal
risk factors for cervical cancer?
-smoking
-HPV types present
-first coitus at early age
-long term oral contraceptive use
-never had pap test or infrequent pap tests
symptoms of cervical cancer
-can be asymptomatic
-postcoital or irregular, painless bleeding
-odorous bloody or purulent discharge
differential diagnoses for cervical cancer/a cervix that is firm or rocklike/lesoin-filled
-metastasis from another primary site
-cervicitis/STi
-cervical polyp
what is considered the gold standard for diagnosing cervical cancer?
pap test!!!
but biopsy necessary if gross lesions are present
colposcopy if no lesion but malignancy is suspected
what is the most common gyn malignancy?
endometrial cancer
-median age is 63, rarely found in women younger than 40
HENCE why post menopausal bleeding always makes us think endometrial cancer until proven otherwise
risk factors for endometrial cancer
(big one includes…)
-length of time or amount of exposure to estrogen (especially unopposed) including:
1. early menarche; late menopause
2. unopposed estrogen therapy
3. obesity
4. oligo-ovulation, anovulation
5. estrogen-secreting tumors (granulosa cells)
others: family history of endometrial OR colorectal cancer
some protective factors against endometrial cancer
-DMPA
-multiparity
-use of oral contraceptive pills
symptoms of endometrial cancer
-painless vaginal bleeding is usually first symptom, followed by watery leukorrhea/odorous discharge that is soon replaced by bloody discharge
-lower abdominal pain
diagnosing endometrial cancer
-pap test may show glandular abnormalities
-EMB
-u/s to measure endometrial stripe
-fractional D&C gold standard for dgx
-hysteroscope may be useful for identifying lesions/polyps not found on biopsy
if the endometrial stripe is < ______, likelihood of endometrial cancer is rare
5 mm
what cancers have pelvic pain or pressure as a symptom?
-uterine (endometrial)
-ovarian
Ovarian carcinoma risk factors
-lifetime risk for general population
-family history in first degree relative
-inherited gene mutations
-others syndromes associated with ovarian cancer
-lifetime risk for general population: 1-2%
-family history in first degree relative: 5% (increases with number of affected 1st and 2nd degree relatives)
-inherited gene mutations: 20-25%; BRCA1 (39-46%) and BRCA 2 (12-20%) gene mutations most common.
-others: Lynch syndrome
other risk factors for ovarian cancer
-history of breast, colon, or endometrial cancer
-early menarche; late menopause
-nulliparity or birth of first child after age 30
-infertility
-endometriosis
-obesity
-postmenopausal estrogen therapy
what has been shown to reduce the risk of ovarian cancer?
breastfeeding and oral contraceptives
ovarian cancer symptoms
-early vs late
EARLY
-asymptomatic, abdominal discomfort, pressure on bladder or rectum, pelvic fullness or bloating, vague GI symptoms
LATE
-increasing abdominal girth, abdominal pain, abnormal vaginal bleeding, GI symptoms (nausea, loss of appetite, dyspepsia)
physical findings of ovarian cancer
-fixed, irregular, nontender adnexal mass- usually bilateral
-ascites
-pleural effusion and subclavicular lymphadenopathy
diagnostic tests/labs for ovarian cancer
- pelvic u/s or CT or MRI
- CA-125: elevated levels not diagnostic for ovarian cancers
what else can make CA-125 elevated
endometriosis, leiomyomata, pelvic inflammatory infection, hepatitis, other malignancies
patient counseling for ovarian cancer patients
-genetic counseling and testing if indicated
physical findings in vaginal cancer
-most common site
-dark lesion suspect…
-upper 1/3rd of vagina most common
-suspect melanoma if lesion is dark
vulvar carcinoma risk factors
-HPV infection with high risk types
-multiple sexual partners
-smoking
-chronic irritation
-vulvar dermatoses
symptoms of vulvar cancer
-most common sx?
-pruritus is most common
-pain, burning, bleeding
-lesion on vulvar
choriocarcinoma
-gestational trophoblastic disease
-symptoms
may follow any gestational event- ectopic or intrauterine pregnancy, abortion
SX: irregular vaginal bleeding, amenorrhea, hemoptysis, cough, dyspnea, evidence of CNS metastasis (HA, dizziness, fainting), GI (rectal bleeding/tarry stools)
**May imitate other diseases: strongly suspect if follows a pregnancy event
diagnostic tests for choriocarcinoma
-quantitative hCG
-abnormal beta hCG regressions titers following molar pregnancy
-CT scan of abdomen, pelvis, head
