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Womens Health > Ovarian & uterine disease > Flashcards

Ovarian & uterine disease Flashcards

1
Q

Ovarian Cysts: Definition

A

A fluid filled or semiliquid filled sac which forms on or inside an ovary
Although anxiety provoking most are benign
Many resolve without surgery
Can form at any stage of life: infancy to menopause

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2
Q

Ovarian Cysts: Etiology

A

functional cysts

Theca Lutein cysts

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3
Q

What are 2 examples of functional cysts

A

Follicular cysts
Most Common, typically asymptomatic, 3-15cm
Corpus luteal cysts
3cm, dull pelvic pain

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4
Q

Theca- Lutein cysts

A

In molar pregnancy, choriocarcinoma or fertility therapy

Bilateral, massive ovarian enlargement, prone to torsion/hemorrhage/rupture

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5
Q

What are follicular cysts?

A 
Follicle fails to rupture
Often asymptomatic
Usually a simple, unilocular cyst
Size range 3 -15 cm
Often regresses spontaneously
More likely to rupture
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6
Q

What are corpus luteum cysts?

A 
Failure of corpus luteum to regress in 14 days
Usually smaller 3 – 6 cm
Firm or solid
More likely to cause pain
Delayed menses
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7
Q

Functional Cysts may what?

A

Rupture
Become hemorrhagic
Increase in pain
Peritoneal signs

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8
Q

How would you diagnose a functional cyst?

A

CBC
Ultrasound
If unilocular and <10 cm in size -risk of malignancy is 0.1%
50% to 70% will resolve

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9
Q

What are 3 layers of ovarian tissue

A

Epithelium
Stroma
Germ cells

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10
Q

Luteoma of pregnancy

A 
Proliferation of luteinized stromal cells
Multifocal and bilateral, 5-10cm
Hormonally active with androgens
Maternal virilization 30%
Female fetus virilization 50%
After delivery, mass typically resolves
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11
Q

What are neoplastic cysts?

A

Overgrowth of cells in the ovary
Malignant or benign
Malignant from all cell types
Most common is surface epithelium (mesothelium)

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12
Q

Teratomas contain what?

A

Cystic teratomas contain all 3 embryonic germ layers

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13
Q

Endometriomas are what?

A

Blood-filled cysts from the ectopic endometrium
“chocolate cysts”
Associated with endometriosis:
Dysmenorrhea, menorrhagia, dyspareunia

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14
Q

Polycystic Ovarian Syndrome

A

Multiple cystic follicles 2-5mm

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15
Q

Risk factors for ovarian cysts?

A 
Infertility treatment
Tamoxifen: benign functional cysts
Pregnancy: in 2nd trimester when hCG peaks
Hypothyroidism
Cigarette smoking
Tubal ligation: functional cysts
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16
Q

Symptoms of ovarian cysts?

A 
Most are asymptomatic
Malignant cysts cause symptoms in late stages
Torsion or rupture causes severe pain:
Sudden, unilateral, sharp
Brought on by exercise , trauma, coitus
May have:
Difficult bowel movements, frequent urination, irregular menses, dyspareunia, Abdominal bloating/fullness
Indigestion, heartburn, early satiety
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17
Q

What is the triad for endometrioma?

A

triad of dysmenorrhea, menorrhagia, dyspareunia

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18
Q

5 findings with polycystic ovary syndrome

A

hirsutism, infertility, oligomenorrhea, obesity, acne

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19
Q

Ovarian Cysts: Physical ExaminationED differential diagnosis

A 
Threatened abortion
Acute appendicitis
Diverticular disease
Endometriosis
Bowel obstruction
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20
Q

What occurs during Ovarian Torsion

A

Occurs when the ovary flips over
Cuts off blood supply to ovary
Ovarian tumors benign or malignant involved 50-60% of cases

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21
Q

Epidemiology of ovarian torsion

A

5th most common gyn surgical emergency
Median age 28 y.o.
20% occur in pregnancy (1 in 1800)
Does occur in premenarchal and postmenopausal women

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22
Q

Ovarian Torsion presentation?

A

2/3 are on the right
Sx – acute unilateral sharp pain, vomiting with onset of pain, pelvic mass, leukocytosis and fever
PE – nonspecific and variable, may have tender unilateral pelvic mass, absence of tenderness does not rule out torsion

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23
Q

Ovarian Torsion complications

A

Infection, peritonitis, sepsis, adhesions, chronic pain

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24
Q

Ovarian Torsion Dx and treatment

A

Testing
Ultrasound with color doppler

Treatment: Surgical
Removal of ovary (oophorectomy), untwisting also possible if done immediately

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25
Q

5 labs that should be done for ovarian cysts

A 
Urine pregnancy test
CBC: check for bleeding/infection
Urinalysis
Cancer antigen 125 
Endocervical swabs: PID check for chlamydia/gonorrhea
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26
Q

Cancer antigen 125

A

6% can be positive in healthy patients
Most useful in combination with ultrasound
Do not draw in acute care settings, elevated in cyst rupture, infections, hemorrhage, endometriosis

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27
Q

Ultrasonography

A

Primary tool for cyst evaluation
Can show morphology
Can show resolution of cyst
Simple: thin walled, uniform, 2.5 to 15cm in diameter
Complex: multilocular, thick walled, projections into lumen
Ovarian torsion: ovarian edema from blocked lymphatic drainage

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28
Q

What are the 2 types of ultrasonography imaging for ovarian cysts

A

Endovaginal
Detailed morphologic examination of pelvic structures
Uses a handheld probe inserted into the vagina
Transabdominal
For evaluating large masses

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29
Q

Ovarian cyst treatment for “most patients” and for “fetal and neonatal cysts”

A

Most patients with simple ovarian cysts require no treatment, resolve in about 60 days

Fetal and neonatal cysts:
Ovarian cyst most frequent abdominal tumor 30%
Most are small and involute within first few months of life
Management: serial ultrasounds

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30
Q

Treatment of ovarian cysts in pregnancy

A

Most resolve by gestational age 14 -16 weeks
If large mass persists, and ultrasound findings are not suggestive of malignancy, may be watched
If symptomatic, pain, or rapid growth: surgery is considered

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31
Q

treatment of ovarian cysts in Post menopausal women <8 cm

A

asymptomatic simple cysts
< 8cm on ultrasound, normal CA125
Repeat ultrasound in 8-12 weeks

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32
Q

treatment of ovarian cysts in Post menopausal women <5cm

A

Asymptomatic <5cm cyst:
Repeat ultrasound in 4-6 weeks with CA125 study
Half resolve in 2 months
If rising CA125 or increase in cyst size, consider surgery
Follow up is important, risk of malignancy rises from 13% in premenopausal to 45% in postmenopausal patients

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33
Q

When is Laparotomy and laparoscopy the preferred treatment for ovarian cysts?

A

For persistent simple ovarian cysts >5-10cm
For complex ovarian cysts
Confirm diagnosis
Assess if appears malignant
Obtain fluid
Remove cyst with or without ovary
Assess opposite ovary and other abdominal organs

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34
Q

Polycystic Ovary Syndrome (PCOS) epidemiology

A

Women with PCOS have abnormalities in the metabolism of androgens and estrogen
One of the most common endocrine disorder of reproductive age women
Prevalence rate of 5 – 10%
5 million women in the U.S.
Up to 10% are diagnosed during gyn visit

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35
Q

How is Polycystic Ovary Syndrome diagnosed?

A

Two of the following
Polycystic ovaries
Signs of androgen excess: acne, hirsutism, temporal balding, male pattern hair loss
Menstrual irregularities: oligomenorrhea or polymenorrhea

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36
Q

Polycystic Ovary Syndrome etiology/patho

A

Unclear etiology although it may result from the abnormal function of the hypothalamic-pituitary-ovary (HPO) axis
Ovaries are
Bilaterally enlarged, spherical rather than ovoid.
Multiple ,1cm follicles, arranged along the periphery
“string of pearls” configuration

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37
Q

What are physical exam findings for Polycystic Ovary Syndrome?

A

Hirsutism/virilizing signs
Excess body hair, acne, alopecia, increased muscle mass, deepening voice
Obesity
50% have abdominal obesity
Acanthosis nigricans: diffuse, velvety thickening and hyperpigmentation of the skin. Nape of neck, axillae, under breasts, intertriginous areas, elbows, knuckles.
HTN
enlarged ovaries

38
Q

Polycystic Ovary Syndrome Ddx

A 
Amenorrhea
Cushing Syndrome
Gigantism and Acromegaly
Hyperprolacinemia
Hyper/hypothyroidism
39
Q

Workup for polycystic ovary syndrome

A 
Thyroid function tests
Serum prolactin levels
Free androgen index
Serum hCG level
Oral glucose tolerance test
Infertility workup
Ultrasound
40
Q

Treatment for polycystic ovary syndrome

A

Lifestyle changes: diet and exercise
supportive care (acne)
Consult Endocrinologist
Thyroid/pituitary causes of menstrual irregularity
Surgery
To restore ovulation: electrocautery, laser drilling, multiple biopsy

41
Q

Epithelial Tumors

A

60 – 80% of ovarian tumors
Serous tumors – peri/postmenapausal, benign
Mucinous Tumors – largest tumors in the human body
Endometrioid Lesions
Clear Cell
Transitional Cell (Benner) Tumors

42
Q

3 types of stromal tumors

A

Thecoma
Fibroma
Hilus Cell

43
Q

Mucinous Cyst or Cystadenocarcinoma (3)

A

May be benign or malignant
Looks very similar to a serous cyst
May be very large

44
Q

Ovarian Neoplasms/Tumors

A

Most ovarian neoplasms are benign

May develop from any histological element of the ovary

45
Q

Theocoma found in who?

A

Usually in postmenopausal women

Tumor produces estrogen

46
Q

Fibroma found in who?

A 
Usually in perimenopausal women
Incidental finding or  >20cm
Meigs’ syndrome: fibroma/ascites/hydrothorax
solid 
benign or malignant
47
Q

Meig’s Syndrome triad includes what?

A 
Ascites
Pleural effusion (right side)
Benign ovarian fibroma
48
Q

Hilus Cell Tumor

A

Rarely palpable Androgen secreting neoplasm

Hirsutism/virilization/menstural irregularities

49
Q

Germ Cell Tumors

A

Mature Cystic Teratomas aka Dermoid Cysts
40 – 50% of all benign ovarian neoplasms
Usually asymptomatic, unless torsion or rupture
15% bilateral, may grow to several kg

50
Q

Ovarian Neoplasms/Tumors treatment

A

Surgical excision with careful exploration of the abdomen
Possible unilateral oophorectomy
Options need to be weighed if future fertility is a concern

51
Q

Epidemiology of ovarian cancer

A

14,000 deaths in the US each year
4th in cancer deaths among women
Prevalence low 1 -2%, but mortality exceeds all other gyn malignancies combined
Can shorten a woman’s life by 18yrs
Low survival rate due to cases not dx advanced stages

52
Q

Risk factors for ovarian cancer

A 
Older age
Early menarche (< 12)
Late menopause (> 50)
Caucasian race > Hispanic> African American> Asian
Infertility
53
Q

2 protective factors for ovarian cancer

A

Use of OCPs – 50% reduction with 15 years of use

Breastfeeding

54
Q

6 symptoms for ovarian cancer

A 
Increase in abdominal girth 
Abdominal pain
Early satiety
Urinary frequency or urgency
Weight gain
Change in bowel habits
55
Q

How to diagnose ovarian cancer?

A

Ultrasound – complex cystic/solid mass
Elevated CA-125
Elevated Inhibin B in

56
Q

Physical exam may show what 2 things in ovarian cancer?

A

Ascites

Pelvic mass – usually fixed, hard, irregular

57
Q

Familial Ovarian Cancer

A 
FH alone increases personal risk by 2-6%
BRCA 1   
35-45% lifetime risk
BRCA 2
15-24% lifetime risk
Ashkenazi Jewish, French Canadians, Icelandic descent
Prevention	
Ultrasound annually
Prophylactic  removal of ovaries
58
Q

Treatment for ovarian cancer (3)?

A

Surgery
Chemotherapy
Marker (CA-125)

59
Q

3 types of uterine disease

A

Prolapse
Leiomyoma
Cancer

60
Q

Pelvic Organ Prolapse (POP) (4 ways)

A

Anterior vaginal
Posterior vaginal
Uterine
Enteroceles

61
Q

Uterine prolapse classification

A

Stage 0: no prolapse
Stage 1: cervix is in the upper ½ of vagina
Stage 2: cervix is 1cm above or below hymen remnants
Stage 3: cervix is >1cm below hymen remnants but the uterus is still at least 2cm in the vaginal canal
Stage 4: the uterus is outside the vaginal canal

62
Q

symptoms of uterine prolapse?

A

Vaginal fullness, pressure, heaviness, presence of soft reducible mass in vagina, urinary complaints

63
Q

Risk factors for uterine prolapse?

A

4.5 fold increase with more than 2 vaginal deliveries

age, obesity, chronic cough, repetitive heavy lifting

64
Q

Epidemiology of Leiomyoma (Fibroids)

A

Very common in women over 40.
More common in African-American women
Chance of malignancy (leiomyosarcoma) is 1/498
Menorrhagia is usually due to submucosal fibroids which cannot be felt on exam.

65
Q

Leiomyoma (Fibroids) pathology

A

Arise form smooth muscle
Usually Benign tumors
Tissue examination needed for diagnosis

66
Q

Presentation of leiomyoma

A 
Menorrhagia
Fullness in pelvic area
Increased abd girth
Frequent urination
Dyspareunia
Low back pain
No symptoms
67
Q

Leiomyoma (Fibroids) Diagnostics?

A 
Ultrasound: Abdominal or intravaginal
MRI
CT
Hysterosalpingogram (HSG): Fluoroscopy
Sonohysterogram: injects water into the uterus and uses ultrasound
68
Q

Leiomyoma (Fibroids) Treatment?

A

Watchful waiting

Operative Hysteroscopy
Removal of submucous fibroids using an electrocautery wire
Embolization –
using arterial catherization, synthetic emboli are introduced into the artery feeding the fibroid.
Not for small fibroids

Hysterectomy

69
Q

Endometrial hyperplasia and presentation

A 
Thickening of endometrium
Thicker lining = heavier period
Can slowly progress to uterine cancer
Presentation
Menorrhagia
Metrorrhagia
Post menopausal bleeding
70
Q

risk factors of endometrial hyperplasia

A 
Obesity
Anovulation
DM
HTN
Age 
Nulliparity
71
Q

Endometrial Hyperplasia treatment

A

Treatment consists of adding extra progesterone during the luteal phase
30 mg medroxyprogesterone day
bx again in 6 months

72
Q

how does hyperplasia progress?

A

simple hyperplasia
complex hyperplasia
Complex hyperplasia with atypical cells

73
Q

epidemiology of uterine cancer?

A

Endometrial cancer is the most common diagnosed gyn malignancy (ovarian is #2)
4th most common cancer in women after breast, lung, and colorectal cancer
Good prognosis, many found in stage one because of recognizable symptoms
10% of postmenopausal bleeding  cancer
Peak incidence is in the 70s
White women have a greater risk than Black women

74
Q

uterine cancer pathology

A

80% are Type I, due to unopposed estrogen stimulation, endometrial hyperplasia
Type II, estrogen independent , occur in older women , papillary serous or clear cell: poor prog
May develop from polyp or multifocal pattern
Most common histologic subtype is endometrioid adenocarcioma

75
Q

Risk factors of uterine cancer

A 
Age, FH
Obesity
DM
HTN
Nulliparity
Late menopause
Early menarche
76
Q

Symptoms of uterine cancer

A

Abnormal menses 80%
Postmenopausal bleeding
Advanced cases: abd pain, bloating, wt loss, change in bowel or bladder habits
Classic presentation: obese, nuliparous, infertile, HTN, and DM white woman

77
Q

Labs for uterine cancer

A

CBC, U/A, endocervical/vaginal cytology, glucose, LFT, BUN/CR
40% missed on Pap test
All postmenopausal women with endometrial cells on a routine Pap require evaluation for uterine cancer with endometrial sampling
CA-125 not used in disease management as it is in ovarian cancer

78
Q

Uterine cancer diagnosis

A

Ultrasound can detect thickening of the endometrium
If less than 4mm, no D&C unless bleeding continues
Endometrial biopsy
D&C (dilation and curettage) definitive procedure for dx

79
Q

uterine cancer treatment

A 
Treatment
Surgery
Hysterectomy 
Bilateral salpingoopherectomy
Pelvic lymphadenectomy  
Radiation
May be indicated if there is invasion of the myometrium
Hormonal therapy
Progesterone
80
Q

prognosis and follow up for uterine cancer

A

Local disease 96% 5 year survival
Routine surveillance every 3-4 months for the first 2 years
85% of recurrences occur in the 1st 2 yrs
Then every 6 months for the next 3yrs, then annually

81
Q

post uterine cancer treatment visit includes what 4 things?

A

Pelvic exam
Pap smear
Lymph node survey
Cxry annually

82
Q

Sarcoma of the uterus epidemiology

A 
3-4% of uterine malignancies
Carcinosarcomas (mixed mesodermal sarcomas (40%–50%)
Average age at Dx 50
Aggressive
More common in African American pts
83
Q

presentation of the uterus

A 
60% have abnormal uterine bleeding
50% have pelvic pain
Constipation, urinary frequency
Uterus is usually enlarged
If advanced, inguinal or supraclavicular node metastases
84
Q

workup for sarcomas of the uterus

A

Lab: CBC, U/A, LFT,
Cxry, Abd/pelvic CT
Pelvic U/S, sigmiodoscopy, cystoscopy

85
Q

Treatment of sarcomas of the uterus?

A 
Endometrial Biopsy
D&C
If above indeterminate= laparotomy
Check all abd viscera and nodes
Surgery
Chemotherapy
Radiation therapy
86
Q

complications for sarcomas of the uterus?

A

Anemia, sepsis, uterine rupture, hemorrhage metastasis, ascites

87
Q

Ectopic pregnancy symptoms

A

Pelvic pain, vag bleeding, tender mass, +hCG

88
Q

ovarian cancer symptoms

A

Pelvic pain?, bloating, increased girth, early satiety, vague GI sx

89
Q

Leiomyoma symptoms

A

Menorrhagia, irregularly enlarged uterus,

90
Q

Tubo-ovarian abscess symptoms

A

Pelvic pain, fever, N/V, rebound, very tender mass

91
Q

PCOS symptoms

A

Oligomenorrhea, hirsutism, infertility, obesity

92
Q

Ovarian torsion symptoms

A

Severe pelvic pain, acute onset, N/V

Womens Health (5 decks)

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