Ovarian & uterine disease Flashcards
Ovarian Cysts: Definition
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
Ovarian Cysts: Etiology
functional cysts
Theca Lutein cysts
What are 2 examples of functional cysts
Follicular cysts
Most Common, typically asymptomatic, 3-15cm
Corpus luteal cysts
3cm, dull pelvic pain
Theca- Lutein cysts
In molar pregnancy, choriocarcinoma or fertility therapy
Bilateral, massive ovarian enlargement, prone to torsion/hemorrhage/rupture
What are follicular cysts?
Follicle fails to rupture Often asymptomatic Usually a simple, unilocular cyst Size range 3 -15 cm Often regresses spontaneously More likely to rupture
What are corpus luteum cysts?
Failure of corpus luteum to regress in 14 days Usually smaller 3 – 6 cm Firm or solid More likely to cause pain Delayed menses
Functional Cysts may what?
Rupture
Become hemorrhagic
Increase in pain
Peritoneal signs
How would you diagnose a functional cyst?
CBC
Ultrasound
If unilocular and <10 cm in size -risk of malignancy is 0.1%
50% to 70% will resolve
What are 3 layers of ovarian tissue
Epithelium
Stroma
Germ cells
Luteoma of pregnancy
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
What are neoplastic cysts?
Overgrowth of cells in the ovary
Malignant or benign
Malignant from all cell types
Most common is surface epithelium (mesothelium)
Teratomas contain what?
Cystic teratomas contain all 3 embryonic germ layers
Endometriomas are what?
Blood-filled cysts from the ectopic endometrium
“chocolate cysts”
Associated with endometriosis:
Dysmenorrhea, menorrhagia, dyspareunia
Polycystic Ovarian Syndrome
Multiple cystic follicles 2-5mm
Risk factors for ovarian cysts?
Infertility treatment Tamoxifen: benign functional cysts Pregnancy: in 2nd trimester when hCG peaks Hypothyroidism Cigarette smoking Tubal ligation: functional cysts
Symptoms of ovarian cysts?
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
What is the triad for endometrioma?
triad of dysmenorrhea, menorrhagia, dyspareunia
5 findings with polycystic ovary syndrome
hirsutism, infertility, oligomenorrhea, obesity, acne
Ovarian Cysts: Physical ExaminationED differential diagnosis
Threatened abortion Acute appendicitis Diverticular disease Endometriosis Bowel obstruction
What occurs during Ovarian Torsion
Occurs when the ovary flips over
Cuts off blood supply to ovary
Ovarian tumors benign or malignant involved 50-60% of cases
Epidemiology of ovarian torsion
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
Ovarian Torsion presentation?
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
Ovarian Torsion complications
Infection, peritonitis, sepsis, adhesions, chronic pain
Ovarian Torsion Dx and treatment
Testing
Ultrasound with color doppler
Treatment: Surgical
Removal of ovary (oophorectomy), untwisting also possible if done immediately
5 labs that should be done for ovarian cysts
Urine pregnancy test CBC: check for bleeding/infection Urinalysis Cancer antigen 125 Endocervical swabs: PID check for chlamydia/gonorrhea
Cancer antigen 125
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
Ultrasonography
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
What are the 2 types of ultrasonography imaging for ovarian cysts
Endovaginal
Detailed morphologic examination of pelvic structures
Uses a handheld probe inserted into the vagina
Transabdominal
For evaluating large masses
Ovarian cyst treatment for “most patients” and for “fetal and neonatal cysts”
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
Treatment of ovarian cysts in pregnancy
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
treatment of ovarian cysts in Post menopausal women <8 cm
asymptomatic simple cysts
< 8cm on ultrasound, normal CA125
Repeat ultrasound in 8-12 weeks
treatment of ovarian cysts in Post menopausal women <5cm
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
When is Laparotomy and laparoscopy the preferred treatment for ovarian cysts?
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
Polycystic Ovary Syndrome (PCOS) epidemiology
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
How is Polycystic Ovary Syndrome diagnosed?
Two of the following
Polycystic ovaries
Signs of androgen excess: acne, hirsutism, temporal balding, male pattern hair loss
Menstrual irregularities: oligomenorrhea or polymenorrhea
Polycystic Ovary Syndrome etiology/patho
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
What are physical exam findings for Polycystic Ovary Syndrome?
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
Polycystic Ovary Syndrome Ddx
Amenorrhea Cushing Syndrome Gigantism and Acromegaly Hyperprolacinemia Hyper/hypothyroidism
Workup for polycystic ovary syndrome
Thyroid function tests Serum prolactin levels Free androgen index Serum hCG level Oral glucose tolerance test Infertility workup Ultrasound
Treatment for polycystic ovary syndrome
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
Epithelial Tumors
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
3 types of stromal tumors
Thecoma
Fibroma
Hilus Cell
Mucinous Cyst or Cystadenocarcinoma (3)
May be benign or malignant
Looks very similar to a serous cyst
May be very large
Ovarian Neoplasms/Tumors
Most ovarian neoplasms are benign
May develop from any histological element of the ovary
Theocoma found in who?
Usually in postmenopausal women
Tumor produces estrogen
Fibroma found in who?
Usually in perimenopausal women Incidental finding or >20cm Meigs’ syndrome: fibroma/ascites/hydrothorax solid benign or malignant
Meig’s Syndrome triad includes what?
Ascites Pleural effusion (right side) Benign ovarian fibroma
Hilus Cell Tumor
Rarely palpable Androgen secreting neoplasm
Hirsutism/virilization/menstural irregularities
Germ Cell Tumors
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
Ovarian Neoplasms/Tumors treatment
Surgical excision with careful exploration of the abdomen
Possible unilateral oophorectomy
Options need to be weighed if future fertility is a concern
Epidemiology of ovarian cancer
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
Risk factors for ovarian cancer
Older age Early menarche (< 12) Late menopause (> 50) Caucasian race > Hispanic> African American> Asian Infertility
2 protective factors for ovarian cancer
Use of OCPs – 50% reduction with 15 years of use
Breastfeeding
6 symptoms for ovarian cancer
Increase in abdominal girth Abdominal pain Early satiety Urinary frequency or urgency Weight gain Change in bowel habits
How to diagnose ovarian cancer?
Ultrasound – complex cystic/solid mass
Elevated CA-125
Elevated Inhibin B in
Physical exam may show what 2 things in ovarian cancer?
Ascites
Pelvic mass – usually fixed, hard, irregular
Familial Ovarian Cancer
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
Treatment for ovarian cancer (3)?
Surgery
Chemotherapy
Marker (CA-125)
3 types of uterine disease
Prolapse
Leiomyoma
Cancer
Pelvic Organ Prolapse (POP) (4 ways)
Anterior vaginal
Posterior vaginal
Uterine
Enteroceles
Uterine prolapse classification
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
symptoms of uterine prolapse?
Vaginal fullness, pressure, heaviness, presence of soft reducible mass in vagina, urinary complaints
Risk factors for uterine prolapse?
4.5 fold increase with more than 2 vaginal deliveries
age, obesity, chronic cough, repetitive heavy lifting
Epidemiology of Leiomyoma (Fibroids)
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.
Leiomyoma (Fibroids) pathology
Arise form smooth muscle
Usually Benign tumors
Tissue examination needed for diagnosis
Presentation of leiomyoma
Menorrhagia Fullness in pelvic area Increased abd girth Frequent urination Dyspareunia Low back pain No symptoms
Leiomyoma (Fibroids) Diagnostics?
Ultrasound: Abdominal or intravaginal MRI CT Hysterosalpingogram (HSG): Fluoroscopy Sonohysterogram: injects water into the uterus and uses ultrasound
Leiomyoma (Fibroids) Treatment?
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
Endometrial hyperplasia and presentation
Thickening of endometrium Thicker lining = heavier period Can slowly progress to uterine cancer Presentation Menorrhagia Metrorrhagia Post menopausal bleeding
risk factors of endometrial hyperplasia
Obesity Anovulation DM HTN Age Nulliparity
Endometrial Hyperplasia treatment
Treatment consists of adding extra progesterone during the luteal phase
30 mg medroxyprogesterone day
bx again in 6 months
how does hyperplasia progress?
simple hyperplasia
complex hyperplasia
Complex hyperplasia with atypical cells
epidemiology of uterine cancer?
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
uterine cancer pathology
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
Risk factors of uterine cancer
Age, FH Obesity DM HTN Nulliparity Late menopause Early menarche
Symptoms of uterine cancer
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
Labs for uterine cancer
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
Uterine cancer diagnosis
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
uterine cancer treatment
Treatment Surgery Hysterectomy Bilateral salpingoopherectomy Pelvic lymphadenectomy Radiation May be indicated if there is invasion of the myometrium Hormonal therapy Progesterone
prognosis and follow up for uterine cancer
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
post uterine cancer treatment visit includes what 4 things?
Pelvic exam
Pap smear
Lymph node survey
Cxry annually
Sarcoma of the uterus epidemiology
3-4% of uterine malignancies Carcinosarcomas (mixed mesodermal sarcomas (40%–50%) Average age at Dx 50 Aggressive More common in African American pts
presentation of the uterus
60% have abnormal uterine bleeding 50% have pelvic pain Constipation, urinary frequency Uterus is usually enlarged If advanced, inguinal or supraclavicular node metastases
workup for sarcomas of the uterus
Lab: CBC, U/A, LFT,
Cxry, Abd/pelvic CT
Pelvic U/S, sigmiodoscopy, cystoscopy
Treatment of sarcomas of the uterus?
Endometrial Biopsy D&C If above indeterminate= laparotomy Check all abd viscera and nodes Surgery Chemotherapy Radiation therapy
complications for sarcomas of the uterus?
Anemia, sepsis, uterine rupture, hemorrhage metastasis, ascites
Ectopic pregnancy symptoms
Pelvic pain, vag bleeding, tender mass, +hCG
ovarian cancer symptoms
Pelvic pain?, bloating, increased girth, early satiety, vague GI sx
Leiomyoma symptoms
Menorrhagia, irregularly enlarged uterus,
Tubo-ovarian abscess symptoms
Pelvic pain, fever, N/V, rebound, very tender mass
PCOS symptoms
Oligomenorrhea, hirsutism, infertility, obesity
Ovarian torsion symptoms
Severe pelvic pain, acute onset, N/V
