pathology of the uterus Flashcards
What kind of mass is missed more than any other?
vaginal masses
What is a Gartner’s duct cyst?
Vaginal mass
remnant of mesonephirc duct
not in cervix, just in the vagina
If you had stool coming out of the vagina what would you find?
a vaginal/rectal fistula
What is the most common congenital abnormality of the female genital tract?
imperforate hymen
What does an obstruction of the uterus and/or vagina result in?
hydrometra (fluid)
hematometria (blood)
pyometra (pus)
what are the two solid cancers of the vagina?
vaginal adenocarcinoma
rhabdomyosarcoma
Are vaginal solid masses common?
no, they are rare
If you do see a soild mass in the vagina what might you see in the tissue?
solid mass occasionally with areas of necrosis
What kind of scan would you do if the Dr. thinks there is a vaginal mass?
translabial/trans peritoneal
Why is sonography used if a solid vaginal mass is found?
for staging
What is a vaginal cuff?
seen in hysterectomy patients
What is the size of a vaginal cuff?
< 2.1 cm
What would nodular areas in the vaginal cuff be from?
postirradiation fibrosis
Why would you scan the vaginal cuff?
suspicion for malignancy, especially in a patient who has previous history of cancer
what are adhesions?
scar tissue
adhere things that shouldn’t be adhered together
What is the smallest amount of fluid in the pouch of douglas that can be detected by US?
5mL
What are pathologic fluid collection associated with?
ascites
blood resulting from ruptured ectopic pregnancy
hemorrhagic cyst
pus resulting from infection
Besides fluid, what else can occur in the pelvic cul-de-sac?
pelvic abscesses
hematomas
Are nebothian cysts benign or malignant?
benign
What is another name for nabothian cyst?
retention cyst
chornic cervicitis
What are the symptoms of nabothian cysts?
asymptomatic
How might cervical polyps clinically present?
with irregular bleeding
What does pedunculated mean?
projecting out of the cervix, or broad based
Will you always see cervical polyps?
maybe, depends on location
What kind of cervical myomas occur in the cervix?
small percentage of leiomyomas occur in the cervix
What are the symptoms of cervical myomas?
when small: asymptomatic
as mass enlarges: bladder or bowel obstruction may result
What is cervical stenosis?
an acquired condition
obstruction of cervical canal at internal or external os
What causes cervical stenosis?
radiation therapy
previous cone biopsy
postmenopausal cervical atrophy
chronic infection
laser or cryosurgery
cervical carcinoma
do menopausal patients have symptoms from cervical stenosis?
no
can cause a distended uterus from fluid
What are the symptoms of cervical stenosis of premenopausal women?
abnormal bleeding
oligomenorrhea
amenorrhea
cramping
dysmenorrhea
infertility
What is cervical Ca (carcinoma)?
squamous cell carcinma
What is the most common type of cervical Ca?
squamous cell carcinoma
What are the precursors of Cervical Ca?
cervical dysplasias
how are cervical dysplasias classified?
mild
moderate
severe
what is carcinoma in situ?
all of the cancer is localized…no evidence of spread
pre-stage I
When is cervical Ca called carcinoma in situ?
when full thickness of epithelium composed of undifferentiated neoplastic cells
What helps detect cervical ca?
Pap smears
most early lesions are asymptomatic
Which is more common cervical ca or endometrial ca?
endometrial
Who does cervical ca affect the most?
women of menstrual age
What is a clinical sign of cervical ca?
vaginal discharge or bleeding
What are the sonographic findings of cervical ca?
retrovesical mass
obstruction of ureters
invasion of bladder
how do you do a translabial or trasperineal sonogram?
5-7.5 MHz sector or curvilinear transducer
covered with a sterile probe cover
applied to vestibule of vagina - sagittal plane
What are the most common uterine calcificatons?
myomas
What arteries in the pelvis calcify?
arcuate arteries in the periphery of the uterus
What pelvic structure can mimic a “mass” on a physical exam?
the uterus
What is the size and shape of the uterus related to?
age
hormonal status
parity
What reasons would you have for an enlarged uterus?
pregnancy
postpartum
leiomyoma (fibroid)
adenomyosis
bicornuate or didelphic uterus
What are the uterine tumors?
leiomyoma benign
carcinoma (malignant)
What would an intrauterine pregnancy give you?
thickened endometrium
what does endometrial hyperplasia cause?
thickened endometrium
What does trophoblastic disease, endometritis and adhesions cause?
thickened endometrium
Polyps, inflammatory disease and endometrial carcinoma with do what to the endometrium?
thicken it
When an abortion is done, what would cause a thickened endometrium?
retained products of conception or an incomplete abortion
What is trophoblasitc disease?
when placenta is left in the endometrium after a pregnancy
What is inflammatory disease?
pus in the endometrium
Why might you find fluid in the endometrium?
endometritis
retained products of conception
pelvic inflammatory diesease
cervical obstruction
What mighth cause endometrial shadowing?
gas (abscess)
intrauterine device
calcified myomas or vessels
retained products of conception
what are the most common gynecological tumors?
leiomyomas
myomas
fibroids
all the same thing
What are 20%-30% of women over age 30 at risk for?
Leiomyomas
myomas
fibroids
more common in african american women
What does a leiomyoma look like?
spindle shaped
smooth muscle cells in a whorl like pattern
various amounts of fibrous connective tissue
Are leiomyomas hormonally influenced?
yes - grow with hormones
tend to shrink after menopause and become calcified
when does degeneration occur to leiomyomas?
when it outgrows its blood supply = calcification
What are the clinical indications of leiomyomas?
enlarged uterus
profuse and prolonged bleeding
pain
What are the different types of fibroids?
submucosal
intramural
subserosal
What is an intramural (aka: interstitial) fibroid?
within myometrium
most common type
may enlarge to cause pressure on adjacent organs
infertility or recurrent pregnancy loss
what is a subserosal fibroid?
arise from myometrium and project exophytically
may enlarge to cause pressure on adjacent organs
What are fibroids dependent on?
estrogen
What is suspicious in an postmenopausal woman when it comes to fibroids?
rapid increase in myoma size is suspicious for neoplasm
if not on hormone replacement therapy
What are pedunculated fibroids?
a fibroid on a stalk outside of the uterus
Which fibroid is the most common?
intraamural/interstital
How do you treat fibroids in the case of infertility?
it has to be subucosal.
surgery by myomectomy
in cases of menorrhagia, how is a fibroid treated?
hormonal suppression (least invasive)
endometrial ablation
uterine artery embolization (UAE)
high intensity focused ultrasound (HIFU)
What is the most common cause of uterine calcifications?
myomas
What is Monckebergs’s arteriosclerosis?
calcium deposits are found in the tunica media of the walls of arteries
What is adenomyosis?
benign disease
is ectopic ocurrence of endometrial tissue within myometrium
more common in posterior aspect
How does an adenomyosis look on US?
presents as a bulky enlarged uterus without a focal mass
Is adenomyosis diffuse or focal?
both
What is another name for adenomyosis?
adenomyoma - referring to isolated implants that typically cause reactive hypertrophy of surrounding myometrium
What are the symptoms of 60% of women with adenomyosis?
hypermenorrhagia
menorrhagia
metrorrhea (irregular, acyclic bleeding)
What is the most common presentation on US of extensive andenomyosis?
diffuse uterine enlargement
thickening of posterior myometrium
indistinct border between endometrium and myometrium
myometrial cysts
What are adenomyomas?
hemorrhage in islands of endometrial tissue appears as small hypoechoic myometrial cysts
looks like Swiss cheese or honeycomb pattern
What are arteriovenous malformations?
a connection between and artery and vein that is abnormal
no capillaries…direct connection
venous and arterial flow in one vessel
What is Uterine arteriovenous malformations (AVMs)?
consist of vascular plexus of arteries and veins without intervening capillary network
What does teratogenic mean?
aquired
How does one get AVM?
congenital or teratogenic
due to pelvic trauma, surgery or gestational trophoblastic neoplasia
What clinical symptoms would a woman with AVM have?
women of childbearing years have metrorrhagia with blood loss and anemia
if an AVM is cut into during a dilation and curettage (D&C)what can happen?
life threatening, catastrophic hemorrhaging
What are sonographic findings of AVM?
serpiginous (creeping or crawling) anechoic structures seen within the pelvis
What does spectral doppler show with an AVM?
high velocity, low resistance
arterial flow coupled with venous flow
What is a uterine leiomyosarcoma?
rare, solid tumor arising from myometrium or endometrium
Where is a leiomyosarcoma commonly found?
in fundus of the uterus
What is the most common age for uterine leiomyosarcoma?
40-60 years old
What is the sonographic finding for leiomyosarcoma?
may resemble myomas or endometrial carcinoma with features of solid or mixed-solid and cystic texture
What is the cervical canal?
from the internal os to the external os
What benign condition arises from hyperplastic protrusion of epithelium of endocervix or ectocervix?
Cervical Polyps
What is the most likely factor for cervical polyps?
chronic inflammation
What are the two most likely ways you would find/describe cervical polyps?
Pedunculated (projecting out of the cervix)
broad based
Depending on location may or may not be seen
Who are most likely to develop cervical polyps?
women in late middle age
what enhances visualization of of cervical myomas?
fluid infusion with sonoysterography
How does sonography assist with a Pedunculated cervical myoma?
by determining the location and thickness of the stalk
It’s possible it may prolapse into the vagina
If you have already scanned translabial in the sagittal plane, what do you do for your second plane?
rotation of transducer obliquely in counterclockwise direction shows coronal images
When does fibrosis occur with a leiomyoma?
after atrophic or degenerative changes
how does a leiomyoma clinically present?
uterine irregularity and enlargement
pelvic pressure and pain
irregular bleeding (menometrorrhagia)
heavy bleeding (menorrhagia)
may contribute to infertility
What is a less common cause of uterine calcifications?
arcuate artery calcification in periphery of uterus
What can indicate underlying disease like diabetes mellitus, hypertension or chronic renal failure?
Calcifications in the the tunica media of arteries
What is the landmark for the long axis of the uterus?
endometrium
what percentage of patient with adenomyosis also suffer from dysmenorrhea?
25%
What two uterine conditions often appear together?
fibroids and andomyosis
On US how do adenomyomas present?
fluid nature of lesions produce increased posterior acoustic enhancement rather than the degree of attenuation normally seen posterior to uterus.
do you typically find arteriovenous malformations usually involve the myometrium or the endometrium?
These are rare
usually myometrium
How do uterine AVM’s appear on US?
can be subtle like:
myometrial inhomogeneity
tubular spaces within myometrium
intramural uterine mass
endometrial or cervical mass
prominent parametrial vessels
Why would you use color doppler on an AVM?
to show blood flow within anechoic structures
may be florid-colored mosaic pattern with apparent flow reversals and areas of color aliasing
What does spectral doppler show in an AVM?
High-velocity/ low resistance arterial flow COUPLED with high velocity venous flow with arterial component
What is a sarcoma botryoides?
type of uterine leiomyosarcoma
very rare condition in children characterized by grapelike clusters of tumor mass
When would concern about development of malignancy occur for solid uterine masses?
When a solid uterine mass rapidly enlarges in a perimenopausal or postmenopausal patient.
What are some endometrial pathologies that can cause abnormal bleeding, especially in the postmenopausal patient?
hyperplasia
polyps
carcinoma
When a patient is receiving tamoxifen therapy for breast cancer, what other disorder can that cause?
disorders of the endometrium
How is tamoxifen used to treat some forms of breast cancer?
tamoxifen is a partial estrogen receptor antagonist used in postmenopausal women with estrogen receptor positive breast cancer.
What is a sonohysterography?
saline infused sonography [SIS]
What is sonohysterography used for?
valuable for further evaluating abnormally thickened endometrium
by distending endometrial cavity with saline, endometrial growths and abnormalities can be distinguished
In premenopausal women when is a sonohysterography performed?
mid-menstrual cycle
usually between days 6-10
When is a sonohysterography not performed?
when the patient has acute pelvic inflammatory disease
When doing a sonohysterography, when would you give a patient prophylactic antibiotics?
given with chronic pelvic inflammatory disease
women with hx of mitral valve prolapse
cardiac disorders
What is endometrial hyperplasia?
occurs when the endometrium becomes too thick
When does endometrial hyperplasia occur?
follows prolonged unopposed estrogen stimulation
What could be a precursor of endometrial cancer?
endometrial hyperplasia
What is the most common cause of of pre and post menopausal abnormal bleeding in women?
endometrial hyperplasia
What does an atrophic endometrium measure?
thin- measures <5mm
What are the measurements for endometrial thickness with hyperplasia?
Premenopausal >14mm
asymptomatic postmenopausal >8mm
symptomatic postmenopausal >5mm
If the uterus is present, what is associated with increased risk for enometrial hyperplasia or carcinoma?
unopposed estrogen - Premarin
What produces endometrial atrophy after 3-6 months?
continuous/combined estrogen and progesterone (Premarin and Provera)
If you take continuous/combined estrogen and progesterone like Premarin and Provera, are you at risk endometrial ca?
usually no risk
What symptoms do women if they have sequential estrogen and progesterone (Premarin first half, Provera second half)
women have predictable withdrawal bleeding at the end of each month
What are the benefits of estrogen?
alleviates menopausal symptoms
reduces risk of osteoporosis, vertebral and hip fractures
reduces risk of heart attacks, strokes
what are the benefits of progesterone?
produces endometrial atrophy
reduces risk of endometrial hyperplasia and Ca.
What are the negative effects of estrogen?
increases risk of endometrial hyperplasia and cancer
What are the negative effects of progesterone?
increases risk of breast cancer
causes irritability, depression, breast tenderness
What are enodmetrial polyps?
histologically: polyps are overgrowths of endometrial tissue covered by epithelium
How do patients with endometrial polyps present?
my be asymptomatic
may have uterine bleeding
During what phase of the month would endometrial polyps appear?
toward the end of the luteal phase
What would the endometrium look like if there were endometrial polyps?
represented by a hypoechoic or isoechoic region within hyperechoic endometrium
initally may appear as nonspecific echogenic endometrial thickening
What can sonographically appear as diffuse or focal, round echogenic mass within the endometrial cavity?
endometrial polyps
should see a feeding artery to the polyp
What is endometritis?
an infection within the endometrium of the uterus
What may be an indication of endometritis?
endometrial thickening
fluid
When does endometritis most often occur?
in association with PID
postpartum state
following instrumentation of uterus
In patients with a pelvic infection, what is a conduit for infectious spread to tubes and adnexa?
the uterus
When might postpartum patients develop endometritis?
after prolonged labor
vaginitis
PROM
retained products of conception
What are the clinical symptoms of endometritis?
patient has intense pelvic pain
How does endometritis appear sonographically?
endometrium appears prominent, irregular or both with small amount of endometrial fluid
What would you find in the cul-de-sac of a patient with endometritis?
pus or echogenic particles/debris
On US with a patient with endometritis, what might the ovaries look like?
enlarged ovaries with multiple cysts and indistinct margins seen secondary to periovarian inflammation
In a patient with endometritis how do the Fallopian tubes appear sonographically?
dilation of Fallopian tubes show fluid filled tubular shapes
folded configuration
well defined echogenic walls
What is a thickened tubal wall, 5mm or more, indicative of?
acute endometritis disease
How do you tell the difference between bowel and infected Fallopian tubes?
gentle compression on pelvic wall to look for peristalsis or movement in bowel lumen
What is a tubo-ovarian complex?
as infection worsens, periovarian adhesions may form and fuse inflamed tube and ovary
How does a tubo-ovarian abscess appear?
appears as complex multiloculated mass with septations
irregular shaggy margins
scattered internal echoes
What are some clinical signs of endometritis?
low back pain and fever
lower abd pain
dysmenorrhea
menorrhagia
sterility
constipation
What is synechiae?
endometrial adhesions (asherman’s syndrome)
When might you find synechiae?
found in women with posttraumatic or postsurgical histories
includes uterine curettage
What conditions might synechiae cause?
infertility
recurrent pregnancy loss
How does synechiae appear sonographically?
bright echoes within endometrial cavity
in a gravid uterus: appear as hyperechoic band traversing uterus from anterior to posterior
During what phase is synechiae best seen?
secretory phase when endometrium is more hyperechoic
typically need fluid distending the endometrial cavity to diagnose
What is the most common gynecologic malignancy in North America?
Endometrial Carcinoma
What stage of life do you see the most endometrial carcinoma?
postmenopausal patients
what is the most common clinical presentation of endometrial carcinoma?
uterine bleeding
What percentage of postmenopausal women with uterine bleeding have endometrial carcinoma?
10%
What are the risk factors for endometrial carcinoma?
replacement estrogen therapy
Premenopausal women:
anovulatory cycles
obesity
What is the earliest change of endometrial carcinoma?
thickened endometrium
How can a transvaginal examination be helpful in screening for early changes of endometrial hyperplasia or carcinoma?
by accurately measuring endometrial thickness
Sonographically, thickened endometrium (>4 to 5mm) must be considered ______ until proved otherwise.
cancer
what is clear evidence for endometrial carcinoma?
demonstration of myometrial invasion
How does TV scanning demonstrate myometrial invasion?
thickening and irregularity of central endometrial interface
with echogenic or hypoechoic patterns
combined with infiltration of hyperdense structures in mymetrium
A sonographic finding of enlarged uterus with irregular areas of low-level echoes would be consistent with what?
endometrial carcinoma
if endometrail carcinoma obstructs the endometrial canal, what could the result be?
hydrometra
hematometra
What does the intactness of subendometrial halo (inner layer of myometrium) usually indicate?
superficial invasion (as relates to endometrial carcinoma)
What does obliteration of subendometrial halo indicate?
deep invasion of myometrium (as it relates to endometrial carcinoma)
When do SMALL endometrial fluid collections occur?
small fluid collections also occur with:
ectopic pregnancy
endometritis
degenerating myomas
recent abortion
obstruction of _____________ results in accumulation of secretions, blood, or both in uterus..
cervical os
before menstruation, accumulation of secretions is referred to as what?
hydrometrocolpos
Following menstruation, hematometrocolpos results from what?
presence of retain menstrual blood
When a patient has a large collection of endometrial fluid and a fever, what does that suggest?
infection of blood collection
lab results would show elevated wbc count
What would a patient with large endometrial fluid collections typically complain about?
abd pain
has enlarged abd mass
When is pyometra more likely to occur?
with uterine cancer
What might an abnormal development of vagina or uterus result in?
cystic uterine or vaginal collection of mucus in children
when menstruation begins collection consists of blood
how do large collections of fluid present sonographically?
centrally cystic
round
moderately enlarged uterus
may contain echogenic material if pus or blood present
What are the two most commonly used IUCD’s?
Paraguard (t-shaped flexible plastic wrapped in copper)
Mirena (t-shaped flexible plastic that releases low amts of progestin)
What is a copper-releasing IUD?
ParaGard
remain in uterus up to 10 years
copper ions are toxic to sperm
What is a progestin-releasing IUD?
Mirena
remain in uterus up to 5 years
levonorgestrel impairs sperm motility and viability
what is hypertrophy?
excessive development of an organ or part
increase in by by thickening of muscle fibers
