UWise - Objectives 50-58 Flashcards
There is a much higher incidence of molar pregnancies among which ethnic group in the US?
Asian (1/800 vs. 1/2000)
List the risk factors for molar pregnancy.
- Women less than 20 or older than 40
- Asian
- Areas where people consume less beta-carotene and folic acid
- 2+ miscarriages
A complete mole has what characteristic appearance on U/S? What causes this appearance?
Snowstorm appearance; presence of multiple hydropic villi
Classic presentation of molar pregnancy?
- Vaginal bleeding (95%)
- Uterine size greater than dates (25-50%)/size less than dates (14-33%)
- No fetus on U/S
- Higher than normal beta-hCG values
In the face of discrepancy between dates and uterine size, a pelvic U/S is indicated - why?
Confirm dates, exclude multiple gestation, uterine abnormalities, and molar pregnancy
True or false - there is no single beta-hCG value that is diagnostic for a molar pregnancy.
True
With a beta-hCG above the discriminatory zone (>___ mIU/mL), an IUP should be identifiable on TV US.
2000
What is the standard treatment for molar pregnancies?
Suction curettage
Compare partial vs. complete moles regarding presence of fetal parts and placenta/cord.
Partial - may contain
Complete - none
Compare partial vs. complete moles regarding karyotype.
Partial - triploid (usually 69 XXY, 69XXX, or 69XYY) resulting from fertilization of egg by dispermy
Complete - diploid resulting from fertilization of an empty egg by a single sperm (46XX, 90%) or by two sperms (XY 6-10%)
Compare partial vs. complete mole in histologic appearance.
Partial - marked villi swelling
Complete - Trophoblastic proliferation with hydropic degeneration
Compare the clinical presentation fo partial vs. complete moles.
Partial - lower beta-hCG levels, older patients, longer gestations, often diagnosed as missed or incomplete abortions
Complete - larger uteri, preeclampsia, higher likelihood of developing into post-molar GTD
In the setting of a complete molar pregnancy what should be done prior to a suction curettage of the uterus?
R/o related problems prior to taking a patient to the OR –> CXR to rule out pulmonary mets + liver and thyroid function
Compare the risk of post-molar GTD in partial vs. complete moles.
Partial - 5%
Complete - 20%
How is choriocarcinoma diagnosed?
Presence of beta-hCG in a reproductive-aged woman who has a history of a recent pregnancy
Why should lesions suspicious for metastatic choriocarcinoma never be biopsied?
They are very vascular
How should a woman be managed following a molar pregnancy?
Follow quantitative eta-hCG levels to 0 after evacuation of the uterus; then wait at least 6 months to conceive
Why is molar pregnancy often associated with bilateral lutein cysts?
High concentrations of hCG, whose alpha subunit is identical to those found in luteinizing hormone and TSH -> ovaries are stimulated to produce lutein cysts + thyroid gland is stimulated to produce thyroid hormone -> TSH levels are suppressed -> hyperthyroid with weight loss and increased DTR; may also lead to early onset preeclampsia and associated elevation in BP
Given the findings of obvious, moderately differentiated carcinoma of the vulva, what definitive treatment is recommended?
Radical vulvectomy and groin node dissection
What is the most common vulvar malignancy?
SqCC (90% of vulvar cancers)
SqCC of the vulva may arise in the setting of chronic irritation from ___.
Lichen sclerosus or any other chronic pruritic vulvar disease
How does SqCC of the vulva present?
Lump + lung-standing history of pruritis; mean age is 65 y/o, smoking increases risk
How does lichen sclerosus appear?
Skin appears thin, inelastic, and white, with a “crinkled tissue paper” appearance
How does Paget’s of the vulva appear?
Lacy white mottling/plaque-like lesions and poorly demarcated erythema (not a discrete mass)
How does verrucous carcinoma appear?
Cauliflower-like lesions
___ represents 5% of vulvar cancer.
Melanoma
What diagnosis can have the same clinical appearance as melanoma?
High-grade VIN
The finding of a mass in the Bartholin gland is highly suspicious for ___.
Malignancy
True or false - any finding of a new Bartholin gland cyst in a post-menopausal woman should be further investigated.
True - for any woman over 40, a biopsy should be obtained
How should VIN III be treated?
Local superficial excision + close surveillance, as recurrence is possible
How is vulvar condyloma treated?
Trichloroacetic acid (TCA) or Imiquimod (Aldara)
What is used to treat cervical dysplasia?
Cryotherapy
Women who are on immunosuppressive therapy are at higher risk for what vulvar disease?
HPV-related conditions such as condyloma or vulvar dysplasia
How is VIN2 treated?
Laser treatment
What is Paget’s disease of the vulva?
In situ carcinoma of the vulva
True or false - Paget’s disease of the vulva is associated with breast cancer.
True
List # risk factors for vulvar cancer.
- HPV exposure (including lower-genital tract dysplasia and cervical cancer)
- Smoking
- Vulvar dystrophy (lichen sclerosus)
- Immunocompromise (HIV, AI disorders, immunosupressive therapies)
What are the two theories of vulvar cancer pathogenesis?
HPV infection and chronic inflammation from vulvar dystrophy
List the major risk factors for cervical cancer.
- Early-onset sexual activity
- Multiple sexual partners
- Sexual partner with multiple partners
- History of HPV or other STDs
- Immunosuppression
- Smoking
- Low SES
- Lack of regular pap tests
What are the management options for ASCUS?
HPV DNA testing or repeat cytology at 12 months
If HPV is negative- routine screening can be resumed at 3 years
If negative, or if repeat cytology at 12 months reveals ASCUS or higher, then colposcopy should be performed* -> for women ages 21-24, if HPV is positive, repeat cytology at 12 months recommended with colpo performed only if the repeat cytology reveals ASC-H, AGC, or HSIL
Fixation of the uterus and thickening of the rectovaginal septum and back pain suggests involvement of the ___ (Stage II) and possible extension to the ___ (Stage III) of cervical cancer.
Parametria; sidewall
True or false - a Pap test should not be used to exclude cervical cancer
True - it is a screening not a diagnostic test
A white plaque found on the cervix is called ___ and should be managed how?
Leukoplakia; biopsy directly or under colpo guidance ASAP
What is the false negative rate of Pap tests?
20-30%
What do punctuations and mosaicism represent?
New blood vessels on end and on their sides, respectively
Why do atypical vessels indicate a more aggressive lesion?
Greater degree of angiogenesis
What is ectropion?
Area of columnar epithelium that has not yet undergone squamous metaplasia; appears as a red ring of tissue surrounding the external os
True or false - endocervical curettage has a relatively low sensitivity and cannot be used to rule out endocervical disease.
True
In the setting of an unsatisfactory colposcopy, what should be done to examine the endocervical canal?
Cervical conization or co-testing repeated at 12 and 24 months
What is a necessary event for the pathogenesis of cervical neoplasia?
Sexual transmission of HPV; note that it is not sufficient
The development of cervical cancer typically takes at least ___ years from time of exposure.
15
At least ___% of sexually active women will have acquired a genital HPV infection by age 50.
75-80
True or false - the use of talc increases the risk of cervical cancer.
False
In microinvasive cancer, cells invade less than ___mm.
3
What is indicated in a patient with a positive endocervical curretage?
Cervical conization
What is the major symptom associated with myomas and what causes it?
Heavy menstrual bleeding;
- Increase in the uterine cavity size that leads to greater surface area for endometrial sloughing
- Obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea
True or false - myomectomy during pregnancy is contraindicated
True
Leiomyomas are an infrequent cause of miscarriages and subfertility, either by ___ or ___.
Mechanical obstruction of fallopian tubes, cervical canal, or endometrial cavity; distortion and interference with implantation
What type of myoma is most likely to cause lower pregnancy and implantation rates.
Submucosal or intracavitary
What are the presumed mechanisms by which submucosal or intracavitary myomas are most likely to cause lower pregnancy and implantation rates?
- Focal endometrial vascular disturbance
- Endometrial inflammation
- Secretion of vasoactive substances
True or false - the majority of patients with uterine fibroids do not require surgical treatment.
True
What is the medical therapy of choice to temporarily reduce symptoms and reduce myoma size?
GnRH agonist
How is GnRH agnoist therapy given?
Short period of time (3-6 months) typically before a surgical procedure or to bridge a woman who is close to menopause
Maximal response to a GnRH agonist is usually achieved by in ___.
3 months
The reduction in myoma size correlates with the ___ level and with body weight.
Estradiol
What happens to menses and myoma/uterine size after cessation of GnRH therapy?
Menses return in 4-10 weeks and myoma and uterine size return to pretreatment levels in 3-4 months
List 5 risk factors for endometrial cancer.
- Nulliparity
- Obesity
- Late menopause
- HTN
- Exposure to unopposed estrogens
- Tamoxifen therapy
- DM
Of the risk factors for endometrial cancer, which confers the greatest risk?
Obesity, especially when the patient is >50 lbs of ideal body weight (10x increase)
Less than ___% of women diagnosed with endometrial cancer are asymptomatic.
5
True or false - endometrial cancer is not typically a genetically inherited malignancy
True
What are the top 5 cancers detected in women?
- Breast
- Lung
- Colorectal
- Uterine
- Thyroid
What are the top 5 gyne cancers?
- Uterine
- Ovarian
- Cervical
- Vulvar
- Vaginal/other
Once a pathologic diagnosis of endometrial cancer is confirmed by biopsy, what treatment is recommended?
Definitive treatment by way of total hysterectomy with BSO + staging w/LN dissection (depending on the depth of invasion and grade of the tumor)
What are the recommended components of the surgical approach to an early endometrial cancer?
Extrafascial total hyst, BSO, and pelvic and para-aortic lymphadenectomy
In the setting of new onset irregular bleeding, endometrial hyperplasia, and an adnexal mass, what should be suspected?
Granulosa cell tumor (estrogen-secreting)
What are the most common causes of postmenopausal bleeding?
- Atrophy of the endometrium (60-80%)
- HRT (15-25%)
- Endometrial cancer (10-15%)
- Polyps (2-12%)
- Hyperplasia (5-10%)
What are the most common places for osteoporotic fractures?
Vertebral, hip, wrist
List the 6 risk factors for ovarian cancer.
- Nulliparity
- Family history
- Early menarche and late menopause
- White race
- Increasing age
- Residence in North America and Northern Europe
(Smoking does not increase risk. OC use decreases risk).
By how much do OC’s that cause anovulation appear to decrease risk for ovarian cancer?
Decreases lifetime risk by 1/2
Inherited BRCA1 and 2 mutations account for ___% of breast cancers and ___% of ovarian cancers among white women in the US.
5-10; 10-15
What causes functional ovarian cysts?
Normal ovulation
How do functional ovarian cysts appear on U/S?
Unilocular simple cyst without evidence of blood, soft tissue elements, or excrescences
What is the most useful radiologic tool for evaluating the entire peritoneal cavity and retroperitoneum?
CT
___ tumors represent 70% of sex-cord stromal tumors and typically affect women in their ___s.
Granulosa cell; 50s
What are the three main histologic sub-types of ovarian cancer?
- Germ cell tumors (5%)
- Sex-cord stromal tumors (1-2%)
- Epithelial tumors (90%)
Germ cell tumors typically affect women of what age groups?
10-30
Epithelial ovarian tumors affect what age groups of women?
All ages, but the malignant types occur in women in their 6th decade
What is a common etiology for ovarian torsion? Why?
Dermoid cyst; these cysts often contain oily contents that are less dense than surrounding tissue, rising to a more anterior position and creating instability of the infundibulopelvic ligament
The 5-year survival of patients with epithelial ovarian cancer is directly correlated with the ___.
Tumor stage (the volume of residual disease following cytoreductive surgery is also directly correlated with survival)
What sonographic characteristics make ovariancancer more likely?
- Complexity with solid components
- Size >10cm
- Mural nodules or excrescences
- Presence of ascites
- Bilaterality
What are the most common ovarian neoplasms in women <30 y/o?
Germ cell tumors
What are the most common ovarian neoplasms in women >30 y/o?
Epithelial cell tumors
True or false - while it is not appropriate to discuss a patient’s sexuality with their parent, the parent has a right to know about the child’s overall health as the legal guardian.
True
What can be used to restore the integrity of the vaginal epithelium and support tissue around the vagina?
Topical estrogen therapy
Why is petroleum jelly contraindicated as a lubricant?
It can cause irritation of the vaginal mucosa
How can female sexual dysfunction be classified?
Disorders in sexual desire, arousal, orgasm, or sexual pain, or a combination
What is the most common cause of insertional dyspareunia in postmenopausal women?
Urogenital atrophy
What is the hallmark of urogenital atrophy?
Estrogen deficit
How does sexual stimulation and activity help to prevent dyspareunia?
It improves blood flow; regular coitus helps to prevent constriction of the introitus
Lubrication during the arousal phase of intercourse is most dependent on…
…transudate of fluid across the vaginal mucosa as the genitalia become increasingly engorged with blood
___ describes how a person chooses to act sexually.
Sexual behavior
What is an involuntary constriction of vaginal musculature that makes coitus painful or impossible?
Vaginismus
How is vaginismus best treated?
Graduated vaginal dilators in the setting of appropriate counseling that allows the woman to control the setting and pace of attempts at penetration
What is sensate focus?
Type of sexual therapy indicated for arousal and orgasmic disorder
True or false - a loss of libido in the postpartum period is common
True - contributing factors include the stress and disruption of having a newborn, hyperprolactinemia and hypoestrogenism related to breastfeeding, perineal pain from delivery and a change in family dynamic
What is indicated for premenopausal hypoactive sexual desire disorder?
Flibanserin
___ infections are common after antibiotic therapy.
Yeast
A child under the age of ___ is legally viewed as incapable of providing consent.
16
What prophylactic treatment should be offered to all adult rape victims?
Antibiotic (ceftriaxone to prevent gonorrhea + prescriptions to prevent chlamydia, trichomonas, and HIV)
At the time of a sexual assault, a woman is routinely screened for HIV and syphilis to establish her baseline serologic status. How should this be followed?
It can take up to 6 weeks for a new syphilis infection to be detectable and up to 6 months for HIV. F/u testing is necessary to check for seroconversion
All women should be offered EC following sexual assault. What are the options and how long are they effective for?
Levonorgestrel - 72 hours
Ulipristal - 5 days
True or false - victims of IPV frequently present with vague physical and emotional complaints consistent with PMS.
True
