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Year 3 - Reproduction and Sexual Health > Week 6 > Flashcards

Week 6 Flashcards

1
Q

The majority of arteries in the pelvis and perineum arise from what vessel?

What are the exceptions?

A

Majority arise from the internal iliac artery

Exceptions - gonadal artery (which comes directly off the abdominal aorta at L2) and the superior rectal artery (continuation of the inferior mesenteric artery)

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2
Q

Describe the anterior and posterior divisions of supply by the internal iliac artery in the male

A

Anterior

  • obturator artery
  • inferior gluteal artery (usually, however may come from posterior division)
  • umbilical artery
  • internal pudendal artery
  • middle rectal artery
  • inferior vesical artery
  • superior vesicular artery

Posterior

  • Iliolumbar artery
  • Lateral sacral artery
  • Superior gluteal artery
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3
Q

What is the corona mortis?

Why is it important and what surgical procedure should it be carefully avoided in?

A

The corona mortis is an artery between the inferior epigastric artery and the obturator artery

It is important because, if damaged, it may go unnoticed but continue to bleed into the pelvis.

It should be kept in mind for hernia repair operations

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4
Q

What are the 3 folds found on the internal aspect of the abdominal wall?

A

Lateral umbilical fold (caused by the inferior epigastric vessels)

Medial umbilical folds (remnant of the umbilical artery)

Median umbilical fold a.k.a. urachus

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5
Q

Describe the arterial supply to the male perineum

A

Internal pudendal artery > perineal artery, which goes on to form the posterior scrotal artery

Internal pudenal > dorsal arteries of the penis

Internal pudendal > deep arteries of the penis (vasoconstricted in erection)

External iliac > anterior scrotal artery

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6
Q

The uterine artery is a branch of the ____

The vaginal artery is a branch of the ____

A

Uterine is a branch of the anterior division of internal iliac artery

Vaginal is a branch of the uterine artery

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7
Q

Describe the arterial supply of the ovary

A

Ovarian artery (directly from the abdominal aorta)

ANASTOMOSIS WITH…

Uterine artery

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8
Q

Why does the uterine artery have a curved, tortuous path along the uterus?

A

Allows the artery to expand with the uterus during pregnancy

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9
Q

Describe the arterial supply to the perineum in the female

A

Internal pudendal a > inferior rectal artery

Internal pudendal a > perineal artery > labial arteries

Internal pudendal a > dorsal artery of the clitoris

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10
Q

What vessel do the majority of veins in the pelvis drain to?

What is the alternative?

A

The internal iliac vein and onto the vena caval circulation

Some will drain into the superior rectal vein, which drains into the portal system

Some others may drain via the lateral sacral veins into the internal vertebral venous plexus

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11
Q

Regarding lymphatics of the pelvis, where do the following drain?

  • Superior pelvic viscera
  • Inferior pelvic viscera
  • Superficial perineum
A

Superior pelvic viscera

  • external iliac nodes
  • on to common iliac nodes, then aortic, then thoracic duct and finally venous system

Inferior pelvic viscera

  • i.e. deep perineum
  • internal iliac nodes
  • then on to the same as the above

Superficial perineum

  • superficial inguinal nodes
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12
Q

Where does the fundus of the uterus drain to?

What is important to note about lymph drainage of the pelvis? Why does this matter clinically?

A

The fundus of the uterus drains to the superficial inguinal nodes

There is a considerable degree of overlap, meaning that cancers can spread in any direction and, as such, the pattern of lymph involvement is not sufficient to predict spread

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13
Q

What nodes do gonadal lymphatics drain to?

A

Aortic/caval nodes

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14
Q

How does the histology of the endocervix differ to that of the ectocervix?

A

Ectocervix has numerous layers…

  • exfolitating cells
  • superficial cells
  • intermediate cells
  • parabasal cells
  • basal cells
  • basement membrane

While the endocervix is completely different in that it is a single monolayer of mucinous epithelium

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15
Q

What is the transformation zone?

Why is it clinically relevant?

A

Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelium

Position of TZ changes through life as a physiological response to menarche, pregnancy and menopause

The TZ is the most common site of cervcal intraepithelial neoplasia (CIN)

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16
Q

What types of pathology might arise at the transformation zone?

Both benign and neoplastic

A

Benign inflammation (common)

  • cervicitis - non-specific acute/chronic inflammation, usually of unknown cause, but can be caused by Chlamydia, HSV infection etc.
  • cervical polyps - localised inflammatory outgrowth, may cause bleeding, not premalignant

Neoplastic

  • Cervical intraepithelial neoplasia (CIN) - graded I-III
  • Cervical cancer
    • squamous carcinoma (most common)
    • adenocarcinoma
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17
Q

What is a Nabothian follicle?

A

Mucous-filled cyst on the surface of the cervix

Most commonly caused by stratified squamous epithelium of the ectocervix growing over the simple columnar epithelium of the endocervix

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18
Q

What virus (specifically what subtypes) is associated with cervical cancer?

A

HPV, types 16 and 18

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19
Q

Is HPV a sexually transmitted infection?

A

Not really, but it only appears in people who have been sexually active. Symptoms can occur years after being infected with the virus

The virus can be found elsewhere in the body

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20
Q

CIN/Cervical Cancer - risk factors

A

Many sexual partners - increased exposure to high risk HPV types

Early age of first intercourse

Long term use of oral contraceptives

Non-use of barrier contraception

Smoking - 3x risk

Immunosuppression

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21
Q

What subtypes of HPV cause genital warts?

A

6 and 11

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22
Q

What criteria dictates if CIN has become cervical cancer?

A

If the abnormal cells have broken through the basement membrane, even if it is just one cell!

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23
Q

How long do the following take…

  • HPV infection progressing to high grade CIN
  • CIN progressing to cervical cancer?
A

HPV to CIN - 6 months to 3 years

High grade CIN to cervical cancer - 5 to 20 years

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24
Q

What are the key features of CIN?

A

Pre-invasive stage of cervical ca

Occurs at the TZ

Area involved can be variable

Dysplasia of squamous cells is seen (dyskaryosis)

Not visible with the naked eye, only detected on smear test

Asymptomatic

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25
Q

What are the 3 grades of CIN characterised by?

A

Degree of koilocytosis

CIN I - raised number of mitotic figures first third of cells from basement membrane

CIN II - mitosis in first 2 thirds

CIN III (squamous carcinoma in situ) - full thickness of koliocytosis

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26
Q

What is seen in the histology of CIN?

A

Delay in maturation/differentiation of basal cells

Nuclear abnormalities (hyperchromasia, increased nucleus:cytoplasm ratio, pleomorphisms)

Excess mitotic activity

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27
Q

How is invasive squamous carcinoma of the cervix staged?

A

Stage 1A1 - depth up to 3mm, width up to 7mm

Stage 1A2 - depth up to 5mm, width up to 7mm

Stage 1B - confined to the cervix

Stage 2 - spread to adjacent organs

Stage 3 - involvement of pelvic wall

Stage 4 - sites of distant mets/involvement of rectum or bladder/any presence of hydronephrosis

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28
Q

Invasive squamous carcinoma of the cervix - symptoms

A

Usually none early

Abnormal bleeding (post coital, post menopausal, contact bleeding suggesting friable epithelium, brownish vaginal discharge)

Pelvic pain

Haematuria/urinary infections

Ureteric obstruction/hydronephrosis (automatic stage 4)

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29
Q

What is more common - squamous carcinoma or adenocarcinoma of the cervix?

A

Squamous carcinoma is more common - 75-95% of malignant cervical tumours

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30
Q

What cell types are seen on histology in HPV infection?

A

Koilocytes

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31
Q

What are the various FIGO stages for invasive squamous carcinoma of the cervix?

A

1A1 - depth up to 3mm, width up to 7mm

1A2 - depth up to 5mm, width up to 7mm. Low risk of lymph node mets

1B - confined to the cervix

2 - spread to adjacent organs

3 - involvement of pelvic wall

4 - spread to distant organs/involvement of the rectum or bladder

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32
Q

Regarding spread of squamous carcinoma of the cervix, where might you see mets if spread occurred via…

  • local spread
  • lymphatics
  • haematogenous
A

Local spread - uterine body, vagina, bladder, ureters, rectum

Lymphatics (early) - pelvic and para-aortic nodes

Haematogenous (late) - liver, lungs, bone

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33
Q

What is the precursor to adenocarcinoma of the cervix?

How does it compare in terms of occurrence and aggression to cervical intraepithelial neoplasia?

Is it easier or harder to diagnose than squamous carcinoma via smear?

A

Cervical Glandular Intraepithelial Neoplasia (CGIN)

Less common, more aggressive

Harder to diagnose on smear, meaning screening is less effective and prognosis is worse

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34
Q

What are some of the risk factors associated with adenocarcinoma of the cervix?

A

Higher socioeconomic class

Later onset of sexual activity

Smoking

HPV again, particularly HPV 18

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35
Q

Vulvar intraepithelial neoplasia (VIN) is described as being bimodal in its distribution, affecting younger women and older women.

How does the condition tend to differ in these two groups?

A

Younger women - often multifocal disease, recurrent/persistent and causing treatment problems

Older women - greater risk of progression to invasive squamous carcinoma

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36
Q

What’s the diagnosis? Crusting rash over the vulva, tumour cells seen in epidermis that contain mucin and arise from sweat glands in the skin

A

Vulvar Paget’s Disease

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37
Q

What is the arterial blood supply to the ovary?

A

2 contributing parts

  1. Ovarian artery (from the abdominal aorta, given off at L2)
  2. Uterine artery (from internal pudendal, from internal iliac)

These two anastomose together

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38
Q

In surgery, how can you tell the difference between the ureter and the uterine artery?

What is the most likely site of damage for the ureter?

A

Ureter runs underneath the uterine artery (water under the bridge)

The ureter will also vermiculate when stroked

Most common site of ureter damage is the uterosacral ligament

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39
Q

What muscles are involved in micturition and which nerves supply these muscles?

A

Contraction of the detrusor in response to parasympathetic innervation from the pelvic splanchnic nerve (S2-S4) - overrides sympathetic control over the bladder that is inhibiting bladder contraction

Stretch sensation of the bladder is carried by visceral afferents to the sacral region of the spinal cord (follows the parasympathetic fibres)

External urethra and pelvic floor (levator ani) muscles relax

Abdominal muscles contract

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40
Q

What is the name of the greate vestibular gland when it is in…

a) males
b) females

A

Males - Cowper’s gland

Females - Bartholin’s gland

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41
Q

How does urinary catheterisation differ in the male and the female?

A

Males - longer catheter required but easier to do. Increased prostate size may make it harder

Females - shorter catheter used

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42
Q

What are the 3 muscles that make up the levator ani?

What nerve innervates these muscles?

A

Puborectalis

Pubococcygeus

Iliococcygeus

Innervated by the pudendal nerve (S2-S4) and the nerve to levator ani (S3-S5)

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43
Q

Other than the levator ani, what other muscles make up the pelvic floor?

A

Coccygeus

Piriformis

Fascia of the obturator internus (tendinous arch)

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44
Q

What vessels can become damaged when inserting a trochar through the obturator membrane, or through the sacrospinous ligament?

A

Obturator artery

Internal pudendal artery

Superior gluteal artery

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45
Q

What is the clinical relevance of the ischioanal fossa?

A

The pudendal canal runs through this space (containing the internal pudendal artery, the internal pudendal veins and the pudendal nerve)

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46
Q

What is the average age of menopause?

Define the following terms…

  • early menopause
  • premature menopause
  • late menopause
A

Average age of menopause - 51 years

Early menopause - <45 years

Premature menopause - <40 years

Late menopause - >54 years

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47
Q

What are some of the effects of oestrogen?

A

Development of secondary sex characteristics

Affects hair growth, body shape and fat distribution

Affects bone growth and collagen

Causes proliferation of the endometrium

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48
Q

How is menopause diagnosed?

A

Clinical history + age + history of menstruation

Explore symptoms

Possible blood tests (including pregnancy test!) - can also look at FSH (recommended if woman is younger) and oestradiol (oestradiol is the dominant oestrogen BEFORE menopause, oestrone is the dominant oestrogen AFTER menopause)

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49
Q

LH and FSH are released steadily/in a pulsatile manner

Is a raised level indicative of menopause?

A

LH and FSH are released in a pulsatile manner

A single raised level does NOT indicate menopause (is raised prior to ovulation, is raised when stopping the COCP, raised with breastfeeding and certain medications e.g. SSRIs)

50
Q

What are some of the physical symptoms of the menopause?

A

Hot flushes

Night sweats

Palpitations

Insomnia

Joint aches

Headaches

Later symptoms - frequency, recurrent UTIs, dysuria, incontinence, dry hair and skin, atrophy of breasts and genitals

51
Q

What are some of the psychological and sexual symptoms of the menopause?

A

Psychological

  • mood swings
  • irritability
  • anxiety
  • difficulty concentrating
  • forgetfulness

Sexual

  • vaginal dryness
  • decreased libido
52
Q

What diagnosis needs to be excluded in women presenting with perimenopausal dysfunctional uterine bleeding (irregular periods, intra-menstrual bleeding, post-menopausal bleeding)?

A

Endometrial ca needs to be excluded - requires biopsy

53
Q

Menopausal symptoms can be managed conservatively with diet modification, weight loss, exercise etc.

If the woman complains of menorrhagia, what treatments can be given?

A

Mefenamic acid (NSAID that reduces the blood supply to the womb)

Tranexamic acid (antifibrinolytic, stops clots from breaking down)

Progesterones (thin the lining of the womb)

IUS

Endometrial ablation

Hysterectomy

54
Q

What hormone replacement therapy (HRT) options are there for a woman going through the menopause?

A

Oestrogen alone

Oestrogen + progesterone

(either topical or oral)

55
Q

What are the risks of HRT?

A

Oestrogen therapy alone is a risk factor for endometrial cancer, only given to women that have had a hysterectomy

Combined progesterone and oestrogen is associated with a small increase in breast cancer risk

Increased risk of blood clots

Increased risk of heart disease, strokes and MI

Increased risk of gallbladder disease

(these risks are largely negligble in younger, healthy women)

56
Q

Other than HRT, what medications might be used to manage the symptoms of menopause?

A

Clonidine (treats hypertension and hot flushes by stimulating alpha2 receptors in the brain stem)

SSRIs - useful for managing anxiety and mood swings

Regelle - vaginal moisturiser

Sylk - lubricant

57
Q

What are some of the causes of dysfunctional uterine bleeding?

A

Fibroids and polyps - common, and often occur around/after the menopause

Endometrial hyperplasia (simple, complex or atypical [precursor of carcinoma])

Adenomyosis (presence of endometrial tissue in the myometrium)

Ovulation disorders

Bleeding disorders

58
Q

Describe ‘Simple’ endometrial hyperplasia in terms of distribution, affected components, gland appearance and cytology

A

Distribution - general

Affected components - glands and stroma

Gland appearance - dilated, not crowded

Cytology - normal

(see cystically dilated glands. This presentation is common around menopause)

59
Q

Describe ‘Complex’ endometrial hyperplasia in terms of distribution, affected components, gland appearance and cytology

A

Distribution - focal

Affected components - glands

Gland appearance - crowded

Cytology - normal

(see cigar shaped nuclei along the basement membrane, but cells retain their shape so are not atypical)

60
Q

Describe ‘Atypical’ endometrial hyperplasia in terms of distribution, affected components, gland appearance and cytology

A

Distribution - focal

Components affected - glands

Glands appearance - crowded

Cytology - atypical

(management is w/ hysterectomy, nuclei appear rounder and more prominent)

61
Q

What age is the peak incidence for endometrial carcinoma?

If present in younger groups, what underlying conditions might you consider?

A

Peak incidence is 50s-60s, uncommon to see in under 40s

If seen in younger women, consider underlying predisposing conditions such as PCOS or Lynch Syndrome

62
Q

What are the two main clinico-pathological types of endometrial carcinoma? Which is most common?

What are the precursors to each?

A

Endometrioid (and mucinous) carcinoma (type 1 tumours, 80% of cases) - precursor is atypical hyperplasia

Serous (and clear cell) carcinoma (type 2 tumours) - precursor for serous carcinoma is serous intraepithelial carcinoma

63
Q

Type 1/Type 2 endometrial tumours are associated with unopposed oestrogen

A

Type 1 (endometrioid and mucinous) is associated with unopposed oestrogen

64
Q

What is often found to be mutated in type 2 endometrial tumours (serous and clear cell)?

A

TP53 is often seen to be mutated

65
Q

What mutations are seen in type 1 endometrial tumours (endometrioid and mucinous)?

The feature of what genetic abnormality, associated with type 1 tumours, suggests that there is an error in DNA mismatch repair?

A

PTEN

KRAS

PIK3CA

Microsatellite instability is seen in type 1 tumours and suggests errors in DNA mismatch repair

66
Q

The presence of sawtooth, irregular glands on histology of suspected endometrial carcinoma would suggest what type of tumour?

A

Endometrioid endometrial carcinoma

67
Q

What lifestyle factor is strongly associated with the development of endometrial cancer?

Why is this the case?

A

Obesity

Excess adipose tissue results in increased endocrine and inflammatory effects.

Adipocytes express aromatase that converts ovarian androgens into oestrogens - induces endometrial proliferation

Insulin action also tends to be altered in obese women - the level of insulin-binding globulins is reduced and free insulin levels are elevated. Insulin/Insulin-like growth factors (IGF) exert proliferative effects on the endometrium

68
Q

What is the lifetime risk of developing endometrial cancer in a woman with Lynch syndrome?

What is the inheritence pattern for this condition?

A

28%

(Also an increased risk of developing ovarian cancer)

Autosomal dominant

69
Q

What other genetic feature do Lynch Syndrome tumours demonstrate (hint: same as type 1 endometrial tumours!)

A

Microsatellite instability indicating errors in DNA mismatch repair

70
Q

Type 2 tumours are less aggressive/more aggressive than Type 1 tumours

What is the precursor to these tumours?

A

Type 2 tumours are more aggressive

Precursor lesion is serous endometrial intraepithelial carcinoma

71
Q

How does serous carcinoma appear on histology?

A

Complex papillary/glandular architecture

Diffuse, marked nuclear polymorphisms

72
Q

How do endometrioid and serous carcinomas spread, and as such which has a better prognosis?

A

Serous - may spread along the fallopian tubes early and get into peritoneal cavity. Worse prognosis, usually requires more intensive surgery and adjuvant chemo/radiotherapy

Endometrioid - better prognosis, tends to be confined to the uterus at presentation

73
Q

How is endometrial carcinoma treated?

A

Hysterectomy +/- adjuvant chemo/radiotherapy

74
Q

How is endometrioid carcinoma graded?

(serous carcinoma and clear cell carcinoma are not formally graded)

A

Graded 1-3, primarily by architecture

Grade 1 - 5% or less solid growth

Grade 2 - 6-50% solid growth

Grade 3 - >50% solid growth

75
Q

How is endometrial carcinoma staged?

A

FIGO/TNM staging

Stage I - confined to the uterus

IA - no or <50% myometrial invasion

IB - invasion equal to or >50% of mymetrium

Stage II - tumour invades local cervical stroma

III - local and or regional tumour spread

IV - tumour invades bladder and/or bowel mucosa (IV A), or distant metastases (IV B)

76
Q

Which is more likely to affect elderly, post-menopausal women - type 1 or type 2 endometrial tumours?

A

Type 2 are more likely due to having a thinner, non-hypertrophic endometrium

77
Q

What’s the condition/organism/treatment: fishy smelling vagina with a positive ‘whiff’ test, clue cells seen on histology and thin white vaginal discharge?

A

Condition - bacterial vaginosis

Organism - Gardnerella vaginalis

Treatment - metronidazole

78
Q

What benign smooth muscle tumour is very common and associated with menorrhagia and inferility?

A

Leiomyoma (fibroids)

79
Q

Leiomyosarcomas are common/rare. What age group are they seen in?

What does their cell morphology show?

What is the 5 year survival?

A

Leiomyosarcomas are relatively rare, accounting for 1-2% of all uterine malignancies

Most commonly seen in women >50 years old

Malignant smooth muscle tumours that commonly display a spindle cell morphology

5 year survival is only 15-25%

80
Q

What are some gynaecological causes of palpable pelvic mass?

A

Uterine - body (pregnancy, fibroids, rarely cancer as usually presents early with post-menopausal bleeding) or cervix (again, rarely cancer)

Ovaries

Tubal (or para-tubal)

81
Q

What is the most common cause of pelvic mass in women over 40 years of age?

A

Leiomyomas - very common

82
Q

Other than a palpable pelvic mass, how might uterine fibroids present?

A

Menorrhagia

Pain/tenderness

‘Pressure’ symptoms i.e. sensation of pushing, heavy etc.

83
Q

How are suspected fibroids investigated?

A

Hb levels if heavy bleeding

USS usually diagnostic, and can MRI for precise location

84
Q

What options are there for treating fibroids?

A

If asymptomatic, just leave them

If family complete, hysterectomy

Alternatively - myomectomy, uterine artery embolisation or hysteroscopic resection

85
Q

What are some of the causes of tubal swellings?

A

Ectopic pregnancy

Hydrosalpinx (blockage of tube and accumulation of serous or clear fluid near the ovary)

Pyosalpinx (as above, but fills with pus)

Paratubal cysts

86
Q

What are ‘functional’ cysts?

A

Related to ovulation - follicular or luteal cysts

Rarely larger than 5cm and usually resolve spontaneously, often asymptomatic

May cause mentrual disturbances, or rupture causing pain

87
Q

What symptoms are endometriotic cysts typically associated with?

What classical distinguishing appearance do endometriomas have?

A

Endometriotic cysts typically present with severe dysmenorrhoea, premenstrual pain, dyspareunia and are often associated with infertility

Classic appearance is of “chocolate cysts” which may rupture

88
Q

There are lots of types of primary ovarian tumour…

What are the subtypes that arise from the surface epithelium (adenoma/adenocarcinomas)?

Which age group is affected?

A

Serous

Mucinous

Endometrioid

Clear cell

Brenner

20+ year olds. NB - this is the most common type of ovarian tumour

89
Q

There are lots of types of primary ovarian tumour…

What are the subtypes that arise from germ cells?

Which age group is affected?

A

Benign cystic teratoma (aka dermoid cyst)

Dysgerminoma

Yolk sac

Choriocarcinoma

Embryonal carcinoma

0-25 year olds

90
Q

There are lots of types of primary ovarian tumour…

What are the subtypes that arise from sex-cord stroma?

Which age group is affected?

A

Adult granulosa cell tumours (may secrete oestrogens)

Fibromas/thecomas (may secrete androgens)

All ages affected

91
Q

What is Meigs syndrome?

A

Triad of ascites, benign ovarian tumour (fibromas) and pleural effusion

Resolves after resection of the tumour

92
Q

What’s the tumour type?

Once removed, was found to contain hair, teeth and sebaceous material. Could also potentially contain thyroid tissue, leading to thyrotoxicosis

A

Teratoma (dermoid cyst)

93
Q

What’s the tumour type?

Patient had precocious puberty and presented with post-menopausal bleeding

A

Granulosa cell tumour, secreting oestrogens

94
Q

What’s the tumour type?

Patient presented with hirsutism and virilisation

A

Thecal tumour producing androgens

95
Q

The ovaries are a common site of metastatic disease spread.

Where are primaries most commonly found?

A

Breast

Pancreas

Stomach

GI locations

96
Q

Ovarian cancer can have a varied presentation. What are some of the symptoms that someone might complain of?

A

Heartburn/indigestion

Early satiety

Weight loss/anorexia

Bloating

Pressure symptoms (especially the bladder)

Changes in bowel habit

Shortness of breath/pleural effusion

Leg oedema or DVT

+/- pelvic mass

97
Q

What % of ovarian cancers have a genetic basis?

What genes are implicated?

A

Only 5% have a genetic basis, but always remember to ask about family history!

BRCA1 and BRCA2 (also associated with breast cancer)

98
Q

What are some of the risk factors for developing ovarian cancer?

A

Things related to having had MORE menstrual cycles

Early menarche/late menopause

Increasing age

Nullparity

FHx

NB - OCP is protective, stops ovulation

99
Q

In a patient with suspected ovarian cancer, what investigations would you perform?

A

Look for tumour markers Ca 125 and Carcino-embryonic antigen (CEA)

Imaging - USS, CT is better for assessing disease outwith of the ovary

100
Q

What are the pros and cons of measuring Ca 125?

A

It’s raised in 80% of ovarian cancers

It’s presence is not diagnostic, as loads of other things can also cause it to be raised (endometriosis, peritonitis, pregnancy, pancreatitis etc.)

101
Q

What is the main function of measuring CEA?

A

Main purpose is to exclude GI primary

May be moderately elevated in ovarian ca (especially mucinous tumours)

102
Q

What features on USS would make you suspicious of ovarian cancer?

A

Complex mass with a solid and cystic area

Multi-loculated

Thick septations

Associated ascites

Bilateral disease

103
Q

How are ovarian cysts/masses managed?

If malignant, how likely is surgery to be curative?

A

If likely benign - removal or drainage

If otherwise - removal of ovaries and uterus w/ removal/biopsy of omentum. ‘Debulking’ of tumour and complete examination of all peritoneal surfaces

Chemo may be given as either neo-adjuvant or adjuvant

Cure is unlikely unless cancer is confined to the ovary at presentation

104
Q

Patients may present acutely with pelvic mass (causing acute abdomen).

What are some of the gynaecological causes of acute abdomen?

A

Cyst

  • rupture
  • haemorrhage into cyst
  • torsion

Fibroid degeneration

  • usually ‘red’ degeneration (seen around pregnancy, haemorrhagic infarction of uterine fibroid)
105
Q

What is a follicular cyst?

A

Benign ovarian cyst that may form when ovulation doesn’t occur, resulting in polycystic ovaries. Follicle doesn’t rupture, just continues to grow into a cyst

Very common

Thin-walled and lined by granulosa cells

Usually resolve within a few months

106
Q

What symptoms are caused by endometroisis?

Where might it be found?

A

Symptoms - pelvic inflammation, pain and infertility

Sites - ovaries (chocolate cysts), Pouch of Douglas, peritoneal surfaces including the uterus, cervix, vagina, vulva, bladder, bowel….

Basically anywhere!

Can disseminate via vascular or lymphatic means

107
Q

What are some of the potential complications associated with endometriosis?

A

Cyst formation

Adhesions

Infertility

Ectopic pregnancy

Malignancy (becoming endometrioid carcinoma)

108
Q

What are the various classifications of ovarian tumour (based on cell type)?

A

Epithelial (adenoma/adenocarcinoma)

Germ cell

Sex-cord/Stromal

Metastatic

109
Q

What are the main types of epithelial ovarian tumour?

A

Serous

Mucinous

Endometrioid

Clear cell

Brenner

110
Q

When classifying epithelial ovarian tumours, what key feature determines if the tumour is benign or malignant?

A

Has the stroma been invaded? If so = malignant

111
Q

Endometrioid and clear cell carcinomas of the ovary are strongly associated with what conditions?

A

Endometriosis of the ovary

Lynch syndrome

112
Q

What is the precursor lesion seen prior to the development of high grade serous carcinoma?

A

Serous tubal intraepithelial carcinoma (STIC)

113
Q

What is a Brenner tumour?

Are they usually benign, borderline or malignant?

A

Tumour of transitional epithelium

Usually benign

114
Q

Germ cell tumours comprise 15-20% of all ovarian tumours

What is by far the most common type of germ cell tumour?

A

Teratomas (dermoid cysts) - 95% of all germ cell tumours

Benign, cystic

Contain sebum, hair, teeth etc. (material from ectoderm, mesoderm and endoderm)

Can rarely become malignant

115
Q

Other than teratomas, what other types of germ cell tumour are there?

A

Dysgerminoma (seminoma in males, usually malignant)

Yolk sac tumour (rare, malignant)

Choriocarcinoma

Mixed germ cell tumour

116
Q

What age group is typically affected by dysgerminomas?

A

Almost exclusively children and young women

Average age is 22

1-2% of all malignant ovarian tumours and the most common malignant primitive germ cell tumour

117
Q

What diagnosis should be considered in any woman of reproductive age that presents with amenorrhoea and acute hypotension or acute abdomen?

A

Ectopic pregnancy

118
Q

What are the 4 stages of FIGO staging?

What feature isn’t really included in FIGO staging that is included in standard TMN staging?

A

I - confined to cervix

II - included basal tissue, periepithelial and fundus

III - distant spread to nodes/tissues in pelvis

IV - distant mets

Lymph nodes are not really featured as much in FIGO staging

119
Q

What is brachytherapy?

What possible complications might develop as a result of this treatment?

A

Brachytherapy - form of radiotherapy in which a sealed source of radiation is placed inside or near the site of the tumour

Avoids surrounding structures being exposed to radiation, as is the case with standard beam radiotherapy

Complications - vaginal stenosis and effects on sexual function. If the patient has a history of anaemia, this could also result in hypoxia developing

120
Q

What investigation is used to grade and stage cervical cancer?

A

PET-CT

121
Q

What are some causes of post-menopausal bleeding?

Which is the most common cause?

A

Endometrial cancer

Endometrial polyp

Atrophic vaginitis (most common cause)

122
Q

If a patient presented complaining of post-coital bleeding and inter-menstrual bleeding, what would be the main diagnosis you should be concerned about?

A

Cervical cancer

Year 3 - Reproduction and Sexual Health (7 decks)

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