GYN Exam 3 - Part 1

Infertility is the inability to conceive within how many months?

12 months if less than 35 years of age

6 months if 35 or older

Approx. one in how many couples are affected by infertility?

1 in 7

Treat yourself to a break and sweet treat queen

yes

What percentage of infertility is attributed to females, males, and combined/unexplained

40% female

40% male

20% combined/unexplained

Infertility will be reviewed for the following causes:

Cervical

Uterine & Endometrium

Fallopian Tube

Ovulatory

Peritoneal

Male factor causes

To remember: Cats Usually Eat Fish Or Pursue Mice

Male factors for infertility

Inadequate number of sperm

Decreased motility of sperm (can’t move enough)

Obstruction of the spermatic ducts

Obstruction of the vas deferens

Scrotal varicoceles (engorged veins around scrotum)

What is the role of the cervix in fertility?

To provide a non-hostile environment to harbor sperm by secreting mucus that hold the sperm

Ex) The cervix has to be a nice host when inviting in their new friend Mr. Sperm, so he feels safe to stay. The cervix makes sticky like mucous; honey treats to make sure Mr. Sperm doesn’t leave.

What is sperms life span

3-6 days

T/F - Ultrasound is used to evaluate cervical length during pregnancy to assess for cervical incompetence

True

What are the two main objectives when evaluating the uterus?

1. Assess structural anatomy

   1. Evaluate uterine shape for congenital malformations

   2. Evaluate echogenicity

2. Assess endometrium

   1. Evaluate the thickness and echogenicity (is it thiuck enough to carry a bebe 🤔

   2. Evaluate for intracavitary lesions

In what percentage of women do uterine anomalies usually happen?

1%

What do congenital uterine anomalies result from?

Defects in the Mullerian duct development, fusion, or resorption; Associated with renal anomalies (remember our previous chapters)

What are the most easily assessed congenital anomalies

Septate or bicornuate uterus and uterus didelphys

T/F - US lowkey sucks for confirming congenital anomalies but it is good at seeing 2 EMCs?

True

Which congenital anomaly is not usually associated with fertility problems?

Uterus didelphys

Which congenital anomaly is associated with a low incidence of fertility problems and is not usually treated?

Bicornuate uterus

Which is the most common Mullerian anomaly that also has the highest incidence of infertility?

Septate uterus

Septate uterus

2 Ut cavities and single fundus; There is no notch and the UT shape has its usual normal shape on the outside but is different on the inside; If a pregnancy implants along the septum, there is not enough blood supply so baby might not make it.

When we evaluate the EMC, what do we look for?

Is uterus uniform in echogenicity and are there masses suggestive of fibroids that may impede implantation of fertilized egg

When assessing endometrium, evaluate?

Thickness, echogenicity characteristics, include evaluation for any intracavitary lesions

How thick does the endometrium need to be to achieve pregnancy?

at least 6mm

What happens in the first half of the menstrual cycle?

Mucosa begins to proliferate because of increasing estrogen levels. This is the best time to access (check) for intracavitary masses

Remember, proliferative phase = 3 line sign

What happens after ovulation

Progesterone is secreted by corpus luteum, beginning the secretory phase of endometrial cycle, resulting in loss of “3 line sign”

Luteal phase deficiency

When not enough progesterone was made during luteal phase, resulting in endometrial lining being thinner than what it should be. Associated with infertility and early pregnancy loss

What are other reasons the endometrium may look irregular or potentially impede implantation?

Submucosal fibroids (da ones that push up against the endometrium)

Polyps (could be in the endometrium or blocking the cervix)

Adhesions

T/F - Removing damaged fallopian tubes increases infertility issues?

False

Besides checking for hydrosalpinx, what else does US check for in the fallopian tubes?

Access patency (basically, is blood flow not obstructed)

What is saline infused sonography used for when looking at the fallopian tubes?

Used to check tubal patency by injecting saline into tube and looking for spillage of fluid into cul-de-sac or by using contrast to evaluate for spillage

Hysterosalpingogram

An x-ray procedure used to see whether the fallopian tubes are patent (open) and if the inside of the uterus (uterine cavity) is normal

What syndrome is it when follicles begin to grow but do not develop normally and immature follicles continue to produce estrogen?

PCOS

The production of estrogen in PCOS inhibits the pituitary glands function of releasing what two hormones, preventing normal ovulation?

LH and FSH

Peritoneal factors, such as adhesions and endometriosis, may be the cause of what amount of infertility cases?

25%

What results from fluid collecting between adhesions?

Peritoneal inclusion cyst

What is ovarian induction therapy?

Treatment in which ovarian stimulation is achieved in a controlled setting, usually by administering Clomid or human menopausal gonadotropins

What is Clomid?

Clomiphene citrate

What is administering clomiphene citrate or human menopausal gonadotropins supposed to result in?

Enlargement of multiple follicles

During what days is US supposed to check the size and number of follicles in a patient who is undergoing ovarian induction therapy?

8-14

What is the optimal measurement of a mature follicle?

Between 16-20mm

How is the endometrium evaluated during OV stimulation

Assessing thickness and echogenicity pattern

What is the normal response of the EMC as a result from OV stimulation?

An increasing thickness from 2-3mm to 12-14mm

What does the treatment plan for IVF consist of

• Ovarian monitoring

• Needle aspiration of oocytes under TVUS before ovulation

• Incubation & fertilization of oocytes

• Transferring embryos into uterus

IUI - Intrauterine insemination

Treats male infertility; A catheter containing da sperm is placed into uterine fundus; US guidance is sometimes used for procedure

Complications associated with Assisted Reproductive Technology

• Ovarian hyperstimulation syndrome (OHSS)

• Multiple gestations

• Ectopic pregnancy

Size of the dominant follicle in reproductive years?

2-2.5cm

Do these ovary characteristics belong to a woman of reproductive age or a postmenopausal woman?

1. Ovary atrophies

2. Follicles disappear with increasing age

3. Often difficult to visualize sonographically

Postmenopausal

Volume of more than (_______) that of opposite side of the ovary should be considered abnormal, regardless of actual size

2x

What measurement is used to determine overall ovarian size?

L x W x H x 0.523

Sonographic criteria of a simple cystic mass

• Thin, smooth wall

• Anechoic

• Acoustic enhancement

Surgery is recommended for a simple cyst IN A PREMENOPAUSAL PATIENT, if it over _____cm and persists over 8 weeks

6

Surgery for a simple cyst in a postmenopausal patient is recommended when it is over ____cm

5

T/F - Most OV masses are not simple cysts or benign

False

What are premenopausal cystic masses also called?

Functional cysts

Remember, any simple cyst that hemorrhages as it involutes may appear as a complex mass

I remember

What is the most common functional cyst

Follicular cyst

What is the most common cause of ovary enlargement in young women

Functional ov cysts

Remember, BCP is administered to suppress cysts

I remember

What kind of cyst results when dominant (graafien) follicle fails to ovulate OR when dominant follicle doesn’t involute post ovulation

Follicular cyst

What kind of cyst results from failure of reabsorption OR excess bleeding into the corpus luteum AND may have a “ring of fire”

Corpus luteum cyst

T/F - If the ovum is fertilized, it will continue as a corpus luteum cyst of pregnancy that secretes progesterone

True

What is the LARGEST (like almost as large as the elephant from Sing) functional cyst that is also a multiloculated cystic mass

Theca-lutein cyst (almost sounds like THICKA lutein cyst)

Which cyst is associated with high levels of HCG

Theca-lutein cyst

Hemorrhagic cyst

Result of internal hemorrhage (cyst bleeds internally) and filled with blood and cystic fluid; You can see it best on transvaginal scans

Acute hemorrhage

Looks hypoechoic and uniform on US, may even mimic a solid mass, and it has a smooth posterior wall with acoustic enhancement

non-acute hemorrhage

Internal pattern is more complex (think about it, the blood and cystic fluid has been marinating in them for longer so it will look more funky)

Clotted blood will be more echogenic and fluid may also be seen

Peritoneal inclusion cyst

Adhesions trap peritoneal fluid around ovaries resulting in a large adnexal mass. Probably resulted from pelvic surgery, trauma, PId, endometriosis

this cyst has nothing to do with the ovarian cycle

Paraovarian cyst

Usually arises from the BROAD ligament and usually located BETWEEN the ovary and fallopian tube. It is a remnant of the Wolffian duct and is also NOT AFFECTED BY HORMONAL CYCLE

How do you differentiate between a paraovarian cyst and other cysts?

You will be able to see a normal, ipsilateral ovarym SEPERATE from the cyst

Remeber PARA means around, next to, or near. Therefore, paraovarian cysts are around, next to, or near the ovary

Which simple cyst often occurs due to stimulation from maternal hormones

Cysts in fetuses

Which simple cyst arises spontaneously or in association with other hormonal abnormality

Cysts in adolescents

Postmenopausal cysts are considered normal if they are simple and less than ____cm

5

Ovarian Torsion

Partial or complete rotation of the OV pedicle (ovarian vein & artery within the suspensory ligament), which restricts blood supply to the ovary (NO BUENO)

Frequently involves the ipsilateral fallopian tube

Rare and VERY SERIOUS AND EMERGENT (if your ovary is doing back flips, go to the ER and get in line for surgery ASAP)

What is the result of taking fertility medicines that stimulate egg production

Ovarian hyperstimulation syndrome (OHS) - ovaries are enlarged with MULTIPLE CYSTS

Actually, so foul because if OHS gets severe enough, the mass will be huge (way bigger than the elephant from SING) and can put fluid around lungs and the pelvis like gyatt

Stein-Leventhal syndrome

Included with PCOS; Oligomenorrhea, amenorrhea, obesity, hirsutism (hair growth all over body)

Ovarian Remnant Syndrome - RARE

Cystic mass on pt. after a bilateral oophorectomy (ovaries are gone as hell)

Basically, a small amount of ovarian tissue was unintentionally left behind and became functional again and started producing cysts WITHOUT THERE EVEN BEING AN OVARY

T/F - US is very reliable in distinguishing between benign and malignant

False

What percentage of ovarian cysts <5cm are malignant

3%

T/F - Most often, OV vascularity demonstrates a high diastolic flow?

False; low

If a mass shows a complete absence or minimal diastolic flow it is usually?

Benign

Remember, a high diastolic flow occurs in the luteal phase

I remember

What does the diastolic flow look like on a high-resistive doppler waveform?

Low

What does the diastolic flow look like on a low-resistive doppler waveform

High

How do you detect and diagnose ovarian cancer?

To detect:

• Physical exam, LABS - CA 125, and imaging

To diagnose:

• Laparotomy - classifies cancer into stages

• Biopsy

• Surgical removal pathology study

T/F - Ovarian Cancer is the 4th leading cause of cancer death AND the leading cause of death by GYN malignancy

True

If a 65yr old patient comes in to the doctor with vague abdominal pain, swelling and indigestion, and has already had breast cancer and has a family history of ovarian cancer, what does she most likely have

Ovarian cancer

80% of cases of ovarian cancer involve women over what age?

60

Ovarian cancer is a silent killer because it is usually not detected until it is advanced. What are the survival rates

If detected in stage 1, 93% chance or surviving

If you find out later, 50% chance of surviving so around 5 years

Most common type of ovarian neoplasm

Epithelial tumors

Epithelial tumors

GYN tumors that arise from surface of epithelium and cover the ovary - can become very large

Account for 65-75% of all OV neoplasms

80-90% of OV malignancies

Two most common types of epithelial tumors

Mucinous and serous

What is the least common epithelial tumor?

Brennar Tumor

Most common ov neoplasm (not type)

Dermoid

Mucinous cystadenoma

Epithelial tumor that is lined by the mucinous elements of the endocervix and bowel; Usually found in women 13-45yrs old

Mucinous cystadenocarcinoma

RARE, malignant ovarian mucinous tumor that most often happens in 40-70yr olds

What is the second most common benign tumor of the ov

Serous cystadenoma

Serous cystadenocarcinoma

Constitutes of 60-80% of all ov carcinomas

Brenner tumor (transitional cell tumor)

Less common form of epithelial tumor that is associated with cystic neoplasms in the ipsilateral ovary

Germ cell tumors usually occur in

Adolescents

T/F - Teratoma and dermoid are not the same thing

False

Tip-of-the-iceburg sign of Dermoids

Mixture of hair & sebum producing ill-defined acoustic shadowing that obscures posterior wall of the mass

Teratoma/Dermoid

Contains fatty, sebaceous material, hair, cartilage, bone, teeth