Benign Gyn Complete

Cervical Polyps

Small, pedunculated or sessile neoplasms that originate from the endocervix, composed of vascular connective tissue stroma covered by epithelium.

Common presentation of cervical polyps

Intermenstrual bleeding, postcoital bleeding, increased vaginal discharge (leukorrhea), and menorrhagia.

Prevalence of cervical polyps

Common in multiparous patients > 20 years old, rare before menarche, may occur postmenopausal.

Pathophysiology of cervical polyps

Develop from focal hyperplasia of endocervical mucosa, triggered by chronic inflammation, hormonal stimulation (especially estrogen), or vascular congestion.

Diagnostic method for cervical polyps

Clinical diagnosis on speculum exam revealing red, flame-shaped, fragile polyps with narrow pedicles (endocervical) or pale, smooth, rounded polyps with broad pedicles (ectocervical).

Treatment of cervical polyps

Office-based removal, cauterization, excision in OR for large or sessile polyps, or hysteroscopy, followed by histologic examination.

Malignancy risk of cervical polyps

Rare, most common would be squamous cell carcinoma or adenocarcinoma

Follicular cysts

Most common functional ovarian cyst, forms when a follicle does not rupture, appears as thin-walled, anechoic, unilocular cysts ranging from 3-10 cm.

Corpus luteum cysts

Forms after ovulation, may hemorrhage causing acute pain, appears more complex with internal echoes, can range from 3-11 cm.

Endometriomas

Cystic formations in endometriosis containing thick brown blood debris ("chocolate cysts"), associated with chronic pelvic pain, dyspareunia, dysmenorrhea, and subfertility.

Benign ovarian cyst features

Unilocular, thin-walled, anechoic or simple fluid, no or thin septations, no vascularity on doppler, size < 5 cm, resolves over time.

Concerning ovarian cyst features

Thick-walled or irregular borders, solid components or nodularity, thick septations (> 3 mm), increased vascularity, persistent growth or size > 10 cm.

Leiomyomas (Fibroids)

Benign monoclonal tumors arising from smooth muscle cells of the uterine wall, most common tumor in the female reproductive tract with 70-80% prevalence in some populations.

Epidemiology of fibroids

7-14% of US women have symptomatic fibroids

Risk factors for fibroids

African-American descent, increasing age, early menarche or late menopause, obesity, family history.

Protective factors for fibroids

Smoking, exercise, increased parity, late menarche/early menopause, oral contraceptive use.

Classification of fibroids (FIGO System)

Submucosal (alters uterine cavity), Intramural (within myometrium), Subserosal (under peritoneal layer), Interligamentous (within broad ligament), Parasitic/Metastatic (detached with external blood supply).

Clinical findings of fibroids

Abnormal uterine bleeding (AUB), heavy menstrual bleeding (HMB), pelvic pain, infertility, bulk symptoms (urinary retention, hydronephrosis, constipation, deep dyspareunia).

Medical management of fibroids

Selective progesterone receptor modulators (SPRMs), GnRH agonists (leuprolide acetate), Aromatase inhibitors, LNG-IUDs, NSAIDs, tranexamic acid.

Surgical management of fibroids

Uterine Artery Embolization (UAE), Magnetic Resonance-Guided Focused Ultrasound (MRgFS), Endometrial Ablation (EA), Myomectomy, Hysterectomy.

Adenomyosis

Benign condition involving ectopic placement of endometrial tissue into the myometrium, often coexists with leiomyomas (40%) and endometriosis (80%).

Epidemiology of adenomyosis

Affects ~20% of reproductive-age women in the U.S., strong association with other pelvic pathologies, especially endometriosis & fibroids.

Pathogenesis theories of adenomyosis

Three mechanisms: 1) Endometrial invagination into the myometrium (most accepted), 2) Embryonic metaplasia from müllerian remnants, 3) Stem cell differentiation leading to adenomyosis.

Clinical findings of adenomyosis

Pelvic pain & dysmenorrhea (50-95% of cases), abnormal uterine bleeding/heavy menstrual bleeding (27-65% of cases), infertility, pregnancy complications.

Diagnosis of adenomyosis

Gold standard is histologic confirmation via hysterectomy

Treatment of adenomyosis

Conservative/Medical: Analgesics (NSAIDs), pelvic floor physical therapy, GnRH agonists, progestins & OCPs. Surgical: Hysterectomy (definitive) or excision of focal/diffuse adenomyotic tissue (uterine-sparing).

Endometrial polyps

Benign overgrowth of endometrial glands and stroma around a vascular core, protruding into the uterine cavity (sessile or pedunculated).

Epidemiology of endometrial polyps

Seen in 25% of women with peak incidence in their 40s

Malignancy risk of endometrial polyps

Clinical presentation of endometrial polyps

Often asymptomatic

Imaging for endometrial polyps

TVUS (good initial test), Sonohysterography (SIS), Hysteroscopy.

Treatment of endometrial polyps

Transcervical polypectomy

Polycystic Ovary Syndrome (PCOS)

Syndrome of persistent anovulation, hyperandrogenism, and polycystic ovaries with prevalence of 5-10%.

Rotterdam diagnostic criteria for PCOS

Must have 2 of the 3: 1) Oligomenorrhea or amenorrhea, 2) Clinical/biochemical hyperandrogenism, 3) Polycystic ovarian morphology on ultrasound.

Pathophysiology of PCOS

Results from hyperandrogenism (increased ovarian androgen production), ovarian follicle dysfunction (impaired follicular maturation), and insulin resistance (elevated insulin stimulates ovarian androgen production).

Laboratory findings in PCOS

Mildly elevated androgens, LH:FSH ratio often ≥2-3:1, insulin resistance markers, TVUS showing bilateral enlarged ovaries with ≥12 small peripheral follicles.

Clinical consequences of PCOS

Chronic anovulation leading to increased risk of endometrial hyperplasia & carcinoma

Treatment of PCOS

First line: Combined OCPs to suppress androgens and induce regular withdrawal bleeding

Hirsutism

Excess coarse body hair in sex hormone-dependent areas in adult male distribution pattern

Common etiologies of hirsutism

PCOS (~70% of cases), Nonclassical congenital adrenal hyperplasia, Androgen secreting tumors, Idiopathic (normal labs), Drug-induced.

Clinical assessment of hirsutism

History (age of onset, tempo, menstrual irregularities, virilization signs), Physical exam (Ferriman-Gallwey score ≥8), Look for acanthosis nigricans and Cushingoid features.

Laboratory workup for hirsutism

First-line: total testosterone, free testosterone, DHEA-S (>700 μg/dL or testosterone >200 ng/dL requires imaging for tumor)

Management of hirsutism

Lifestyle (weight loss), Combined Oral Contraceptives, Anti-androgens (spironolactone, finasteride, flutamide), Topical eflornithine cream, Cosmetic treatments (laser hair removal or electrolysis).

Endometriosis

Disorder in which abnormal growths of endometrium-like tissue (epithelium and stroma) are present in locations other than the uterine lining, found almost exclusively in women of reproductive age.

Epidemiology of endometriosis

Estimated prevalence: 6-10% of reproductive-age women

Etiology of endometriosis

Multifactorial: retrograde menstruation, coelomic metaplasia, vascular of lymphatic dissemination, altered immunity

Risk factors for endometriosis

Family history, early menarche, long duration of menstrual flow, heavy bleeding during menses, shorter cycles.

Protective factors for endometriosis

Regular exercise of >4 hrs per week, higher parity, longer duration of lactation.

Symptoms of endometriosis

Classic triad: infertility, dysmenorrhea, deep dyspareunia

Signs of endometriosis

Tender uterosacral nodules and posterior fornix on uterine motion, fixed retroverted uterus from cul-de-sac adhesions, adnexal masses (endometriomas), implants in scars/fornix/cervix.

Definitive diagnosis of endometriosis

Laparoscopy (or laparotomy) with direct visualization ± biopsy showing glands, stroma, hemosiderin-laden macrophages.

Hormonal therapy for endometriosis

OCPs (continuous use induces decidualization), Progestins (comparable to GnRH agonists but less bone loss), Danazol (rarely used despite 90% efficacy due to androgenic effects), GnRH Agonists (limited to 6 months due to bone loss), Aromatase Inhibitors.

Surgical treatment for endometriosis

Conservative surgery (laparoscopic excision) for fertility preservation

Prognosis of endometriosis

Most patients achieve significant pelvic pain relief and improved fertility with treatment