Vagina, Vulva, Ovaries, Uterus

gyn

woman

OB

pregnant

bartholin's glands

produce a mucus secretion to lubricate the vagina

blood supply to vagina

vaginal branch of the uterine artery

collective term for the external part of the female genitalia

vulva

rounded folds of adipose tissue forming the outer boundaries of the vagina

labia majora

the thinner, inner folds of skin

labia minora

homologue to the penis

clitoris

majority of vaginal malignancies are ____________

metastatic

most common vaginal carcinoma

squamous cell

risk factors for neoplasm of the vagina

same as in cervical neoplasia (HPV)

multiple lifetime sexual partners, early age at first intercourse, and being a current smoker

presentation and diagnosis of neoplasm of the vagina

Presentation: vaginal bleeding

Diagnosis: biopsy

vaginal cancer staging - 1

The carcinoma is limited to the vaginal wall.

The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall.

Stage II

The carcinoma has extended to the pelvic wall.

Stage III

The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum; bullous edemas as such does not permit a case to be allotted to this stage

Stage IV

The carcinoma is limited to the vaginal wall.

Stage I

stage I tumor treatment

surgical excision, radiation

stage II to IV treatment

radiation, surgery, chemoradiation

vaginal stenosis treatment

Vaginal dilator following radiation or chemoradiation

vulvar neoplasm prevention

HPV vaccine

treatment vulvar squamous cell carcinoma

surgical excision or vulvectomy

types of ovarian cysts

Physiologic cysts (more common) - Follicular cyst, corpus luteal cyst

Pathologic cysts (less common)- Endometriomas, benign adult teratomas, cystadenomas, malignant neoplasms

diagnosis ovarian cyst

ultrasound

causes of ovarian cysts

- Ovulation or pregnancy

- Dermoid cysts

- Polycystic ovary syndrome (PCOS)

- Endometriosis

- Cancer

treatment for ovarian cysts

Treat the underlying condition

Watchful waiting - repeat ultrasound every couple of months to reevaluate the size of the cyst

OCP - Limits new cysts from growing

Surgery to remove a cyst or the whole ovary

dermoid cyst

ovarian cyst containing skin and sometimes hair, teeth, bone, or cartilage

when is surgery indicated for ovarian cysts?

if they are complex

presentation ruptured ovarian cyst

- Cyst rupture may be asymptomatic

- Associated with mild mid-cycle pain (mittelschmerz)

- Characterized by the sudden onset of unilateral, lower abdominal pain --> Often following strenuous physical activity (sexual intercourse, exercise)

- bleeding

concerns with ruptured ovarian cysts

the release of cyst contents into peritoneal cavity causing irritation --> serous fluid, blood, sebaceous material

diagnosis ruptured ovarian cyst

Ultrasound findings of an ovarian cyst plus blood or a large amount of serous fluid in the pelvis

treatment ruptured ovarian cyst

Uncomplicated (most cases) - observation

Complicated cases (ie, hemodynamic instability, large or ongoing blood loss, signs of an infection process, findings suggestive of malignancy) may require inpatient management and/or surgery

Laparoscopy

premenopausal vs postmenopausal treatment ruptured ovarian cyst

In a premenopausal patient with a benign ovarian cyst (physiologic or nonphysiologic), preservation of ovarian tissue via cystectomy is generally preferable to complete oophorectomy

In a postmenopausal patient, unilateral oophorectomy is generally performed; bilateral salpingo-oophorectomy is only indicated if malignancy is suspected

Clinical features of PCOS

Menstrual dysfunction

- Menarche may be delayed

- Oligomenorrhea

- Fewer than nine menstrual periods in a year

- Amenorrhea less often

- No menstrual periods for three or more consecutive months

- Women with PCOS often experience more regular cycles after age 40 years

Hyperandrogenism

- Hirsutism, acne, male-pattern hair loss

- Elevated serum androgen concentrations (hyperandrogenemia)

- Virilization - Signs of more severe androgen excess

- Deepening of the voice and clitoromegaly (rare)

diagnosis PCOS

Transvaginal ultrasound (TVUS)

treatment PCOS

Manage abnormal uterine bleeding, infertility, insulin resistance, obesity, and hirsutism

second most common gynecologic malignancy (second to uterine carcinoma)

ovarian neoplasm

average age at diagnosis of ovarian cancer in the US

63 years old

Increasing age, infertility, endometriosis, polycystic ovarian syndrome, and cigarette smoking

BRCA-1, BRCA-2

risk factors for?

ovarian neoplasm

Cancer is confined to one or both ovaries.

stage I

Cancer has spread to the uterus or other nearby organs

stage II

Cancer has spread to the lymph nodes or abdominal lining

stage III

Cancer has spread to distant organs, such as the lungs or liver.

stage IV

treatment of ovarian neoplasm

Total hysterectomy and bilateral salpingo-oophorectomy with pelvic lymph node dissection

Bowel or partial hepatic resection (with metastases)

Most patients with EOC also require adjuvant chemotherapy treatment

Acute onset of severe pelvic pain, often with nausea and vomiting, in a patient with an adnexal mass; unilateral

History of recent vigorous activity

Sudden increase in abdominal pressure may also be an inciting event

PE: pelvic tenderness

presentation of?

ovarian torsion

diagnosis ovarian torsion

Pelvic ultrasound

Pain is elicited when scanning over the adnexa with a vaginal ultrasound probe on side of the torsion

treatment ovarian torsion

Premenopausal patients with torsion of a nonmalignant ovary - Detorsion and ovarian conservation

Postmenopausal patients - Salpingo-oophorectomy

irregularities in the menstrual cycle involving frequency, regularity, duration, and volume of flow outside of pregnancy

AUB (abnormal uterine bleeding)

chronic AUB is defined as irregularities in menstrual bleeding for most of the previous ______ months

6

Occurs at intervals of > 38 days and usually is caused by a prolonged follicular phase

oligomenorrhea

heavy flow - normal cycle

menorrhagia

intermenstrual bleeding

occurs between ovulatory cycles

metrorrhagia

frequent (<21 day interval b/w menses)

polymenorrhea

causes of abnormal uterine bleeding (uterine and nonuterine)

Uterine pathology - fibroids, endometrial polyps, adenomyosis, neoplasia

Nonuterine causes - ovulatory dysfunction, disorders of hemostasis, medications, thyroid disease, STD

first line evaluation of abnormal uterine bleeding

TVUS

secondary evaluation of abnormal uterine bleeding

possibly endometrial sampling

endometrial sampling indication

nonpregnant patients with any bleeding pattern if obesity or other risk factors for endometrial hyperplasia or cancer are present

treatment AUB

Estrogen-progestin contraceptives

Effective treatments for AUB

●**Therapy with contraceptive doses of estrogen is contraindicated in patients at risk of venous or arterial thrombosis, ≥35 years-old with concomitant smoking, hypertension

●LNG 52 (IUS)

●LNG 52 (IUS) is the most effective medical treatment of heavy menstrual bleeding (HMB)

Presence of both endometrial glands & stroma outside the uterine cavity and musculature

endometriosis

risk factors endometriosis

nulliparity, prolonged exposure to estrogen, exposure to DES in utero, & lower BMI

Present as hemorrhagic petechiae, white plaques, chocolate cysts, rust colored spots

Occur on ovaries, pelvic structures, sigmoid colon

endometriosis

Symptoms

- Pelvic pain

- Dysmenorrhea

- Dyspareunia

- Abnormal bleeding

- Infertility

Signs

- Fixed uterus

- Tenderness

- Endometriomas on ovary

- None!

endometriosis

diagnosis endometriosis

direct visualization and biopsy by laparoscopy

treatment endometriosis

- Oral contraceptives

- Oral & IM progestins

- Danazol - suppresses LH & FSH (rare)

- GnRH agonist injections (Lupron)

- Surgery

when is conservative surgery indicated in endometriosis?

- Women who want to get pregnant

- Hormonal treatments are not effective

conservative vs nonconservative surgery for endometriosis

Laparoscopy (minimally invasive surgery)

Total hysterectomy (non conservative)

complication of endometriosis

epithelial ovarian cancer (EOC)

ectopic placement of endometrial tissue in myometrium

adenomyosis

etiology of adenomyosis

microtrauma to the myometrium and subsequent deposition of endometrial implants into the damaged area

diagnosis and treatment adenomyosis

TVUS, MRI - may see diffusely enlarged uterus, increased junctional zone width between endometrium and myometrium (JZ), myometrial cysts

GnRH agonists, oral contraceptives, or hysterectomy

leiomyoma

benign tumor of myometrium

most common pelvic tumor

leiomyoma

treatment leiomyoma

observation, myomectomy, hysterectomy

Cystocele

bladder prolapse

Rectocele

rectal prolapse

Enterocele

Hernia of the intestines to or through the vaginal wall

pelvic pressure/heaviness or protrusion

incontinence, constipation, and/or sexual dysfunction

signs of?

prolapse

conservative treatment for prolapse

vaginal pessaries and pelvic floor muscle exercises (Kegel)

surgical treatment for prolapse

Surgical candidates include women with symptomatic prolapse, who have failed or declined conservative management of their prolapse.

There are numerous surgeries for prolapse, including vaginal and abdominal approaches (open, laparoscopic, or robotic) and with and without graft materials.

prolapse prevention

Perform Kegel exercises regularly. These exercises can strengthen your pelvic floor muscles — especially important after you have a baby.

Treat and prevent constipation. Drink plenty of fluids and eat high-fiber foods, such as fruits, vegetables, beans and whole-grain cereals.

Avoid heavy lifting and lift correctly. When lifting, use your legs instead of your waist or back.

Control coughing. Treatment for chronic cough or bronchitis, and don't smoke.

Avoid weight gain. Talk with your doctor to determine your ideal weight and get advice on weight-loss strategies, if you need them.