OBGYN - Exam 2

Which pathology of the vagina is characterized a duct that is present in the fetus and usually disappears after birth?

Gartner Duct Cyst

What is the most common congenital abnormality of the genital tract?

Imperforate hymen

What causes obstruction of the UT (metra) and/or Vagina (colpos) and accumulation of fluid, blood, or pus?

Imperforate hymen

T/F - Solid masses of vagina are rare, and US is used to diagnose?

False: US is not used to diagnose

What are the upper limits of the normal size of the vaginal cuff?

2.1cm

What is the most common finding of the cervix?

Nabothian cyst

What is another name for the nabothian cyst?

Epithelial inclusion cyst

What do nabothian cysts usually result from?

Chronic cervicitis

What is the abnormal growth of tissue projection from a mucus membrane that causes irregular bleeding and is caused by chronic inflammation?

Cervical polyp

Where can cervical leiomyomas/fibroids/myomas be found?

Located within the CX or pedunculated

What can cause cervical stenosis (obstruction of cervical canal at internal or external os)?

• Radiation therapy

• Chronic infection

• Cervical BX, laser or cryosurgery

• Cervical carcinoma

• Postmenopausal CX atrophy

What is the most common type of cervical cancer

Squamous cell carcinoma

In which women are leiomyomas/myomas/fibroids most common in?

African American women AND women over 30yrs old

Because leiomyomas are sensitive to ESTROGEN STIMULATION, it may cause???

1. Pelvic pressure/ pain (yeeeouch)

2. Enlarged UT

3. Irregular or heavy bleeding

4. May increase in size during pregnancy, causing miscarriage or impair fetal growth

5. Most stabilize or decrease in size menopausal due to decreased estrogen

T/F - Estrogen stimulation can actually cause leiomyomas to stabilize or decrease in size in menopause women due to decreased estrogen?

True

What is the appearance of a variable mass (know for test fr!!)

Usually hypoechoic

What is number 1

Intramural fibroid

What is number 2

Pedunculated fibroid

What is number 3

Submucosal fibroid

What is number 4

Pedunculated cervical fibroid

What is number 5

Cervical fibroid

What is number 6

Subserosal fibroid

What is number 7

Intracavitary fibroid

What age group of women is more affected by squamous cell carcinoma?

Women of menstrual age

What is the term for a mass of smooth muscle cells, encapsulated from surrounding myometrium?

Leiomyoma/myoma/fibroid

What rarely develops in postmenopausal women, unless they are on HRT?

Leiomyoma/myoma/fibroid

Determine the type of Leiomyoma:

Leiomyoma that may erode into endo cavity, distorting or displacing the endometrium; Causes irregular or heavy menses and infertility or miscarriage

Submucosal

Determine the type of Leiomyoma:

Most common; Found within the myometrium

Intramural

Determine the type of Leiomyoma:

Leiomyoma that projects from the peritoneal surface of the uterus and may become pedunculated; Risk for torsion and may appear as extra-uterine mass

Subserosal

Determine the type of Leiomyoma:

Leiomyoma found within the endo cavity and causes irregular or heavy menses and infertility or miscarriage

Intracavitary

Determine the type of Leiomyoma:

Results when subserosal myomas develop a stem/stalk (a slender base that supports the tumor and attaches it to the outside of the uterus)

Pedunculated

What is the treatment for a fibroid that is causing infertility

Surgical removal (myomectomy) of submucosal myoma

Endometrial ablation

Treatment for menorrhagia as a result from leiomyoma:

Uses radiofrequency, microwaves, freezing or heat ablative technology

What is the least invasive method to stop menorrhagia as a result from leiomyomas

Hormonal suppression

UT artery embolization (UAE)

Treatment for menorrhagia as a result from leiomyoma:

Obstructs blood flow to large myomas

High-intensity focused ultrasound (HIFU)

Treatment for menorrhagia as a result from leiomyoma:

Myoma is heated, causing tissue death; HIFU is MRI-guided in the United States

What term describes the benign disease where endometrial tissue is found within the myometrium?

Adenomyosis

Symptoms of adenomyosis

Menorrhagia, dysmenorrhea, metrorrhea, enlarged/bulky UT on exam, or some patients are asymptomatic

Characteristics of diffure adenomyosis

Bulky enlarged UT (more common in posterior) and myometrial cysts

Characteristics of a focal mass (adenomyoma)

Lacks a hypoechoic border and rarely demonstrates a feeding artery

What does AVMS stand for?

Arteriovenous malformation

What is AVMS?

The vascular plexus of arteries and veins that usually involves the myometrium

Usually acquired as a result of pelvic trauma or surgery

Clinical of symptoms of AVMS?

Metrorrhagia and anemia from blood loss

Heavy or prolonged UT bleeding?

Menorrhagia

Painful UT bleeding

Dysmenorrhea

Irregular UT bleeding

Metrorrhea

Sonographic appearance of AVMS

Varies;

1. Can have an intramural UT mass

2. tubular spaces within myometrium (color doppler shows hypervascularity and mosaic pattern)

3. Subtle myometrial inhomogeneity

Treatment for AVMS

Angiography and embolic therapy

What is the most common cause of abnormal UT bleeding in pre & post menopausal women

Endometrial hyperplasia

What causes endometrial hyperplasia (diffusely THICK endometrium)

• PCOS

• Estrogen producing tumors

• Obesity

• HRT

What are the clinical symptoms of endometrial hyperplasia

Abnormal/excessive UT bleeding and postmenopausal bleeding

Sonographic findings of endometrial hyperplasia?

Abnormally thick endometrial canal (EMC)

Small dilated cyst glands may also be present; Size depends on if patient is pre- or post-menopausal as well as asymptomatic or symptomatic

What are treatments for endometrial hyperplasia?

Biopsy necessary for diagnosis d/t nonspecific US appearance

Sonohyst can be done to evaluate internal contents

Hormones

D&C

Hysterectomy

Between what days of a premenopausal patient’s cycle should their endometrium be measured?

6-10

T/F - Fluid should always be included in EMC measurements

False

How would you determine the EMC measurement of an endometrium that has fluid in it?

2 AP measurements taken and added together

What are overgrowths of EMC tissue covered by the epithelium that can be solitary or multiple?

Endometrial polyps

Clinical symptoms for endometrial polyps

• Asymptomatic

• Menometrorrhagia

• Infertility

• PMB (post-menopausal bleeding)

T/F - Myomas have 1 primary feeding vessel and polyps have multiple micro-vessels within

True

What is endometritis most often associated with?

PID and postpartum or post-procedure involving UT

Clinical symptoms of endometritis

Intense pelvic pain or low back pain, fever

What pathology’s sonographic findings consist of:

EMC appearing prominent or irregular and can have fluid within as well as

• Puss in cul de sac (looks complex and may have gas bubbles)

• Enlarged ovaries

• Dilated fallopian tubes

Endometritis

Endometrial synechiae

EMC adhesions - scarring

Acquired from post-trauma or surgery and can cause infertility or recurrent pregnancy loss

Asherman’s Syndrome (pg 1358)

UT synechiae & infertility

Sonographic findings of endometrial synechiae

Best seen during sonohysto; Hyperechoic bands traversing UT from one side to the other, distorting EMC

What is the most common GYN malignancy in North America

Endometrial carcinoma

What is the most common type of endometrial carcinoma?

Adenocarcinoma

What is endometrial carcinoma associated with?

Estrogen stimulation

What is the first sign that someone may have an endometrial carcinoma?

Postmenopausal bleeding

Sonographic findings of endometrial carcinoma

1. Thickened EMC. Double thickness of <5mm excludes significant abnormality (EMC biopsy done for symptomatic patients and for definite diagnosis

2. Enlarged Ut, with lobulated contour and mixed echogenicity in advanced stages

3. US is helpful in distinguishing intrauterine vs. extrauterine tumors (MRI & CT useful in staging distant disease lymph involvement

4. Color & spectral doppler may or may not be useful (girl make up your mind, are you gonna help me or what??)

Why is low resistance arterial flow suspicious for endometrial carcinoma? 🤔

Because cancer wants ALL the blood to grow (greedy ahh cancer)

A small EMC fluid collection of what amount is normal during menses, ectopic pregnancies or recent AB, and endometritis or degenerating myomas?

less than 2ml

What should you do when there is large EMC fluid collection such as obstruction of the cervical os

Regard with suspicion

T/F - Large EMC fluid collection can be both congenital or acquired, but it is always associated with malignant conditions

False; It can be associated with malignant and benign conditions

IUD or IUCD

Intrauterine Contraceptive Device; Used for birth control or HRT; Placed during menses and US is sometimes used to guide the insertion

The patient should do self-checks to make sure the string hasn’t disappeared (spooky). If the string is not found, it could mean the UT shot it out

Most common IUDs are?

Mirena and Paraguard

Mirena IUCD

T-shaped, flexible plastic that releases low amount of progestin as additional pregnancy prevention

Paraguard IUCD

T-shaped, flexible plastic wrapped in copper

What are the older IUDS

1. Copper 7 - copper wire spiraled around vertical shaft

2. Tatum T & Progestasert - T-shaped

3. Lippes loop - serpentine shaped

Sonographic appearance of IUD

US - Mildly echogenic linear structure within EMC

3D US - greatly enchances the ability to see IUD position

X-RAY - Used to located extrauterine location

T/F - Displaced IUCD can cause pelvic or back pain

True

What happens when IUCD and pregnancy occur?

The IUCD location should be documented

50% of pregnancies abort on extraction of IUCD

What is the term for a diffuse disease process of the female pelvic cavity and is also the all-inclusive term for all pelvic infections

PID - Pelvic Inflammatory Disease

Which of the following IS NOT a PID?

Endometritis

Endometriosis

Salpingitis

Hydrosalpinx

Pyosalpinx

Periovarian inflammation

Tubo ovarian complex

Tubo ovarian abscess

Endometriosis

What is the most common location for PID?

Fallopian tubes (salpingitis)

What is the most common risk factor of PID

History of sexually transmitted disease

What clinical symptom of PID is missing from this list?

1. Intense pelvic pain, tenderness

2. Constant vaginal discharge

3. Irregular menses

4. Infertility

5. Elevated WBC count

6. Asymptomatic - can still cause serious damage to reproductive organs

Fever

T/F - PID may be normal in acute process

True

What is endometritis?

Infection of the endometrium that consists of thickening or fluid in endometrium; Can be divided into obstetric and non-obstetric cases

Symptoms include pelvic pain and dysmenorrhea

Non-obstetric endometritis

Infection associated with PID or gynecologic instrumentation; Can be acute or chronic

Ex) STI or dirty OBGYN exams with musty tools and doctors

Obstetric enometritis

Happens in immediate postpartum period; Endometritis is the MOST COMMON CAUSE OF FEVER IN POSTPARTUM PATIENT

Ex) This happens when products of birth (like placenta) are left over inside the uterus and causes infection

Scenario: A postpartum woman walks into the doctor with a high fever and is complaining of lots of pelvic pain that started after giving birth. Upon examination, the sonographer finds her EMC is super thick but still appears normal but after further investigation sees it measure more than 20mm. What is the most probable diagnosis of this patient?

Endometritis

What can increase the risk for endometritis?

1. Premature rupture of membranes (Ex. water breaking early)

2. Retained clot or POCs

3. Prolonged labor

Scenario: A patient wants into the clinic complaining of left lower quadrant discomfort. She states she feels fins besides a low fever, but she has constantly been feeling as if her pelvis were full. A US finds what looks like a blood vessel or cyst near the fallopian tube area but upon closer look, the sonographer notices that the patients left fallopian tube is very dilated and torturous. What is the possible diagnosis for this patient?

Salpingitis

Scenario: Bille Jean has been noticing very constant and strange vaginal discharge recently, she has also been suffering from a low-grade fever which she thinks is a result of the weather changes. After the vaginal discharge doesn’t get better and she starts to feel worse, she heads to the clinic. She gets bloodwork done and finds her WBCs are elevated. The sonographer finds that her fallopian tube is very dilated and is echogenic, resulting in poor sound transmission. What she finds is something that looks like a complex mass. What could Billie Jean be suffering from?

Pyosalpinx

What occurs secondary to PID, endometriosis or postoperative adhesions (scarring)?

Hydrosalpinx

Scenario: A 27-year old patient walks into the clinic with pelvic fullness that has been going on for a while. She has endometriosis so she is afraid it has gotten worse and wants to get it checked out. A US shows that the patient has a tubular structure that appears to be anechoic on her lower right quadrant. What could it be?

Hydrosalpinx

Scenario: Jean Grey was recently experiencing severe fevers and pelvic pain that just would not go away. When she went to the doctor, the sonographer had trouble finding her ovaries because it was as if they were fused with her fallopian tubes and overall, just looked like a huge mass. The sonographer found that both her ovaries had strange lines in them, maybe septations, as well as what seemed to be internal echoes. After diagnosing her, she was put on a round of antibiotics that helped her a lot with her diagnosis. It seems the antibiotics responded very well to her condition. What was Jean Grey suffering from?

Tubo-ovarian abscess

Scenario:

Labubu Dabubu recently underwent the very invasive procedure of removing ascites from her abdomen as a result of her liver disease. Ever since this procedure, she has been suffering from pelvic pain as well as a fever. A US shows that fluid within her pelvic recesses and gas-forming bubbles that make it really difficult to see. The doctor finds that she has peritonitis that has spread to her ladder, ureter, bowel, and adnexal areas due to not being treated for so long. What has Miss Dabubu’s peritonitis developed into?

Pelvic Peritonitis

T/F - Ectopic tissue as a result from endometriosis can be found almost anywhere in the body?

True