GYN- Structural abnormalities / Reproductive cancers

What is painful menstruation that interfere with ADLs?

Dysmenorrhea

Primary or secondary dysmenorrhea?

• No known pelvic pathology

• Usually onsets 1-2 yrs after menarche

• MC due to increased or hypersensitivity to PGs

Primary

Primary or secondary dysmenorrhea?

• Due to pelvic pathology → fibroids, endometriosis, adenomyosis, uterine polyp, IUD, adhesions, PUD, etc

• suspect if onset after 25 y/o

Secondary

What symptoms are associated with dysmenorrhea?

Diffuse pelvic pain before or with onset of menses, ± HA, N, V, D,

Mittelschmerzs (extreme lower abd pain on ovulation, self limiting)

What is the workup for dysmenorrhea?

Pelvic exam w/ bimanual, U/S

What are non rx treatment options for dysmenorrhea?

Diet modification, aerobic exercise, heat/cold compress, TENS unit

Supplements → ginger, magnesium bisglycinate/gluconate

What are the pharmacological treatment options for dysmenorrhea?

1st line: NSAIDS

alt: hormonal BC (combo is best for sx)

Surgery if anatomical abnorms (fibroids, adhesions, etc)

How can NSAIDs be used cyclically to treat dysmenorrhea?

Start 1 day prior to start of period or at first sign of cramping & continue for 2-3 days into menses, then use PRN

What patients should NSAIDs be used with caution?

Hx GERD, ulcerative dz, renal dysfunction

What condition is characterized by endometrial tissue & glands embedding into the myometrium, inducing hypertrophy and hyperplasia causing a globally enlarged uterus?

Adenomyosis

What are risk factors for adenomyosis?

Hx C-section or child birth, prior uterine procedures where uterus was left intact (myomectomies)

MC middle aged women

The following clinical presentation is associated with what condition?

• classic sx: menorrhagia that gets progressively worse

• dysmenorrhea

• enlarged uterus → bloating, pelvic heaviness & pain, dyspareunia, urgency & frequency from pressure on bladder, incontinence, prolapse

• +/- infertility (affects implantation)

Adenomyosis

What is the diagnostic workup for adenomyosis?

PE- tender, symmetrically boggy uterus w/ globular enlargement

U/S- Venetian blind sign (echo bright tissue in endometrium)

MRI

*dx of exclusion, only confirmed w/ histology after hysterectomy

What is the treatment for adenomyosis?

NSAIDs, hormonal contraceptives to reduce AUB (Progestin IUD best), Mifepristone

Diagnostic, therapeutic, and only effective option → total abdominal hysterectomy

What is a benign smooth muscle tumor of the uterine wall that is caused by localized proliferation of smooth muscle cells and fibroblasts in myometrium, surrounded by a pseudo capsule of compressed muscle fibers?

Fibroid

What is the growth potential of a fibroid dependent on?

Estrogen (worse w/ menses/pregnancy/HRT, better w/ menopause)

The following risk factors are for what condition?

• MC in 30s (esp after 35) d/t higher estrogen production

• MC in AA

• genetics, early menarche, nulliparity

• Early OCP exposure, DES eposure

• Vit D deficiency, poor diet

• HTN, DM, obesity

Fibroids

What is the MC benign pelvic lesion in females?

Fibroid

What are the types of fibroids?

based on layer of uterus - subserosal, intramural, submucosal, cervical myomas

Which type of fibroid develops under the endometrium and is the most symptomatic with a negative impact on fertility?

Submucosal

Which type of fibroid develops on the outer surface of the myometrium and tend to be largest due to unrestricted growth?

Subserosal

Which type of fibroid develops within the myometrium?

Intramural

What is the MC presenting symptom with submucosal fibroids?

abnormal bleeding (MC menorrhagia / menometrorrhagia)

The following sx are associated with what condition?

• generally asx

• abnormal bleeding (menorrhagia/menometrorrhagia MC)

• pelvic pain, dyspareunia, inc abd girth

• urinary frequency, urgency or straining; constpation

• degeneration of fibroid tissue → pain, fever, inc WBCs

• pedunculated can become twisted → torsion & acute pain

Fibroids

What type of fibroid is most commonly associated with increased VTE risk due to compression of the vena cava?

Subserosal

What is the diagnostic workup for fibroids?

Abd & bimanual exam → mobile, solid pelvic mass w/ irregular contour

CBC ± Fe studies, can secrete erythropoietin → polycythemia

Pelvic U/S, MRI > CT

Hysteroscopy, laparoscopy

How should fibroids be monitored?

Imaging done yearly, more often if change in sx

What lifestyle mods can be made for fibroids?

Diet, exercise, Vit D

What is the most effective treatment for uterine fibroids?

Leuprolide

What are the surgical treatment options for fibroids?

Uterine artery embolization, myomectomies, hysterectomy (definitive)

What are RX treatment options for fibroids?

Tranexamic acid, birth control (LNG IUD best), GnRH ag/antags (Leuprolide), NSAIDs

What can be used as bridging therapy in fibroids until surgery can be done to reduce size or in peril menopausal patients?

GnRH ag/antag (Leuprolide)

What condition is the presence of ectopic endometrial stroma and glands on sites outside of the uterine cavity, influenced by cyclic hormones (worse w/ menses)?

Endometriosis

Where is the most common site for endometriosis?

Ovaries

What are RF for endometriosis?

MC 25-35 y/o, prolgoned estrogen exposure (nulliparity, early menarche, short cycles), genetics

The following sx are seen with what condition?

• severe pain- usually increases cyclically, can affect pelvis, low back, vagina, rectum

• Dyspareunia, dyschezia, dysuria

• spotting pre/post menses, menorrhagia

• abd fullness, N, V, D, constipation

• infertility

• ovarian/vaginal endometriomas - painful blood filled lesions

Endometriosis

What is a chocolate cyst?

Tumor sized ectopic lesion of ovaries usually filled “old blood” giving it’s chocolate appearance

What is the diagnostic workup for endometriosis?

Mainly dx of exclusion; PE normal +/- masses, imaging normal +/- endometrioma

definitive → laparoscopy bx (raised patched of thick, discolored, scared or powder burned tissues)

What is the treatment for endometriosis?

Combo OCPs & NSAIDs (best), continuous progesterone (POP, IUD, DMPA, implant), Leuprolide, Danazol

Surgery - laparoscopy w/ ectopic tissue ablation, TAH w/ BSO

What is diagnostic and therapeutic for Endometriosis and is used especially when fertility is desired?

Laparoscopy w/ ablation of ectopic tissue

What is the localized overgrowth of endometrial glands and storm centered around a vessel, often pedunculated or w/ stalk attached to uterine wall?

Endometrial polyps

What are RF for endometrial polyps?

Tamoxifen, obesity, ERT w/ intact uterus, Lynch cowden syndrome

Endometrial polyps has estrogen receptors, which have ______ ; and progesterone receptors, which have ________

Proliferative effect ; anti proliferative effect

What are preventative options for endometrial polyps?

Combo or progesterone only OCPs or hormonal IUD (LNG-IUD)

The following sx are associated with what condition?

• MC asx & found incidentally on imaging

• if sx- bleeding MC (intermenstrual, post coital, straining/lifting)

• cramping, dyspareunia

• early pregnancy loss

Endometrial polyps

What is the diagnostic workup for endometrial polyps?

TV U/S, hysterosalpingogram, hysteroscopy (diagnostic)

What is the treatment for endometrial polys that are asymptomatic and low risk?

Expectant mgmt, repeat imaging if concerning sx develop

What is the treatment for endometrial polyps that cause bleeding or discomfort, are large or multiple, or in a high risk patient?

Polypectomy

What is endometrial hyperplasia a precursor to?

Endometrial cancer

What is endometrial gland hyperproliferation +/- cytologic atypia?

Endometrial hyerplasia

What is the MCC of endometrial hyperplasia?

Inc unopposed estrogen - MC w/ chronic anovulation (PCOS), or in perimenopause, obesity, estrogen only tx (tamoxifen)

In what patients is endometrial hyperplasia MC in?

Postmenopausal women

PM is considered _____ until proven otherwise.

Cancer

What ssx are seen with endometrial hyperplasia?

AUB (menorrhagia, metrorrhagia, PM) +/- abnormal vaginal discharge

What is the diagnostic workup for endometrial hyperplasia?

TV U/S, endometrial stripe thickness, endometrial bx/EMB (definitive)

What can be done to reduce the unopposed estrogen effects in endometrial hyperplasia?

Dec soy, lose weight, d/c HRT

What is the treatment for endometrial hyperplasia w/o atypia?

Progestin therapy & repeat bx in 3-6 mos

What is the treatment for endometrial hyperplasia with atypia (pre-cancerous changes)?

Hysterectomy / TAH w/ BSO or progestin if desires fertility / not surgical candidate

What is the MC gynecological cancer in the US and 4th MC malignancy in women?

Endometrial cancer

What is the MC type of endometrial cancer?

Adenocarcinoma (MC endometrioid)

Who is endometrial cancer MC in?

Post menopausal women 50-60 y/o

Endometrial cancer is dependent on what hormone?

Estrogen

What are RF for endometrial cancer?

Unopposed/increased estrogen exposure, HTN, DM, Lynch syndrome**

What are protective factors for endometrial cancer?

Progestin or combo BCs

What cancers are progestin and combo birth controls protective against?

Endometrial & Ovarian cancer

What sx are seen with endometrial cancer?

ASX, AUB, menorrhagia ± metrorrhagia in premenopausal women

What is the MCC of postmenopausal bleeding?

Endometrial cancer

What is the diagnostic workup for endometrial cancer?

U/S- endometrium thickened

Consider EGD/Colonoscopy & genetic testing

EMB definitive

What is the treatment for endometrial cancer?

Stage 1: TAH-BSO +/- post op RT

Stage 2-3: TAH-BSO & LN excision +/- post op RT

Stage 4: chemo

What is a cyst that develops during the menstrual cycle w/ physiologic function or purpose (not related to disease state)?

Functional ovarian cyst

When are functional ovarian cysts MC?

Reproductive / menstruating years

What cysts occur when follicles fail to rupture during ovulation and continue to grow?

Follicular cysts

What cysts occur when there is failure to resorb after ovulation?

Corpus luteal cysts

What cysts occur when there is excess beta HCG (seen w/ twin gestations, hydatidiform molar pregnancies)?

Theca lutein cysts

What is the MC presentation of functional ovarian cysts?

Asx, found incidentally

If a functional cyst is symptomatic, what sx can be seen?

U/L pelvic pain, dyspareunia, menstrual disturbance, mass in pelvis if large, constipation or pain w/ BM, inc frequency/urgency, rupture or torsion

what is the diagnostic workup for functional ovarian cysts?

PE (U/L pelvic pain ± mobile mass), U/S

What is the treatment for a follicular or CL cyst that is asx?

Self limiting, monitor w/ U/S to ensure stability 6-8 wks

What is the treatment for a functional ovarian cysts that are < 8 cm?

NSAIDs, heat, prevent constipation, intercourse / lifting precautions, repeat U/S in 4-6 wks

What is the treatment for functional ovarian cyst that is > 8 cm or in postmenopausal women?

surgery d/t risk of rupture/torsion

How do OCPs treat functional ovarian cysts?

Does not affect clinical course of existing sx, suppresses cyclical cyst formation reducing risk of future formation

What is a solid ovarian neoplasm, MC in reproductive years, can grow teeth/hair/nails, can secrete ACTH, has a small cancer risk and is tx w/ surgical removal?

Benign ovarian neoplasm

What is the MC type of ovarian cancer?

Serous cystadenocarcinoma (epithelial type)

What is the 2nd MC gynecologic cancer and 5th MC cancer overall?

Ovarian cancer

What gynecologic cancer has the highest mortality rate?

Ovarian cancer

When is ovarian cancer MC?

5th and 6th decades

What are the RF for ovarian cancer?

Fhx, caucasian, greater number ovulatory cycles, Lynch syndrome (DNA mismatch in MLHL, MSH2, MSH6, PMS2, EPCAM), plus more that’s not bolded

what is Lynch syndrome associated with?

Hereditary nonpolyposis CRC, inc risk endometrial, ovarian, stomach, pancreatic, and prostatic cancer

Lynch syndrome is associated with DNA mismatch repair mutation in which genes?

MLHL, MSH2, MSH6, PMS2, EPCAM

What are protective factors for ovarian cancer?

Dec ovulatory cycles → OCPs, high parity, breast feeding, salpingectomy > tubal ligation or TAH

The following sx are associated with what condition?

• rarely symptomatic until late stages (inc risk of mets / mortality)

• abd fullness or distension, pelvic heaviness, pain, constipation

• early satiety, N, dec appetite, unintentional wt loss

• irregular menses, menorrhagia, PM bleeding

Ovarian cancer

Wha tis the dx workup for ovarian cancer?

PE- palpable abd/ovarian mass, ± ascites, sister Mary Joseph Node (if met to umbilical LN)

U/S & MRI, labs, biopsy

In what patients are germ cell ovarian tumors MC in?

Women < 30

What is the treatment for ovarian cancer?

Early stage: TAH-BSO + selective lymphadenectomy

Surgery - tumor debunking for sx relief

Chemo- Paclitael + Cisplatic or Carboplatin

What are mostly benign growths of vascular connective storm covered with epithelium projecting from the cervix or cervical canal, MC in multiparous women?

Cervical polyps

What sx are seen with cervical polyps?

Leukorrhea, blood discharge, post contact bleeding, post menopausal bleeding, metrorrhagia +/- menorrhagia

What is the diagnostic workup for cervical polyps?

Pap ± colposcopy w/ biopsy/polypectomy to confirm

U/S to r/o extension into uterus

What is the treatment for cervical polyps?

Monitor w/ expectant mgmt, regular repeat paps annually, removal

What is the 3rd MC gynecologic cancer, 9th MC cancer overall, and 5th leading cause of cancer death in women in the US?

Cervical cancer

What is the MCC of cervical cancer?

Oncogenic HPV (16, 18, 45 > 31, 33, 45)

*acquired not genetic