Ch.11 Structural Disorders and Neoplasms of the Reproductive System Study Reproductive System Lecture notes (completed)

Structural Disorders of the Uterus and Vagina

Alterations in Pelvic Support
- Uterine Displacement:
  - This is a variation of the normal placement of the uterus.
  - The most common variation is posterior displacement or retroversion.
  - Another variation is anteflexion.
- Uterine Prolapse (Pelvic Relaxation):
  - Definition: A condition where the uterus and cervix protrude through the vagina.
  - Gravity/Severity: The extent of the prolapse varies from mild to complete protrusion.
  - Risk Factors: Weakness of the pelvic support structures. This weakness is often secondary to trauma, strain, stress, the natural aging process, or birth-related injuries.
  - Common Complaints/Symptoms: Patients frequently report sensations of pelvic pressure, low back pain, and fatigue.
  - Management ( $Mx$ ):
    - Conservative approaches.
    - Kegel’s exercises to strengthen pelvic floor muscles.
    - Use of a fitted pessary (a device inserted into the vagina to provide support).
    - Knee-chest position.
Other Types of Pelvic Organ Prolapse
- Cystocele:
  - Definition: The protrusion of the bladder into the vagina.
  - Pathophysiology: Results from injury to the supporting structures in the vesicovaginal septum.
- Rectocele:
  - Definition: The herniation of the anterior rectal wall through a relaxed or ruptured vaginal fascia and rectovaginal septum.
- Presentation of Cystocele and Rectocele:
  - Complaints of a "bearing down" sensation.
  - Recurrent Urinary Tract Infections ( $UTIs$ ).
  - Constipation.
- Management ( $Mx$ ):
  - Use of a pessary.
  - Surgical intervention known as colporrhaphy.

Benign Neoplasms of the Female Reproductive System

Ovarian Cysts
- Follicular Cysts:
  - Occurrence: Occurs when a mature Graafian follicle fails to rupture or when an immature follicle does not resorb fluid after ovulation.
  - Demographics: Very common in young women.
- Corpus Luteum Cysts:
  - Occurrence: Develops after ovulation.
  - Pathophysiology: An increased amount of progesterone leads to increased fluid accumulation in the corpus luteum.
  - Symptoms: The client may complain of pain and tenderness.
  - Menstrual Impact: Menstrual cycles can be delayed.
- Theca-Lutein Cysts:
  - Pathophysiology: Associated with abnormal growth of tissue from a fertilized egg or overgrowth of placental tissue.
  - Etiology: Can be caused by prolonged overstimulation of the ovaries by Human Chorionic Gonadotropin ( $hCG$ ) or the use of ovulation induction drugs.
- Dermoid Cysts:
  - Classification: A germ cell tumor.
  - Development: Typically develops during childhood.
  - Composition: Contains specialized tissues such as hair, teeth, and bones.
Polycystic Ovarian Syndrome (PCOS)
- Description: An endocrine imbalance characterized by specific hormonal levels.
- Hormonal Profile:
  - High levels of Estrogen.
  - High levels of Testosterone.
  - High levels of Luteinizing Hormone ( $LH$ ).
  - Decreased secretion of Follicle-Stimulating Hormone ( $FSH$ ).
- Pathophysiology: Often related to problems within the hypothalamic-pituitary axis or the presence of androgen-producing tumors.
- Genetics: Can be transmitted as an $X$ -linked dominant or autosomal dominant trait.
- Physical Findings: Multiple cysts are typically noted on the ovaries during examination or imaging.
- Clinical Manifestations:
  - Hirsutism (excessive hair growth).
  - Irregular menses.
  - Infertility.
- Health Risks: Diabetes Mellitus ( $DM$ ) and Cardiovascular Disease ( $CVD$ ).
- Management ( $Mx$ ):
  - Treatment of specific symptoms.
  - Oral Contraceptives ( $OC$ ).
  - Weight loss.
  - Metformin (to manage insulin resistance).
Uterine Polyps and Leiomyomas
- Uterine Polyps:
  - Definition: Benign tumors arising from the uterine or cervical mucosa.
  - Etiology: Derived from hormonal influences or inflammation.
  - Management ( $Mx$ ): Surgical removal, which can be performed in an office setting or a hospital.
- Leiomyomas (Fibroids, Fibromas, Myomas):
  - Definition: Benign tumors derived from the muscle tissue of the uterus.
  - Prevalence: The most common benign tumor of the uterus.
  - Location: They can develop in different areas within the uterine wall.
  - Anatomical Classifications:
    - Subserous.
    - Intramural.
    - Submucosal.
    - Cervical.
    - Pedunculated.
  - Manifestations: Abnormal bleeding, backache, constipation, and a distended abdomen.
  - Management ( $Mx$ ):
    - Uterine artery embolization.
    - Surgery (Myomectomy or Hysterectomy).

Malignant Neoplasms: Endometrial/Ovarian Cancer

Endometrial Cancer (Most common)
- Demographics: Most common in postmenopausal women, typically around the age of $60$ .
- Risk Factors: Obesity, Diabetes Mellitus ( $DM$ ), Hypertension ( $HTN$ ), infertility, late onset of menopause, hormone imbalance, and the use of Tamoxifen.
- Progression: The cancer typically starts in the fundus, spreads to the myometrium and cervix, and then potentially to other organs in the reproductive system.
- Presentation: Abnormal uterine bleeding, postmenopausal bleeding, and back or pelvic pain.
- Diagnosis: Pap test or endometrial biopsy.
- Management ( $Mx$ ): Radical hysterectomy; chemotherapy or radiotherapy depending on the cancer stage.
Ovarian Cancer
- Presentation: Symptoms are often vague; typically seen in women in the $50+$ age group.
- Etiology: Unknown causes.
- Risk Factors: Personal or family history of breast or ovarian cancer, inherited genetic mutations ( $BRCA1$ or $BRCA2$ ), obesity, nulliparity (never having given birth), and pregnancy at a later age.
- Protective Factors: Birth control use for more than > 5 years, having given birth, and surgical tubal ligation.
- Presentation: Abdominal distention or fullness, and increased urinary frequency.
- Diagnosis: Ultrasound imaging.
- Management ( $Mx$ ): Surgical removal of the tumor, radiation, chemotherapy, or hormone therapy, based on the specific type and stage of cancer.

Cervical and Vulval Cancer

Cervical Cancer
- Prevalence: The 4th most common cancer in women and the most preventable.
- Pathology: Dysplasia is noted in epithelial cells, categorized as Cervical Intraepithelial Neoplasia ( $CIN$ ).
- Stages of Neoplasia:
  - Preinvasive Lesions: Limited to the cervix at the squamocolumnar junction (also known as the transformation zone).
  - CIN 1: Abnormal cells are found in the lower $1/3$ of the epithelium. These are often self-limiting and may regress to normal.
  - CIN 2: Involves the lower $1/2$ or even the lower $2/3$ of the epithelium.
  - CIN 3: Involves the full thickness of the epithelium. This progresses to Carcinoma In Situ ( $CIS$ ).
  - Carcinoma In Situ ( $CIS$ ): The full thickness of the epithelium is replaced with abnormal cells.
  - Invasive Carcinoma: The cancer has penetrated into the stroma cells.
- Risk Factors: HPV (linked to approximately $90\%$ of cases), first coitus at age less than $20$ years, multiple partners, and high parity.
- Clinical Presentation: Abnormal bleeding and post-coital bleeding (considered the classic sign).
- Screening: Papanicolaou (Pap) test, recommended after the age of $21$ .
- Management ( $Mx$ ): Based on the results of the Pap test and HPV screening.
  - Procedures include Colposcopy, Conization (cone biopsy), and Loop Electrosurgical Excision Procedure ( $LEEP$ ). [WILL NOT BE TESTED]
  - Treatment for invasive cancer involves surgery, radiation, and chemotherapy.
Vulval Cancer
- Incidence: Primarily in the $50+$ age group, though incidence is increasing in younger populations.
- Presentation: Vulval itching, a lump on the labia majora (usually in advanced stages), or a lump in the groin.
- Diagnosis: Confirmed via biopsy.
- Management ( $Mx$ ): Depends on the extent of the condition; may include vulvectomy, radiotherapy, or topical application of chemotherapy drugs.

Surgical Procedures and Diagnostic Methods

General Women's Health Surgeries
- Hysterectomy: Surgical removal of the entire uterus. It can be performed abdominally (using a vertical or low transverse incision) or vaginally.
  - Total Hysterectomy: Removal of the uterus and cervix.
  - Radical Hysterectomy: Removal of the uterus, cervix, and nearby tissue.
  - Total Hysterectomy with Salpingo-oophorectomy: Removal of the uterus, cervix, fallopian tubes, and ovaries.
- Hysteroscopy: The use of a special endoscope to examine the interior of the uterus.
- Myomectomy: A surgical procedure specifically to remove a benign tumor (leiomyoma/fibroid).
- Salpingectomy: Surgical removal of one or both fallopian tubes.
- Salpingostomy: Surgical opening made in a fallopian tube.
- Oophorectomy: Surgical removal of one or both ovaries.
- Salpingo-oophorectomy: Surgical removal of a fallopian tube and an ovary together.
- Laparoscopy: A procedure that enables direct visualization of the pelvic organs using a scope.
Dilation and Curettage (D&C)
- Step 1: Widening of the cervical canal using a dilator.
- Step 2: The uterine walls are scraped with an instrument called a curette.
Papanicolaou (Pap) Test
- Purpose: Screening for cervical cancer.
- Procedure:
  1. A speculum is used to separate the vaginal walls.
  2. A swab is inserted into the vagina to collect cell samples from the cervix.
  3. The cell samples are sent to a pathology lab for analysis.
- Timing: Performed for women over the age of $21$ .
Procedures for Preinvasive Cervical Cancer [NOT TESTED]
- Cryosurgery: Freezing of the abnormal cells.
- Laser Ablation: The use of heat to remove diseased tissue.
- LEEP (Loop Electrosurgical Excision Procedure): A treatment that uses a wire loop electrode to excise and simultaneously cauterize tissue.
- Cone Biopsy: The removal of a cone-shaped portion of the diseased endocervix.

Cancer and Pregnancy

Prevalence: Cancer during pregnancy is relatively infrequent, occurring in approximately $1:1000$ pregnancies.
Complexity: Therapeutic issues are highly complex, and the emotional reactions of the woman and her family can be intense.
Decision Making: Critical decisions involve whether to continue or terminate the pregnancy. Considerations include:
- Timing of therapies and surgery.
- The duration of the pregnancy.
- Potential complications.
- The balance of benefits vs. risks for both the woman and the fetus.
- The specific presentation of the tumor.
Support: Ongoing emotional support for the patient and their family is essential.