question

Embryologic origin of uterus

answer

Fusion of the 2 Mullerian ducts

question

When is transvaginal transducer ultrasound used? Transabdominal transducer?

answer

Transvaginal transducer: ("pie shaped image") - lower pelvic masses - not influenced by thickness of maternal abdominal wall Transabdominal transducer: - entire pelvis as well as abdomen imaging Ultrasound works best when adjacent tissues have differing echodensities, particularly fluid/tissue interfaces

question

Average age range of menarche? Thelarche?

answer

menarche: 10-16.5y thelarche: breast development; 8~11y

question

What is the average age for Tanner II stage of breast development? Presentation?

answer

Tanner II: Breast development - 8-13 yrs - Breast buds begin

question

ASCUS?

answer

Atypical Squamous Cells of Uncertain Significance misreadings on Pap smears due to mechanical errors (drying, etc.)

question

Major structures of the uterus (3)

answer

Corpus (body) - Cornu (uterus join with fallopian tubes) Isthmus Cervix

question

Describe satisfactory colposcopy vs. unsatisfactory colposcopy

answer

Satisfactory colposcopy 1. T-zone does NOT extend into the endocervical canal 2. No lesions visualized within T-zone Unsatisfactory is the opposite..

question

Tanner stages: Pubic Hair

answer

Male + Female Tanner I: None (prepubertal state) Tanner II: small amount of long, downy hair with slight pigmentation on the labia majora Tanner III: hair becomes more coarse and curly and begins to extend laterally Tanner IV: adult-like hair quality, extending across pubis but sparing medial thighs Tanner V: hair extends to medial surface of the thighs

question

What are the risks of cone biopsy? (3)

answer

1. incompetent cervix (cutting too much) 2. cervical stenosis (can cause amenorrhea) 3. preterm birth

question

Traditional Pap vs. Liquid-based Pap

answer

Traditional Pap: - spatula for ectocervix* - cyto-brush for endocervical canal* (rotating in 1 direction 360°) - both specimens are smeared onto a glass slide, fixed with formalin, then stained *Potential problems* - ASCUS (atypical squamous cells of uncertain significance) cannot be diagnosed - insufficient smearing, air-drying artifacts if process is delayed, mechanical problems makes traditional technique obsolete Liquid-based Pap: - cervical broom* to collect specimens (rotated 5 times in same direction) - broom is placed into "formalin" solution and rotated 10 times to release collected material - this method is more preferred vs. traditional Pap due to absence of mechanical errors - ASCUS can also be used for HPV-DNA typing

question

What is special about Tanner IV stage of breast development?

answer

Papilla and areola forms a 2' mound not contour with surrounding breast

question

LEEP (loop electrosurgical excision procedure) description, procedure, followup, risks

answer

A thin low-voltaged loop cuts out abnormal cervical tissue identified with colposcopy advantage: visual confirmation lesions have been removed; no anesthesia needed followup Pap smear every 3-6 months for 2 years to ensure dysplastic changes to not return long-term risks of LEEP include - cervical stenosis - cervical insufficiency

question

What type of blood supply do oviducts receive? From where?

answer

Dual blood supply* Receives blood from the uterine artery and ovarian artery

question

What is the average age range for Tanner V stage of breast development?

answer

Tanner V: Breast development - 12.5~18.5 yrs - development is complete

question

What does the ovarian stroma produce?

answer

androgen Important for libido after menopause

question

Dilation and Curettage (D&C) procedure

answer

under anesthesia examines histology of endometrial lesions similar to endometrial biopsy; dilation of cervix is required to introduce curette can collect large amounts of endometrial tissue (>endometrial biopsy)

question

What are the 4 segments of the oviducts?

answer

Proximal → Distal "INTERcourse IS AMP and FUN" 1. Interstitium 2. Isthmus 3. Ampulla 4. Infundibulum

question

American Cancer Society recommendations

answer

1. initial study at age 34 if there are risk factors (breast cancer in first degree relative, BRCA genes, etc.) 2. routine screening at age 40 if there are no risk factors

question

Explain the formation of the T-zone

answer

at puberty the vaginal pH falls (due to estrogen dominance) the "native" columnar epithelium goes through metaplasia and becomes the transformation zone; normal-appearing "metaplastic" stratified squamous epithelium Old→New squamocolumnar junction (outer-to-inner)

question

Procedure associated with assessment of Asherman's syndrome

answer

HSG hysterosalpingogram

question

Cryotherapy description, procedure, followup, risks

answer

Destroys dysplastic cervical tissue identified by colposcopy and cervical biopsy; no anesthesia needed Cryo probe at -50℃ with liquid nitrogen Freeze and destroy tissue; 3 minutes intervals of freezing Watery discharge will occur over next few weeks as destroyed tissue sloughs off Followup Pap smears every 3-6 months for 2 years; disadvantage of not knowing if lesions are destroyed until followups Risks: cervical stenosis

question

Phases of development: Folliculogenesis

answer

Primordial: - dormant, small - 1 layer of flat granulosa cells Primary: - Mitotic cells - cuboidal granulosa cells Secondary: - Theca cells - Multiple layers of granulosa cells Tertiary: - Fully formed antrum Graafian (vesicular) follicle: - preovulatory follicle; fully mature

question

Tanner stages: Breast development

answer

Tanner I: no glandular tissue; areola follows skin contours of the chest (prepubertal) Tanner II: breast bud forms with small area of surrounding glandular tissue; areola beings to widen - 8-13yrs Tanner III: breast begins to become more elevated and extends beyond borders of areola; remains in contour with surrounding breast Tanner IV: increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast Tanner V: adult size; areola returns to contour of the surrounding breast, with projecting central papilla (nipple) - 12.5-18.5yrs

question

Colposcopy description

answer

"binoculars into the vagina" 1. *visually* identify where abnormal Pap smear cells originated 2. biopsy that area to send for histologic diagnosis

question

Average length of a vagina

answer

8-9cm

question

What is the lymphatic drainage of the ovaries?

answer

Pelvic nodes Para-aortic nodes

question

What are the organ systems we need to consider involving pelvic pain/pelvic mass?

answer

GI (colons) Uterus Bladder

question

What is the most common anatomical position of the uterus?

answer

Anteverted (50%) mid-position (25%) retroverted (25%)

question

Endometrial biopsy

answer

examines histology of endometrial lesions hollow suction cannula is placed into uterine cavity and suction is applied; rotation of cannula before fixing with formalin

question

Which portion of the cervix is most concerned for scrapings during a Pap smear?

answer

Transformation zone (T-zone) - 95% of cervical dysplasia and cancer develops here - screening for squamous cell carcinoma (most common cancer of the cervix 80%) - area between old (outer, "O") squamocolumnar junction and new (inner) squamocolumnar junction

question

Risks of mammography

answer

high radiation (0.7 mSv) same as background radiation in 3 months 1 rad = 10 mSv

question

What is the specimens required for a Pap smear? What diseases are they mostly screening for?

answer

2 areas 1. T-zone of the ectocervix (squamous cell carcinoma; most common cancer of cervix 80%) 2. columnar epithelium of endocervical canal (adenocarcinoma; 2nd most common cancer of cervix 15%)

question

Hysterosalpingogram (HSG) description and procedure

answer

procedure performed without anesthesia, radio-opaque fluid injected at endocervical canal allowing assessment of uterine malformations and Asherman's syndrome dye is supposed to spill into pelvic cavity; non-spillage can be a sign of fallopian tube occlusion or blockage

question

Vulvar biopsy

answer

done with punch biopsy or scalpel performed under local anesthesia, histology of vulvar lesions

question

Hysterectomy types

answer

removal of uterus "hyster" root comes from the misled belief women are crazy because of their uterus 1. subtotal: removes only teh corpus, leaving cervix in place 2. total: removes both corpus and cervix of uterus (aka simple hysterectomy) 3. radical hysterectomy: performed for early stage CIN, involves removal of the uterus, cervix, and surrounding tissues, including cardinal ligaments, uterosacral ligaments, and the upper vagina (can involve removing lymph nodes depending on stages of CIN)

question

What is the term for the surgery of removing ovaries?

answer

removal of ovaries Salpingo-oophorectomy

question

Cone biopsy: wide-shallow cone vs. narrow-deep cone

answer

Cone biopsy; both procedures need anesthesia Wide-shallow cone: - performed if Pap smear shows changes more severe than the colposcopically directed biopsy Narrow-deep cone: - performed if a lesion extends from the exocervix into teh endocervical canal

question

The pelvic floor is made up of which diaphragms? What structures do they hold?

answer

Pelvic diaphragm: - levator ani (puborectalis, pubococcygeus, ileococcygeus) - coccygeus muscles Perineal membrane (urogenital diaphragm): - triangular sheet of dense fibromuscular tissue "anterior triangle" that spans the anterior half of the pelvic outlet - vagina and urethra pass through the perineal membrane

question

Most common cause of uterine prolapse?

answer

childbirth

question

Uterine prolapse classification

answer

Grade I: cervix descends half way to introitus Grade II: cervix descends to introitus Grade III: cervix extends outside the introitus Grade IV or procidentia: entire uterus, as well as the anterior and posterior vaginal walls, extends outside the introitus

question

What is procidentia?

answer

Grade IV Uterine prolapse entire uterus + anterior and posterior vaginal walls extends outside the introitus

question

Vaginal prolapse classification

answer

Cystocele (most common): anterior vaginal wall prolapse; contains the bladder Rectocele (2nd most common): posterior vaginal wall prolapse; contains the rectum Enterocele (3rd): rectouterine pouch/pouch of Douglas prolapse

question

What is the triad for rectocele diagnosis?

answer

1. postmenopausal woman 2. Posterior vaginal wall protrusion 3. Digitally assisted removal of stool "digital splitting"

question

Management of pelvic relaxation: non-surgical

answer

Non-surgical: - Kegel exercises (learning to control pubococcygeus muscle; "magazine for better sex"; kegel weights) - Estrogen replacement in postmenopausal women - Pessaries (mechanical method)

question

Management of pelvic relaxation: surgical

answer

Surgical: when conservative methods fail - vaginal hysterectomy (with vagina vault suspension) + anterior/posterior vaginal repair - anterior and posterior colporrhaphy: uses endopelvic fascia that supports bladder and rectum

question

Diagnosis of prolapse in pelvic relaxation is done how?

answer

Tell the patient to perform Valsalva in lithotomy position

question

Average age of menopause?

answer

51-52

question

Physiology: continence vs. micturition

answer

balance between urethral closure & detrusor muscle (bladder muscle) activity urethral sphincter pressure normally > bladder pressure = urine continence urethral pressure decreases < bladder pressure = micturition/voiding Normally proximal urethra + bladder both within the pelvis (prolapse can alter this state leading to incontinence); intraabdominal pressure increases (valsalva) are transmitted equally to both, leaving the pressure difference unchanged; continence detrusor muscle spontaneous contractions are normally easily suppressed

question

Pharmacology: bladder receptors innervation

answer

α-adrenergic receptors: Sympathetic nervous system - "Sympathetic SHOOTS" hence urethral sphincters contract to inhibit incontinence during ejaculation - primarily found in urethra - *prevent* micturition; *contraction* of urethral - Drugs agonists: ephedrine, imipramine, estrogens - Drugs antagonists: phenoxybenzamine β-adrenergic receptors: Sym. nervous system - *prevents micturition*; relaxation of bladder detrusor muscles hence prevents urination - primarily in the detrusor muscle - Drugs agonists: flavoxate, progestins Cholinergic receptors: Parasympathetic innervation - *enhances micturition* - primarily also in detrusor muscle; *contraction* - Drugs agonists: bethanecol, neostigmine - Drugs antagonists: oxybutynin, propantheline

question

Cystometry Volume Measurements

answer

Post-void residual volume = <50mL Sensation of fullness = 200-225mL Urge to void = 400-500mL Normally a patient should be able to suppress the urge to void. (shown on graph) Involuntary contractions can be seen by watching saline level in the syringe rise/fall; normally there should not be any involuntary contractions

question

Sensory Irritative Incontinence: etiology, history, examination, investigative studies, management

answer

Etiology: - involuntary rises in bladder pressure - results in detrusor contractions - possible causes: infection, stone, tumor, foreign body History: - loss of urine occurs with *urgency, frequency and dysuria* - can take place *day or night* Examination: - suprapubic tenderness may be elicited - pelvic examination normal (no prolapse of any sort) - neurological exam normal (anal contraction reflex normal, S2-3-4; by stimulating labia majora we get a anal contraction) Investigative study: *urinalysis* - bacteria and WBC (infection) - RBC (stone, foreign body, tumor) - positive urine culture (infection) - normal cystometric studies (normal RV with involuntary detrusor contractions present) Management: - antibiotics (infections) - cystoscopy to diagnose and remove stones, foreign bodies, tumors

question

Inhibit voiding Tx: bladder relaxants/antispasmodics

answer

oxybutynin (Ditropan) flavoxate (Urispas)

question

Inhibit voiding Tx: bladder relaxant/anticholinergics

answer

Pro-Banthine

question

Inhibit voiding Tx: bladder relaxant/tricyclics

answer

Imipramine (Tofranil)

question

Inhibit voiding Tx: vesical neck contraction/alpha adrenergics

answer

ephedrine Imipramine Estrogen stimulates alpha receptors Progesterone stimulates beta receptors

question

Which receptors do estrogen stimulate? progesterone?

answer

Estrogen stimulates alpha receptors Progesterone stimulates beta receptors

question

Promote voiding Tx: bladder contraction/cholinergics

answer

Bethanechol (Urecholine) Neostigmine (Prostigmin)

question

Promote voiding Tx: vesicle neck relaxants/alpha antagonists

answer

methyldopa phenothiazines

question

Genuine Stress Incontinence: Etiology, history, examination, investigative studies, management

answer

Etiology: - most common form of true urinary incontinence - rises in bladder pressure because of intraabdominal pressure increase - not transmitted to proximal urethra due to pelvic relaxation and not being a part of pelvic structures anymore - *loss of bladder support* History: - loss of urine occurs in small spurts simultaneously with coughing or sneezing - *Does NOT* take place when patient is sleeping Examination: - cystocele may be seen - Neurologic examination is normal - Q-tip test is positive (q-tip placed within the urethra and patient increases intraabdominal pressure, the q-tip will rotate >30 degrees) Investigative studies: - urinalysis + culture are normal - cystometric studies are normal - *no* involuntary detrusor contractions seen Management: Mostly similar to pelvic relaxation management - Kegel exercises - estrogen replacement (stimulates alpha receptors) - surgical therapy aims to elevate the urethral sphincter (Burch procedure, MML, tension-free vaginal tape procedure)

question

What is the most common form of true urinary incontinence?

answer

Genuine stress incontinence

question

What is the only incontinence that does not result in voiding during the night?

answer

Genuine stress incontinence

question

What is the triad of stress incontinence?

answer

Involuntary loss of urine (large) with coughing and sneezing (increase abdominal pressure) No urine lost at night

question

Motor Urge (Hypertonic) Incontinence: etiology, history, examination, investigative studies, management

answer

Etiology: 'Itty-Bitty Bladder Syndrome' - involuntary rises in bladder pressure from idiopathic detrusor contractions that cannot be voluntarily suppressed History: - loss of urine occurs in large amounts; often without warning - day + night - most common symptom is urgency Examination: - pelvic examination shows normal anatomy - neurologic examination is normal Investigative studies: - urinalysis + culture normal - cystometric studies show normal residual volume - *involuntary detrusor contractions are present even with small volumes of urine in the bladder* Management: - anticholinergic medications - NSAIDS to inhibit detrusor contractions - tricyclic anti-depressants - calcium-channel blockers

question

What is the triad for hypertonic bladder?

answer

Involuntary loss of urine cannot suppress urge to void urine loss day + night

question

Hypertonic incontinence vs. Hypotonic incontinence

answer

Hypertonic: - large volume urine loss - idiopathic detrusor muscle contraction - day + night Hypotonic: - small volume urine loss (until urethral sphincter = bladder pressure) - bladder never empties; detrusor muscle relaxation - day + night

question

Overflow/Neurogenic (Hypotonic) Incontinence: etiology, history, examination, investigative studies, management

answer

etiology: - Rises in bladder pressure occur gradually from over-distended, hypotonic bladder - voiding occurs only when bladder pressure > urethral sphincter pressure - *bladder never empties*; voiding occurs only until bladder pressure = urethral sphincter pressure - may be due to denervated bladder (diabetic neuropathy, MS, or systemic medication) history: - loss of urine occurs intermittently in small amounts* - day + night - pelvic fullness is a common symptom examination: - pelvic examination may show normal anatomy - *decreased pudendal nerve sensation* investigative studies: - urinalysis and culture usually normal; may show infection - cystometric studies show markedly increased residual volume - involuntary detrusor muscle contractions do NOT occur management: - intermittent self-catheterization may be necessary - discontinue the offending systemic medications - bladder contraction stimulation (alpha receptor blocker; cholinergic drugs)

question

What is the triad for hypotonic bladder?

answer

involuntary loss of urine detrusor muscle not contracted urine loss day + night

question

Types of urinary incontinence with irregular detrusor muscle contractions

answer

Hypertonic incontinence

question

Types of urinary incontinence with no involuntary detrusor muscle contractions

answer

Stress incontinence Hypotonic incontinence

question

Fistula incontinence: etiology, history, examination, investigative studies, management

answer

etiology: - normal urethral-bladder mechanism is intact - bypassed by urine leaking out through a fistula from urinary tract history: - *radical pelvic surgery* or *pelvic radiation therapy* - loss of urine occurs continually in small amounts - day + night examination: - normal anatomy and normal neurologic findings investigative studies: - urinalysis and culture are normal - IVP (intravenous pyelogram) will demonstrate dye leakage from urinary tract fistula management: - surgical repair of the fistula

question

Triad for bypass incontinence

answer

involuntary loss of urine history: radical pelvic surgery or radiation urine loss day + night continuously* (small amounts)

question

Vaginal discharge: BV, parasitic, yeast

answer

BV; bacterial vaginosis (most common) - fishy odor - pH↑; thin grayish exudate - no inflammation; endogenous transmission - diagnostic: clue cells - Rx: metronidazole; clindamycin Trichomonas vaginalis - itching, burning "strawberry cervix" - inflammation prominent; pH↑ - green/yellowish frothy discharge - Methylene blue wet mount; mobile flagellates - Rx: Metronidazole Candida albicans - itching, burning - inflammation not as prominent as Trichomonas vaginalis; white "cottage cheese" discharge - pH stays same or ↓ - KOH: pseudohyphae/hyphae - Rx: fluconazole; azole cream Note: metronidazole is safe to use in all trimesters of pregnancy; class B

question

Most common cause of vagina discharge? 2nd? 3rd?

answer

Bacterial vaginosis (50%) Candidiasis (30%) Trichomonas (15%)...STD's

question

What is the predominant bacteria in the vagina?

answer

Lactobacillus Normal flora (70%) in BV it decreases to 15%

question

What is the normal pH of the vagina?

answer

pH < 4.5 estrogen dominance

question

Diagnostic Test: Vaginal Discharge

answer

Visual inspection: the vulva and vagina should be examined for evidence of inflammatory response; check vaginal discharge on speculum Vaginal pH: normal <4.5 Microscopic examination 2 drops of vaginal discharge are placed on glass slide (saline on one side, KOH on the other) looking for clue cells, hyphae, flagellates, WBC's

question

What is a positive "whiff" test in BV?

answer

when KOH is placed on the discharge, releasing a fishy odor KOH is for Candida albicans diagnostics; but it dissolves tissue

question

How does BV most commonly present as?

answer

asymptomatic 50%

question

Rx: Bacterial vaginosis

answer

Metronidazole - safe to use in all 3 trimesters of pregnancy - 250mg - t.i.d. for 7 days - no alcohol for 24-48 hrs Clindamycin - 300mg - b.i.d. for 7 days

question

Trimethylamineuria

answer

Fish odor syndrome AR a rare clinical entity where the patient has an offensive persistent odor that no amount of bathing can correct differential diagnosis with BV

question

What is associated with bubbly vaginal discharge?

answer

Trichomonas vaginalis

question

Trichomoniasis: Men vs. Woman symptoms

answer

Men: 90% asymptomatic Woman: 50% asymptomatic Both needs treatment despite presentations

question

What is associated with strawberry cervix?

answer

Trichomonas vaginalis

question

Rx: Vaginal Trichomoniasis

answer

Metronidazole - 24~48hrs no liquor - recommended: 2g orally in a single dose - alternative: 500mg b.i.d for 7 days - pregnancy: 2g orally in a single dose

question

Rx: Vaginal Candidiasis

answer

Oral fluconazole - 150mg single dose azole cream

question

Physiologic discharge: Sx, risk factors, speculum exam, management

answer

Sx: - most common complaint is increased watery vaginal discharge - no burning or itching Speculum: - columnar epithelium of endocervical canal extends over a wide area of the ectocervix, producing abundant mucus discharge - thin and watery - pH is normal (<4.5) Risk factors: - chronic anovulatory conditions - PCOS, etc. (polycystic ovarian syndrome) Management: - steroid contraception with progestins - convert watery thin discharge into thick sticky progestin-dominant mucus

question

Most common symptom of benign/malignant vulvar lesions

answer

Vulvar itching

question

Premalignant vulvar dermatosis

answer

benign lesions with malignant predisposition - most common symptom is vulvar itching, most lesions are asymptomatic Diseases: - Squamous hyperplasia - Lichen sclerosis - Squamous dysplasia - CIS

question

Squamous hyperplasia : appearance, palpation, histology, management

answer

premalignant vulvar dermatosis Appearance: - lesions appear whitish focal or diffuse areas Palpation: - firm and cartilaginous on palpation Histologically: - thickened keratin - epithelial proliferation Management: - fluorinated corticosteroid cream

question

Lichen sclerosis: appearance, palpation, histology, management

answer

premalignant vulvar dermatosis Appearance: - lesions are bluish-white papula that can coalesce into white plaques Palpation: - thin and parchment-like Histology: - epithelial thinning Management: - Clobetasol cream

question

Vulvar squamous dysplasia: appearance, histology, management

answer

premalignant vulvar dermatosis Appearance: - lesions are white, red, or pigmented, often multifocal in location - almost identical to cervical dysplasia Histology: - cellular atypia restricted to the epithelium without breaking through the basement membrane Management: - surgical excision

question

CIS: appearance, histology, management

answer

premalignant vulvar dermatosis Appearance: - indistinguishable from vulvar dysplasia - white, red, or pigmented, often multifocal lesions Histology: - cellular atypia is full thickness but does not penetrate the basement membrane Management: - laser vaporization and vulvar wide local excision

question

Malignant vulvar lesions

answer

uncommon gynecologic malignancy (4th most common gynecologic malignancy) mean age 65 risk factors: old age, cigarette smoking, HIV, premalignant vulvar dermatosis Diseases: - squamous cell - melanoma - Paget disease

question

Squamous cell (malignant vulvar lesion)

answer

most common type of invasive vulvar cancer (90%) association with HPV Pathogenesis is chronic inflammation (for older woman) and HPV infection (for younger women) Most common stage at diagnosis is Stage 1

question

Melanoma (malignant vulvar lesion)

answer

second most common histologic type of vulvar cancer (5%) most important prognostic factor is the depth of invasion Any dark or black lesion in vulva should be biopsied and considered for melanoma

question

Paget disease (malignant vulvar lesion)

answer

Characteristics: - red lesion - most common in postmenopausal white women Any patient with red vulvar lesion must be considered for the possibility of Paget disease Most common form of Paget disease is intraepithelial process 18~20% of cases invasion of basement membrane is identified association with other cancers (mainly GI, urinary, and breast)

question

Malignant vulvar lesions: diagnosis

answer

Biopsy

question

Malignant vulvar lesions: pattern of spread

answer

starts with local growth and extension that embolizes to inguinal lymph nodes and finally, hemtogenous spread to distant sites

question

Malignant vulvar lesions: staging

answer

Staging is surgical Stage 0: CIS (basement membrane is intact) Stage I: - tumor confined to vulva with size </= 2cm - nodes not palpable Stage IA: invasion 1mm deep Stage II: - tumor confined to the vulva with size >2cm - nodes not palpable Stage III: - Tumor any size with spread to lower urethra, vagina, or anus - unilateral nodes Stage IV: widespread metastasis Stage IVA: involves upper urethra, bladder or rectum, pelvic bone, bilateral nodes Stage IVB: distant metastasis

question

Malignant vulvar lesions: management

answer

1) Wide local excision 2) Modified radical vulvectomy 3) Radical vulvectomy 4) Pelvic exenteration 5) Radiation therapy

question

Management for stage IA malignant vulvar lesions

answer

Wide local excision only

question

Malignant vulvar lesions management: wide local excision

answer

Stage IA only risk of metastasis is negligible No lymphadenectomy is needed

question

Malignant vulvar lesions management: Modified radical vulvectomy

answer

involves radical local excision - Ipsilateral inguinal dissection is used only if stage is IB and unifocal lesion > 1cm from midline AND no palpable nodes (less sexual morbidity) - Bilateral inguinal dissection is used if at least stage IB or a centrally located lesion OR palpable inguinal nodes or positive ipsilateral nodes (lower-extremity edema)

question

Malignant vulvar lesions management: radical vulvectomy

answer

involves removal of labia minora + majora, clitoris, perineum, perineal body, mons pubis seldom performed due to high morbidity sexual dysfunction may result

question

Malignant vulvar lesions management: pelvic exenteration

answer

radical vulvectomy + removal of cervix, vagina, ovaries + lower colon, rectum + bladder create appropriate stomas if necessary seldom indicated or performed due to high morbidity

question

Malignant vulvar lesions management: radiation therapy

answer

only used for patients who cannot undergo surgery

question

Benign vulvar lesions: diseases

answer

1) Mulluscom contagiosum 2) Condylomata acuminata 3) Bartholin cyst

question

Mulluscom contagiosum: at risk group, Sx, transmission, management

answer

Benign vulvar lesion Children, sexually active adults, immunodeficient patients Sx: - spontaneously regressing, umbilicated tumors of skin Transmission: - direct skin contact Management: - observation - curettage - cryotherapy

question

Condylomata acuminata: causative agent, Sx, management

answer

Benign vulvar lesions HPV 6, 11 (no malignant predisposition) Sx: - cauliflower-like vulvar lesions Management: - treat clinical lesions only

question

Bartholin cyst: pathogenesis, management

answer

Benign vulvar lesions obstruction of the Bartholins gland duct may occur due to infection (GC) After immune defenses overcome, duct remains obstructed resulting in cystic dilation of the gland aspiration of the cyst yields sterile fluid Management: - conservative unless pressure symptoms due to size

question

gynecologic cancer rankings 1~4 and age relevance

answer

1. endometrium (61) 2. ovaries (69) 3. cervix (45) 4. vulva (65)

question

What is the type of gynecological cancer occurs earliest in life? Oldest?

answer

Cervical cancer (45) Ovaries (69)

question

Cervical polyps: description, cause, at risk group, findings, management

answer

Description: fingerlike growths that start on the surface of the cervix or originate within endocervical canal/columnar epithelium (more common), can extend out of the cervical os. Cause: - Idiopathic - Associated with chronic inflammation - Associated with increased levels of estrogen (ex: pregnancy) - Associated with thrombosed cervical blood vessels At risk group: - relatively common - older multiparous women more common Findings: - vaginal bleeding, often after intercourse - bleeding occurs between normal menstrual periods - speculum examination: smooth, red/purple, fingerlike projections from cervical canal - biopsy typically reveals mildly atypical cells and signs of infection Management: - polyps can be removed by gentle twisting or by surgical string removal method (electrocautery/laser) - due to infected polyps being common, antibiotic may be given after the removal even if there are no or few signs of infection - although most polyps are benign, pathology exam of biopsy should still be done - regrowth of polyps is uncommon

question

What are cervical polyps associated with?

answer

Associations: - chronic inflammation - increased estrogen levels (pregnancy, etc.) - thrombosed cervical blood vessels - idiopathic

question

What do people with cervical polyps most commonly present with?

answer

vaginal bleeding, mostly after intercourse bleeding between normal menstrual cycles

question

What is the management of cervical polyps?

answer

polyps can be removed by gentle twisting or by surgical string removal method - electrocautery - laser antibiotics given after procedure due to common association of polyps with infection biopsy sent to pathology regardless of nature of polyps

question

Which group of people are at risk for developing cervical polyps?

answer

older women multiparous women

question

Nabothian cysts: description, cause, findings, management

answer

Description: mucus-filled cyst on the surface of the uterine cervix. These endocervical glands can become *covered* by squamous epithelium through metaplasia. Cause: - during the metaplasia and formation of the T-zone, columnar epithelium morphs into squamous epithelium; if the columnar cells beneath did not completely go through metaplasia, they can secrete mucus which can push the squamous epithelium outwards. Findings: - benign condition; rarely large enough to cause clinically relevant problems - pelvic examination reveals small, smooth, rounded lump (or collection of bumps) - rarely, colposcopic exam can be used to distinguish nabothian cysts from other types of cervical lesions Management: - no treatment necessary - Nabothian cysts do not clear spontaneously - Easily cured through electrocautery or cryotherapy

question

The cervical canal is lined by what type of cells? Function?

answer

Glandular cells / columnar epithelium secrete mucus

question

What does the Nabothian cyst present as? How do you treat it?

answer

small, smooth, rounded lump or collection of bumps caused by mucus-fileld cysts on the surface of the cervix (ectocervix) due to incomplete metaplasia of columnar epithelium beneath the T-zone during transformation benign condition No treatment necessary - electrocautery or cryotherapy can easily cure cyst

question

Cervicitis: symptoms, examination, investigative findings, management

answer

Symptoms: - no symptoms most common - vaginal discharge Examination: - most common finding is mucopurulent cervical discharge - friable cervix: endocervical bleeding easily induced by cotton swab palpation of cervical os - No pelvic tenderness noted - Patient is afebrile Investigative findings: DNA probe - Routine cervical cultures are positive for chlamydia or gonorrhea - STDs - WBC and ESR normal (no inflammation) Management: - Oral azithromycin in single dose - Oral doxycycline BID for 7 days

question

What is the most common finding in cervicitis?

answer

mucopurulent discharge from cervix friable cervix no pelvic tenderness or febrile condition

question

How do you manage cervicitis?

answer

Oral azithromycin single dose or Oral doxycycline BID for 7 days

question

Cervical neoplasia: presentation, etiology, risk factors

answer

Presentation: - usually asymptomatic - progression from premalignant to invasive cancer has been reported to be approximately 8~10 yrs (good prognosis for early detection and slow progression) - Most regress (young women) Etiology: - most common* etiology of cervical cancer is HPV - Over 75 subtypes - most common HPV types: 16, 18, 31, 33, 35, 45 - most common for condyloma accuminata: 6, 11 risk factors: - early age intercourse - multiple sexual partners* (strong positive correlation) - cigarette smoking - immunosuppression

question

What is the most common presentation of cervical cancer? What is the most common progression? Associated age groups and types?

answer

most common presentation is asymptomatic progression is most commonly regression, especially in young women - age 14~19 has 33% HPV risk - age 20~29 has 28% HPV risk 65% regress, associated with HPV 6, 11 - young women most commonly regress, 61% within 1 yr, and 91% within 3 years 20% same + 15% progress - associated with HPV 16, 18, 30s

question

What are the risk factors for developing cervical cancer?

answer

early age of intercourse cigarette smoking multiple sex partners immunosuppression

question

What are the most common HPV types for cervical cancer? Order of malignancy? Condyloma accuminata?

answer

CIN: HPV-16, 18, 31, 33, 35, 45 (16>18>45>31>33) Condyloma accuminata: HPV-6, 11

question

What is the most effective medically cancer screening test ever developed?

answer

PAP smear 70~80% decrease of death rate

question

Which HPV is most associated with squamous cell carcinoma of cervix?

answer

HPV-16

question

Which HPV is most associated with adenocarcinoma of the cervix?

answer

HPV-18

question

Rank the most common malignant HPV types that causes cancer in the cervix + association

answer

HPV-16 (squamo)....59% HPV-18 (adeno)....12% HPV-45>31>33....squamo

question

Why do we NOT start PAP smear before age of 21?

answer

Most cases of HPV infection regresses (65%) More so, most cases of HPV infection in young woman regresses completely in 3 years (91%) HPV infection is correlated with sexual intercourse at young age if HPV is going to regress mostly in 3 years there isn't a point of starting PAP smears until after 21yrs old

question

When doing a Pap smear on pregnant women what should you use?

answer

spatula for T-zone *cotton swab for endocervical canal

question

Pap smear should be started at the following ages:

answer

Age < 21: - NO Pap test or screening for HPV, regardless of sexual activity Age 21: start Pap test with cytology alone *without HPV testing; the recommendation is the same whether HPV vaccinated or not

question

What is the frequency of recommended Pap smear for Age groups 21-29? 30-65?

answer

Age 21-29: - repeat Pap every 3 years with cytology alone; do not perform HPV testing in this age group (due to slow progression of the disease) Age 30-65: - Pap every 3 years with cytology but no HPV testing OR - repeat Pap every 5 years if both cytology + HPV (recommended choice)

question

When should Pap smears be discontinued?

answer

After age 65 - if negative cytology and/or HPV tests for past 10 years AND no history of CIN-2, 3, or cervical carcinoma Any age if total hysterectomy and no history of CIN

question

What is the system used to classify Pap smears in the U.S.?

answer

Bethesda system

question

Classification os Bethesda system

answer

Negative: No intraepithelial lesions - may report trichomoniasis, candida, BV, HSV, atrophy, etc. Abnormal squamous cells (99% of abnormal Pap smears) ASCUS: (5%~20%) - atypical squamous cells of undetermined significance - suggestive of LSIL but not adequate - decrease ASCUS findings by making a thinner prep ASCH: - atypical squamous cells can't rule out HSIL - suggestive of but not adequate to label HSIL LSIL: - low-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings of HPV, mild dysplasia, or CIN 1 HSIL: - high-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings of moderate-severe dysplasia, CIN 2, 3, CIS Squamous cell carcinoma: - biopsy expected to show histologic findings of invasive cancer Abnormal endocervical cells (1% of abnormal Pap smears) AGC-NOS: - atypical glandular cells, not otherwise specified AGC-neoplastic: - atypical glandular cells, can't rule out neoplasia - changes suggestive of but not adequate to call AIS or cancer AIS: - adenocarcinoma in situ Adenocarcinoma

question

Describe ASCH on Bethesda system

answer

atypical squamous cells can't rule out HSIL - changes suggestive of but not adequate to label HSIL

question

Describe ASCUS on Bethesda system

answer

atypical squamous cells of undetermined significance - changes suggestive of but not adequate to label LSIL

question

Describe LSIL on Bethesda system

answer

low-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings of HPV, mild dysplasia, CIN1

question

Describe HSIL on Bethesda system

answer

high-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings moderate-severe dysplasia, CIN2, CIN3, CIS

question

Squamous cell carcinoma on Bethesda system

answer

Invasive carcinoma will enter staging instead of CIN numbers Stage 1 is after CIS - <2cm lesion (1a = 1mm deep lesion)

question

Describe AGC-NOS on Bethesda system

answer

atypical glandular cells not otherwise specified

question

Describe AGC-neoplastic on Bethesda system

answer

atypical glandular cells can't rule out neoplasia

question

Describe AIS on Bethesda system

answer

adenocarcinoma in situ

question

High-grade squamous intraepithelial lesions are associated with which histologic findings?

answer

moderate-severe dysplasia CIN-2 CIN-3 CIS

question

Low-grade squamous intraepithelial lesions are associated with which histologic findings?

answer

mild dysplasia HPV CIN 1

question

How often does ASCUS show up on Pap smears? How do you decrease ASCUS diagnosis? What is the management of ASCUS?

answer

<5% but up to 20% Decrease ASCUS findings by: - make a thinner prep or HPV/DNA typing: - if 6, 11 it will most likely regress (low-risk) but repeat Pap within 1 year - if 16, 18, 30s it is high-risk and need colposcopy and biopsy

question

If you find ASCUS on Pap smear, what are the tests you could run? (3)

answer

Accelerate repeat Pap: - 4~6 month intervals until 2 consecutive negative Paps - if a repeat Pap is again ASCUS or worse, this is an indication for colposcopy HPV-DNA testing: - if liquid-based cytology was used on initial Pap smear, it can be used for DNA testing (100% diagnostic) - indications for colposcopy: high-risk HPV types Colposcopy: - uses acetic acid to make vascular patterns more visible - 10~12 times magnification - satisfactory/non-satisfactory - unsatisfactory = t-zone invading into endocervical canal

question

What if you find cells other than ASCUS on a Pap smear, what tests should you run?

answer

Colposcopy and biopsy

question

If you find cells others than ASCUS (ASC-H, LSIL, etc.) on a Pap smear, what is your plan of management?

answer

Colposcopy Endocervical curettage (ECC) - not in pregnancy - ***colposcopy shows T-zone extending into endocervical canal, etc. Ectocervical biopsy - lesions identified on ectocervix by colposcopy*** - mosaicism, punctation, white lesions, abnormal vessels - biopsy and send for histology Compare Pap smear and biopsy - ensure level of severity is comparable with colposcopy - *Pap smear should not be worse than biopsy; means you missed the more malignant area on biopsy Diagnostic Cone biopsy indications: - Pap smear is worse than biopsy - ECC: abnormal cells - Lesions entering endocervical canal*** - Biopsy: microinvasive carcinoma Manage by histology: - observation: CIN1, repeat Pap in 6~12 months, colposcopy and repeat Pap in 12 months, or HPV/DNA testing in 12 months - ablation: CIN1, 2, 3 (cryotherapy, laser vaporization, electrofulguration) - resection: CIN1, 2, 3 (LEEP, cold-knife conization) - hysterectomy: biopsy-confirmed, recurrent CIN2 or 3 only

question

What are the risk of cone biopsy?

answer

incompetent cervix cervical stenosis

question

When Pap smear shows worse dysplasia than ASCUS, you use colposcopy examination and you see metaplastic epithelium entering the endocervical canal, what will you do next?

answer

ECC endocervical canal curettage

question

When Pap smear shows worse dysplasia than ASCUS, you use colposcopy examination and you see ectocervical lesions, what will you do next?

answer

Ectocervical biopsy

question

When Pap smear shows worse dysplasia than ASCUS, you use colposcopy examination and you see lesions entering the endocervical canal, what will you do next?

answer

Narrow cone biopsy

question

What are follow-up options for CIN1?

answer

Observation (repeat Pap, colposcopy and Pap, HPV-DNA) Ablative therapy (cryotherapy, laser, electrofulguration) Excisional procedure (LEEP, cold-knife)

question

What are follow-up options for CIN2?

answer

Ablative therapy (cryotherapy, laser, electrofulguration) Excisional procedure (LEEP, cold-knife cone) Hysterectomy (recurrent CIN2 only)

question

What are follow-up options for CIN3?

answer

Ablative therapy (cryotherapy, laser, electrofulguration) Excisional procedure (LEEP, cold-knife cone) Hysterectomy (recurrent CIN3 only)

question

When is hysterectomy indicated in CIN?

answer

recurrent CIN2, 3

question

CIN follow-up management: Observation

answer

Indicated for CIN1 Repeat Pap in 6~12 months Colposcopy and repeat Pap in 12 months HPV-DNA testing in 12 months

question

CIN follow-up management: Ablative therapy

answer

Indicated for CIN1, 2, 3 Cryotherapy Laser vaporization Electrofulguration Follow-up: repeat Pap smears, colposcopy and Pap smear, or HPV-DNA testing every 4~6 months for 2 years

question

CIN follow-up management: Excision/Resection

answer

Indicated for CIN1, 2, 3 LEEP cold-knife conization Follow-up: repeat Pap smears, colposcopy and Pap smear, or HPV-DNA testing every 4~6 months for 2 years

question

CIN follow-up management: hysterectomy

answer

CIN2, 3 only indicated in recurrent infections

question

What follow-up procedures are required for ablative therapy and excisional procedure patients for CIN?

answer

Follow-up: repeat Pap smears, colposcopy and Pap smear, or HPV-DNA testing every 4~6 months for 2 years

question

If cytologic findings of Pap smear reveals HSIL, what is the next step for patients ages 25-64?

answer

colposcopy + biopsy immediate LEEP**

question

Invasive Cervical Cancer definition

answer

cervical neoplasia that has penetrated through the basement membrane >CIS

question

Cervical cancer: definition, presentation, epidemiology, diagnostic findings

answer

Definition: cervical neoplasia penetrated through the basement membrane Presentation: - normal menstrual cycles - postcoital vaginal bleeding - irregular vaginal bleeding - lower extremity pain and edema in advanced stages Epidemiology: - 3rd most common gynecological carcinoma - ~45 years of age (youngest occurrence) - 250,000 deaths/yr world wide; 10,000/yr in U.S. Diagnostic Tests/Findings: - Cervical biopsy* - Metastatic workup: pelvic examination, chest x-ray, intravenous pyelogram, cystoscopy, sigmoidoscopy - Imaging studies: invasive cervical cancer is the ONLY gynecological cancer staged clinically (CT and MRI cannot be used for clinical staging)

question

What is the only gynecological carcinoma that uses clinical staging?

answer

Cervical cancer

question

Common presentation of cervical carcinoma?

answer

normal menstrual cycle postcoital vaginal bleeding irregular vaginal bleeding

question

Cervical cancer: staging

answer

CLINICAL (only gynecological carcinoma staged clinically) Stage 0: CIS (basement membrane is intact) Stage I: Spread limited to the cervix. *most common* - Ia1: 3mm but 5mm deep (frank invasion) Stage II: spread adjacent to cervix - IIa: involves upper 2/3 of vagina - IIb: invasion of parametria Stage III: spread further from the cervix - IIIA: involves lower one third of vagina - IIIB: extends to pelvic side wall or hydronephrosis Stage IV: spread furthest from cervix - IVA: involves bladder or rectum or beyond true pelvis - IVB: Distant metastasis

question

What is the most common stage of cervical cancer?

answer

Stage 1 limited to the cervix

question

What is the staging for minimally invasive cervical cancer? Management? Management in pregnancy?

answer

Ia1 </= 3mm deep total simple hysterectomy during pregnancy: cone biopsy during pregnancy follow conservatively, deliver vaginally reevaluated and treated 2 months postpartum

question

What is the staging for microinvasive cervical cancer? Management? Management in pregnancy?

answer

Ia2 <3mm but </=5mm deep modified radical hysterectomy during pregnancy: cone biopsy during pregnancy follow conservatively, deliver vaginally reevaluated and treated 2 months postpartum

question

What is the staging for frank invasion cervical cancer? Management? Management in pregnancy?

answer

IB >5mm deep radical hysterectomy or radiation (IIa) during pregnancy: based on gestational age - before 24 weeks: receive definitive treatment as shown above - after 24 weeks: conservative management to 32-33 weeks, after C-section definitive treatment can be done

question

What ist he staging for cervical cancer that has spread adjacent to the cervix? Management? Management in pregnancy?

answer

II IIa: upper 2/3 of vagina involved Management: radical hysterectomy or radiation IIb: invasion of parametria Management IIb or above: radiation therapy and chemotherapy for all ages during pregnancy: based on gestational age - before 24 weeks: receive definitive treatment as shown above - after 24 weeks: conservative management to 32-33 weeks, after C-section definitive treatment can be done

question

Cervical cancer: staging management

answer

Stage Ia1: - 3mm but 5mm frank invasion - IIa: involves upper 2/3 of vagina - radical hysterectomy with/without radiation Stage IIb, III, IV: - radiation therapy and chemotherapy for all ages

question

Cervical cancer: follow-up

answer

All patients with invasive cervical cancer should be followed up with... - Pap smear every 3 months for 2 years after treatment - then every 6 months for subsequent 3 years Patients who have local recurrence can be treated with radiation therapy Patients with distant metastases should be considered for chemotherapy treatment - Cisplatinum

question

What is the most active chemotherapeutic agent for cervical cancer?

answer

Cisplatinum

question

What is the effect of pregnancy in cervical neoplasia

answer

pregnancy does NOT predispose abnormal cytology and does not accelerate precancerous lesions progression

question

Diagnostic tests and findings for pregnant patients in cervical cancer

answer

Pregnant with abnormal Pap smear should be evaluated in the SAME FASHION - owing to increased cervical vascularity ECC is not performed during pregnancy (endocervical canal curettage)

question

What is the plan of management in pregnant patients with cervical cancer in CIN stages?

answer

Pap smear and colposcopy every 3 months during pregnancy 6~8 weeks postpartum the patient should be reevaluated with repeat colposcopy an dPap smear Any persistent lesions can be definitively treated postpartum

question

What is the plan of management for microinvasion cervical cancer in pregnant patients?

answer

evaluated with cone biopsy to ensure no rank invasion patients can be followed conservatively delivery can be vaginal reevaluation and treatment 2 months postpartum

question

What is the plan of management for frank invasion carcinoma in pregnant patients?

answer

Based on gestational age before 24 weeks - definitive treatment based on staging after 24 weeks - conservative management to about 32-33 weeks - C-section - definitive treatment after delivery

question

Gardasil: recommendation, coverage, regimen

answer

Recommendation: - females 8~26; target group 11~12yrs - Efficacy is highest before patient's immune system is exposed to HPV - No point in testing for HPV before vaccination, no easy method of identifying all HPV types - Pap smear continued to guidelines due to >70 types of HPV strains and vaccine covers only 4 most common - sexually active women can receive vaccine, same with women who has previous abnormal cervical cytology or genital warts, just less effective - patients with previous CIN, benefits limited - not recommended for pregnant, lactating, or immunosuppressed women, but no tests has been done to prove clinical relevant harm Coverage: - HPV 6, 11, 16, 18 - covers 70% of cervical cancer and 90% of genital warts of HPV strains Regimen: - initial, 2 months, 6 months - $300

question

What is the target group for Gardasil? Why?

answer

11~12 age group Efficacy best before host immune system is exposed to HPV strains

question

What strains of HPV does Gardasil cover?

answer

HPV 6, 11, 16, 18

question

When is the Gardasil vaccine contraindicated?

answer

Pregnant women Lactating women Immunosuppressed women Not clinically proven to be true

question

How many types of uterine anomalies are there? How are they divided?

answer

7 types by the American Fertility Society (1988) Divided by - failure to form - failure to fuse - failure to dissolve the septum

question

Hypoplasia/Agenesis of Uterus: description, cause, association

answer

description: - may lack a vagina, cervix, fallopian tubes, body of uterus - developmental problem with a section of both mullerian ducts association - urinary tract anomalies - urinary tract embryologically lie close to mullerian ducts

question

Unicornuate uterus: defect, description, complications, symptoms

answer

defect and description: - when ONE of the mullerian ducts fails to form - *sing-horn (banana-shaped) uterus develops from the remainder healthy mullerian duct - single uterus may stand alone complications: - 65% of women with unicornuate uterus, the defected mullerian duct may form an incomplete rudimentary horn - may or may not have cavity in the rudimentary horn but the opening that communicates with the healthy uterus is either small or nonexistent symptoms: if rudimentary horn forms - monthly pain during adolescence because no outlet for menses from rudimentary horn - risk of pregnancy in rudimentary horn, 90% ruptures due to anatomical limitations

question

Didelphys uterus: defect, description, risks

answer

defect and description: - results from complete failure of the 2 mullerian ducts to fuse together (stage 1 development) - each duct develops into a separate uterus - each uterus can have their own cervix or share a cervix - 67% of cases is associated with 2 vaginas separated by a thin wall risks: - preterm delivery is common

question

Bicornuate uterus: defects, description, types, risks

answer

defect and description: - most common congenital uterine anomaly (45%) - results from failure of fusion between the mullerian ducts at the fundus - 'complete' failure to fuse results in 2 separate single-horn uterine bodies sharing 1 cervix* - 'partial' failure to fuse results in fusion at the bottom but not the fundus causing single uterine cavity with 2 distinct horns on top and a shared cervix* Risks: - preterm delivery - malpresentations with pregnancy

question

What is the most common congenital uterine anomaly?

answer

Bicornuate uterus 45%

question

Septate uterus: defect, description, types, risks

answer

defect and description: - failure in degeneration of the median septum - complete failure: 2 single-horned uteri that share one cervix - partial failure: shared cavity at lower portion of uterus with 1 cervix - *external shape of uterus is normal-appearing* risks: - preterm delivery

question

Septate uterus vs. Bicornuate uterus

answer

septate uterus looks normal-appearing single unit exteriorly bicornuate uterus has distinct 2 separate horns at fundus both can result in separate cavity but sharing 1 cervix or partial shared cavity with 1 cervix

question

Arcuate uterus: defect, description, risks

answer

defect and description: - essentially NORMAL in shape - NORMAL in function as well - small midline indentation in the uterine fundus, results from failure to dissolve the median septum completely risks: - essentially none

question

DES uterus: defect, description, cause, risks

answer

defect and description: - *T-shaped cavity - mothers exposed to DES (diethylstilbestrol) which was used 30yrs ago to prevent miscarriages are predisposed to uterine abnormalities and clear cell carcinoma of the vagina, idiopathic risks: - cervical insufficiency

question

What teratogen is associated with predisposition of clear cell carcinoma of the vagina?

answer

DES (diethylstilbestrol) DES uterus + clear cell carcinoma of vagina idiopathic

question

Leiomyoma Uteri: description, at risk group, different locations

answer

Description: benign smooth muscle growth of myometrium causing non-tender asymmetric distortions of the uterus; most common benign uterine tumor At risk group: 5x more common in black women than white women Location: Intramural: - most common location is within uterine wall - asymptomatic and cannot be felt on examination unless enlargement of uterus is altering external contour Submucosal: - located beneath the endometrium and can distort the uterine cavity - since endometrium may not respond appropriately to normal hormonal fluctuation the result is unpredictable, often intermenstrual, bleeding* - *most common symptom is vaginal bleeding and can result in anemia Subserosal: - located beneath uterine serosa; they can distort the external contour of the uterus - pedunculated subserosal leiomyomas can become parasitic fibroids - they break away from uterus and receive their blood supply form another abdominal organ

question

Leiomyoma uteri: natural history

answer

Natural history: - slow growth*: most leiomyomas are small, grow slowly and cause no symptoms - rapid growth: estrogen receptors are increased in leiomyomas resulting in rapid enlargement during times of high estrogen levels, such as pregnancy - degeneration: during rapid growth, myomas may outgrow their blood supply, resulting in ischemic degeneration of a fibroid (hyaline, calcific, red degeneration/carneous degeneration) - Shrinkage: when estrogen levels fall, leiomyomas will typically decrease in size; physiologically (menopause) or through treatment (GnRH agonist suppression of FSH)

question

How does most leiomyomas present clinically?

answer

Slow growth small, grow slowly, and asymptomatic

question

What is the most common form of leiomyoma of uterus?

answer

Intramural leiomyoma found within the uterine wall

question

What is the most common presentation of a submucosal leiomyoma of the uterus?

answer

vaginal bleeding metrorrhagia = irregular bleeding between menses menorrhagia = heavy menses

question

Which type of uterine leiomyoma can become parasitic fibroids?

answer

Pedunculated subserosal uterine leiomyoma Break away from uterus and receive blood supply from another organ in the abdomen

question

Where is the intramural leiomyoma of the uterus found? How does it present?

answer

Most common location of leiomyoma uteri Found within the wall of the uterus Mostly asymptomatic and cannot be felt on examination unless it enlarges to where the normal uterine external contour is altered

question

Where is the submucosal leiomyoma of the uterus found? How does it present?

answer

It is found beneath the endometrium and can distort the uterine cavity It can be pedunculated and extend into the vagina through the cervix Due to overlying endometrium may not respond appropriately to the normal hormonal fluctuations, it results in unpredictable and often intermenstrual bleeding - menorrhagia - metrorrhagia - menometrorrhagia = combined of irregular bleeding between menses and heavy menses Most common presentation is vaginal bleeding

question

Where is the subserosal leiomyoma of the uterus found? How does it present?

answer

It is found beneath the uterine serosa They can distort the external contour of the uterus causing firm, nontender asymmetry Pedunculated subserosal leiomyomas can break away from uterus and form parasitic fibroids receiving blood supply from another organ

question

What are the top causes of uterine enlargement?

answer

1. pregnancy 2. leiomyoma 3. adenomyosis 4. leiomyosarcoma (extremely rare)

question

What is the cause of leiomyoma uteri degeneration? What are the types? Presentations?

answer

Sometimes the leiomyoma outgrows its blood supply and can result in ischemic infarction causing degeneration hyaline, calcified, red degeneration Red degeneration is also called carneous degeneration - cause extreme, acute pain - morphine and narcotics required - this is most common during pregnancy

question

What is the most common type of degeneration of uterine leiomyoma during pregnancy?

answer

Red degeneration

question

When does uterine leiomyoma present with rapid growth?

answer

estrogen receptors are increased in leiomyomas resulting in rapid enlargement during times of high estrogen levels example: pregnancy

question

Leiomyoma uteri: management

answer

Observation: - most leiomyomas can be managed conservatively and followed expectantly with regular pelvic examinations Presurgical shrinkage: - 3~6 months GnRH analog therapy; leuprolide/Lupron - adjuvant to surgical removal - reduction in size up to 60%~70% - decrease in blood loss in myomectomy - makes vaginal hysterectomy possible Myomectomy: - removal of myoma - maintains fertility - laparoscopic or laparotomy - future deliveries through cesarean section Embolization: - catheter placed into vessels supplying myoma - microspheres are injected, causing ischemia and necrosis of myoma - ~10% mortality rate (wrong vessel; uterine necrosis) Hysterectomy: - definitive therapy

question

How can you shrink a uterine leiomyoma before surgery? Purpose?

answer

3~6 months of GnRH (gonadotropin releasing hormone) analog therapy; Lupron (leuprolide) Results in 60%~70% shrinkage in size Not used for definitive cure, due to stoppage of leuprolide can cause regrowth of leiomyoma Mostly used as an adjuvant to surgical removal of myoma; decreases blood loss in myomectomy the decrease in size can also result in vaginal hysterectomy instead of abdominal hysterectomy

question

Uterine leiomyoma: diagnosis methods

answer

Diagnosis: Pelvic examination: enlarged, asymmetric, non-tender uterus in teh absence of pregnancy most common - 20wks gestation size = uterus reaching umbilicus (belly button) - 12wks gestation size = uterus reaching pubis symphysis Sonography: ultrasound, saline infusion sonography is helpful for identifying submucosal myomas Hysteroscopy Histology is only confirmed through surgical confirmation of excised tissue

question

Adenomyosis: definition, presentation, diagnosis, Sx, examination, imaging, management

answer

Definition: ectopic endometrial glands and stroma are located within the myometrium of the uterine wall Presentation: - most common presentation is diffuse involvement of the myometrium - adenomyoma is termed for focal involvement, surrounded by a pseudocapsule Diagnosis: - enlarged, symmetric, tender uterus in teh absence of pregnancy - definitive diagnosis is by histologic confirmation of the surgically excised tissue Sx: - mostly asymptomatic - most common symptoms are secondary dysmenorrhea and menorrhagia Examination: - uterus is globular and up to 2~3x normal size - tenderness is most common immediately before and during menses Imaging: - ultrasound - MRI - *cystic areas found within the myometrial wall Management: - surgery is the definitive treatment - LNG-IUS (levonorgestrel intrauterine system may decrease heavy menstrual bleeding)

question

Primary dysmenorrhea findings

answer

onset 2~3yrs after menarche menarche = 11~16.5 yrs

question

What is the most common presentation of adenomyosis? Otherwise?

answer

Most common is diffuse involvement resulting in symmetric, soft, tender enlargement of the uterus When it becomes focalized and surrounded by a pseudocapsule, it is called adenomyoma

question

What is the most common symptoms of adenomyosis?

answer

mostly asymptomatic most common symptomatic presentation is - menorrhagia - 2° dysmenorrhea

question

When does tenderness most likely occur in patients with adenomyosis?

answer

most common immediately before and during menses

question

What is the most likely diagnosis upon seeing cystic areas found within the myometrial wall and the uterus is symmetrically enlarged?

answer

Adenomyosis

question

What is the management for adenomyosis?

answer

LNG-IUS - levonorgestrel intrauterine system - T-shaped intrauterine device that secretes progesterone into the uterine cavity - decreases heavy menstrual bleeding Surgery - hysterectomy is the definitive treatment

question

Define menopause

answer

3 continuous months of cessation of menses and elevated gonadotropins ~52 years old

question

What is the most common cause of postmenopausal bleeding?

answer

vaginal or endometrial atrophy

question

BMI range

answer

formula = kg/m² 40: obesity class 3 (very severely obese)

question

Synopsis: Postmenopausal bleeding steps of diagnosis and management

answer

Speculum exam: rule out vaginal lesions and cervical lesions Once ruled out... obtaining upper tract tissue: - endometrial biopsy - hysteroscopy and ultrasonography - send biopsy to pathology If finding is... atrophy: - management is estrogen with progestin polyps: - benign - hysteroscopic resection hyperplasia: - simple *without atypia: progestin treatment - complex *with atypia: total vaginal or abdominal hysterectomy carcinoma: - stage & grade - total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH-BSO) + lymph node dissection - according to staging and necessary radiation + chemotherapy

question

Most common cause of endometrial carcinomas?

answer

upposed estrogen without the stabilizing effect of progesterone

question

What are the major risk factors of postmenopausal bleeding?

answer

Obesity***: increased peripheral conversion of androgen to estrogen due to increased adipose tissue hypertension, diabetes mellitus (both points towards obesity) nulliparity: no kids means no exposure to the long period of progesterone during pregnancy; equal to possible unopposed estrogen chronic anovulation conditions (PCOS, etc.): no ovulation means no progesterone

question

What are some the diagnostic tests to confirm cause of postmenopausal bleeding?

answer

Endometrial sampling: - sampling process may miss diagnosis due to localized growth in the endometrium - example: dilatation and curettage of endometrial misses a small section where neoplastic growth is occurring Hysteroscopy: - with hysteroscope, cervical or endometrial polyps can be identified as cause of postmenopausal bleeding Ultrasound: - ultrasonography can be used to measure the thickness of the lining of the endometrium (postmenopausal patients should be <5mm)

question

What is the endometrial lining stripe measurement supposed to be for postmenopausal women?

answer

<5mm Ultrasound

question

Endometrial cancer: staging

answer

Most common cause of gynecological cancer Staging is surgical Stage I: spread limited to the uterus (most common stage at diagnosis) - IA: limited to the endometrium or invasion *less than 1/2 of myometrium* - IB: invasion *more than 1/2 of myometrium* Stage II: extension to teh cervix but not outside the uterus Stage III: Spread adjacent to teh uterus - IIIA: invades serosa or adnexa or positive cytology - IIIB: invasion of vagina - IIIC: invasion of pelvic or para-aortic nodes Stage IV: Spread further from the uterus - IVA: involves bladder or rectum - IVB: distant metastasis

question

What is the management of atrophy of endometrium induced postmenopausal bleeding?

answer

hormone replacement therapy estrogen + progestin

question

Endometrial cancer: management

answer

Stages I~IV: TAH-BSO + lymph node resection - TAH: total abdominal hysterectomy - BSO: bilateral salpingo-oophorectomy After surgery: radiation and chemotherapy - Stage I: none - Stage II: radiation - Stage III + IV: radiation + chemotherapy

question

What is the management for endometrial hyperplasia? What is the most common cause?

answer

Unopposed estrogen can cause hyperplasia of endometrium Simple hyperplasia with no atypia: progestin Complex hyperplasia, no atypia: progestin Complex hyperplasia with atypia: hysterectomy or progestin for non-surgical candidates Endometrial carcinoma: staging + TAH/BSO

question

Which types of hyperplasia can be managed with progestin?

answer

simple hyperplasia with no atypia complex hyperplasia with no atypia

question

How does complex hyperplasia histologically present? Complex hyperplasia with atypia?

answer

decreased stroma with increased glandular tissue atypia will show misshapen nucleus, etc.

question

What are some prevention methods of postmenopausal bleeding? Reproductive age women bleeding? Dietary?

answer

postmenopausal patient: - estrogen replacement therapy with progestin reproductive age women: - most likely due to chronic anovulation (PCOS, etc.) - progestin treatment Dietary - soy: 30~40% reduction of endometrial cancer risk

question

Tamoxifen association with vaginal bleeding

answer

Tamoxifen is used for breast cancer prevention by its estrogen antagonistic effects on the breast However, it has estrogen agonist effects on the uterus It can induce hyperplasia and endometrial polyps

question

Embryologic origin of uterus

answer

Fusion of the 2 Mullerian ducts

question

When is transvaginal transducer ultrasound used? Transabdominal transducer?

answer

Transvaginal transducer: ("pie shaped image") - lower pelvic masses - not influenced by thickness of maternal abdominal wall Transabdominal transducer: - entire pelvis as well as abdomen imaging Ultrasound works best when adjacent tissues have differing echodensities, particularly fluid/tissue interfaces

question

Average age range of menarche? Thelarche?

answer

menarche: 10-16.5y thelarche: breast development; 8~11y

question

What is the average age for Tanner II stage of breast development? Presentation?

answer

Tanner II: Breast development - 8-13 yrs - Breast buds begin

question

ASCUS?

answer

Atypical Squamous Cells of Uncertain Significance misreadings on Pap smears due to mechanical errors (drying, etc.)

question

Major structures of the uterus (3)

answer

Corpus (body) - Cornu (uterus join with fallopian tubes) Isthmus Cervix

question

Describe satisfactory colposcopy vs. unsatisfactory colposcopy

answer

Satisfactory colposcopy 1. T-zone does NOT extend into the endocervical canal 2. No lesions visualized within T-zone Unsatisfactory is the opposite..

question

Tanner stages: Pubic Hair

answer

Male + Female Tanner I: None (prepubertal state) Tanner II: small amount of long, downy hair with slight pigmentation on the labia majora Tanner III: hair becomes more coarse and curly and begins to extend laterally Tanner IV: adult-like hair quality, extending across pubis but sparing medial thighs Tanner V: hair extends to medial surface of the thighs

question

What are the risks of cone biopsy? (3)

answer

1. incompetent cervix (cutting too much) 2. cervical stenosis (can cause amenorrhea) 3. preterm birth

question

Traditional Pap vs. Liquid-based Pap

answer

Traditional Pap: - spatula for ectocervix* - cyto-brush for endocervical canal* (rotating in 1 direction 360°) - both specimens are smeared onto a glass slide, fixed with formalin, then stained *Potential problems* - ASCUS (atypical squamous cells of uncertain significance) cannot be diagnosed - insufficient smearing, air-drying artifacts if process is delayed, mechanical problems makes traditional technique obsolete Liquid-based Pap: - cervical broom* to collect specimens (rotated 5 times in same direction) - broom is placed into "formalin" solution and rotated 10 times to release collected material - this method is more preferred vs. traditional Pap due to absence of mechanical errors - ASCUS can also be used for HPV-DNA typing

question

What is special about Tanner IV stage of breast development?

answer

Papilla and areola forms a 2' mound not contour with surrounding breast

question

LEEP (loop electrosurgical excision procedure) description, procedure, followup, risks

answer

A thin low-voltaged loop cuts out abnormal cervical tissue identified with colposcopy advantage: visual confirmation lesions have been removed; no anesthesia needed followup Pap smear every 3-6 months for 2 years to ensure dysplastic changes to not return long-term risks of LEEP include - cervical stenosis - cervical insufficiency

question

What type of blood supply do oviducts receive? From where?

answer

Dual blood supply* Receives blood from the uterine artery and ovarian artery

question

What is the average age range for Tanner V stage of breast development?

answer

Tanner V: Breast development - 12.5~18.5 yrs - development is complete

question

What does the ovarian stroma produce?

answer

androgen Important for libido after menopause

question

Dilation and Curettage (D&C) procedure

answer

under anesthesia examines histology of endometrial lesions similar to endometrial biopsy; dilation of cervix is required to introduce curette can collect large amounts of endometrial tissue (>endometrial biopsy)

question

What are the 4 segments of the oviducts?

answer

Proximal → Distal "INTERcourse IS AMP and FUN" 1. Interstitium 2. Isthmus 3. Ampulla 4. Infundibulum

question

American Cancer Society recommendations

answer

1. initial study at age 34 if there are risk factors (breast cancer in first degree relative, BRCA genes, etc.) 2. routine screening at age 40 if there are no risk factors

question

Explain the formation of the T-zone

answer

at puberty the vaginal pH falls (due to estrogen dominance) the "native" columnar epithelium goes through metaplasia and becomes the transformation zone; normal-appearing "metaplastic" stratified squamous epithelium Old→New squamocolumnar junction (outer-to-inner)

question

Procedure associated with assessment of Asherman's syndrome

answer

HSG hysterosalpingogram

question

Cryotherapy description, procedure, followup, risks

answer

Destroys dysplastic cervical tissue identified by colposcopy and cervical biopsy; no anesthesia needed Cryo probe at -50℃ with liquid nitrogen Freeze and destroy tissue; 3 minutes intervals of freezing Watery discharge will occur over next few weeks as destroyed tissue sloughs off Followup Pap smears every 3-6 months for 2 years; disadvantage of not knowing if lesions are destroyed until followups Risks: cervical stenosis

question

Phases of development: Folliculogenesis

answer

Primordial: - dormant, small - 1 layer of flat granulosa cells Primary: - Mitotic cells - cuboidal granulosa cells Secondary: - Theca cells - Multiple layers of granulosa cells Tertiary: - Fully formed antrum Graafian (vesicular) follicle: - preovulatory follicle; fully mature

question

Tanner stages: Breast development

answer

Tanner I: no glandular tissue; areola follows skin contours of the chest (prepubertal) Tanner II: breast bud forms with small area of surrounding glandular tissue; areola beings to widen - 8-13yrs Tanner III: breast begins to become more elevated and extends beyond borders of areola; remains in contour with surrounding breast Tanner IV: increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast Tanner V: adult size; areola returns to contour of the surrounding breast, with projecting central papilla (nipple) - 12.5-18.5yrs

question

Colposcopy description

answer

"binoculars into the vagina" 1. *visually* identify where abnormal Pap smear cells originated 2. biopsy that area to send for histologic diagnosis

question

Average length of a vagina

answer

8-9cm

question

What is the lymphatic drainage of the ovaries?

answer

Pelvic nodes Para-aortic nodes

question

What are the organ systems we need to consider involving pelvic pain/pelvic mass?

answer

GI (colons) Uterus Bladder

question

What is the most common anatomical position of the uterus?

answer

Anteverted (50%) mid-position (25%) retroverted (25%)

question

Endometrial biopsy

answer

examines histology of endometrial lesions hollow suction cannula is placed into uterine cavity and suction is applied; rotation of cannula before fixing with formalin

question

Which portion of the cervix is most concerned for scrapings during a Pap smear?

answer

Transformation zone (T-zone) - 95% of cervical dysplasia and cancer develops here - screening for squamous cell carcinoma (most common cancer of the cervix 80%) - area between old (outer, "O") squamocolumnar junction and new (inner) squamocolumnar junction

question

Risks of mammography

answer

high radiation (0.7 mSv) same as background radiation in 3 months 1 rad = 10 mSv

question

What is the specimens required for a Pap smear? What diseases are they mostly screening for?

answer

2 areas 1. T-zone of the ectocervix (squamous cell carcinoma; most common cancer of cervix 80%) 2. columnar epithelium of endocervical canal (adenocarcinoma; 2nd most common cancer of cervix 15%)

question

Hysterosalpingogram (HSG) description and procedure

answer

procedure performed without anesthesia, radio-opaque fluid injected at endocervical canal allowing assessment of uterine malformations and Asherman's syndrome dye is supposed to spill into pelvic cavity; non-spillage can be a sign of fallopian tube occlusion or blockage

question

Vulvar biopsy

answer

done with punch biopsy or scalpel performed under local anesthesia, histology of vulvar lesions

question

Hysterectomy types

answer

removal of uterus "hyster" root comes from the misled belief women are crazy because of their uterus 1. subtotal: removes only teh corpus, leaving cervix in place 2. total: removes both corpus and cervix of uterus (aka simple hysterectomy) 3. radical hysterectomy: performed for early stage CIN, involves removal of the uterus, cervix, and surrounding tissues, including cardinal ligaments, uterosacral ligaments, and the upper vagina (can involve removing lymph nodes depending on stages of CIN)

question

What is the term for the surgery of removing ovaries?

answer

removal of ovaries Salpingo-oophorectomy

question

Cone biopsy: wide-shallow cone vs. narrow-deep cone

answer

Cone biopsy; both procedures need anesthesia Wide-shallow cone: - performed if Pap smear shows changes more severe than the colposcopically directed biopsy Narrow-deep cone: - performed if a lesion extends from the exocervix into teh endocervical canal

question

The pelvic floor is made up of which diaphragms? What structures do they hold?

answer

Pelvic diaphragm: - levator ani (puborectalis, pubococcygeus, ileococcygeus) - coccygeus muscles Perineal membrane (urogenital diaphragm): - triangular sheet of dense fibromuscular tissue "anterior triangle" that spans the anterior half of the pelvic outlet - vagina and urethra pass through the perineal membrane

question

Most common cause of uterine prolapse?

answer

childbirth

question

Uterine prolapse classification

answer

Grade I: cervix descends half way to introitus Grade II: cervix descends to introitus Grade III: cervix extends outside the introitus Grade IV or procidentia: entire uterus, as well as the anterior and posterior vaginal walls, extends outside the introitus

question

What is procidentia?

answer

Grade IV Uterine prolapse entire uterus + anterior and posterior vaginal walls extends outside the introitus

question

Vaginal prolapse classification

answer

Cystocele (most common): anterior vaginal wall prolapse; contains the bladder Rectocele (2nd most common): posterior vaginal wall prolapse; contains the rectum Enterocele (3rd): rectouterine pouch/pouch of Douglas prolapse

question

What is the triad for rectocele diagnosis?

answer

1. postmenopausal woman 2. Posterior vaginal wall protrusion 3. Digitally assisted removal of stool "digital splitting"

question

Management of pelvic relaxation: non-surgical

answer

Non-surgical: - Kegel exercises (learning to control pubococcygeus muscle; "magazine for better sex"; kegel weights) - Estrogen replacement in postmenopausal women - Pessaries (mechanical method)

question

Management of pelvic relaxation: surgical

answer

Surgical: when conservative methods fail - vaginal hysterectomy (with vagina vault suspension) + anterior/posterior vaginal repair - anterior and posterior colporrhaphy: uses endopelvic fascia that supports bladder and rectum

question

Diagnosis of prolapse in pelvic relaxation is done how?

answer

Tell the patient to perform Valsalva in lithotomy position

question

Average age of menopause?

answer

51-52

question

Physiology: continence vs. micturition

answer

balance between urethral closure & detrusor muscle (bladder muscle) activity urethral sphincter pressure normally > bladder pressure = urine continence urethral pressure decreases < bladder pressure = micturition/voiding Normally proximal urethra + bladder both within the pelvis (prolapse can alter this state leading to incontinence); intraabdominal pressure increases (valsalva) are transmitted equally to both, leaving the pressure difference unchanged; continence detrusor muscle spontaneous contractions are normally easily suppressed

question

Pharmacology: bladder receptors innervation

answer

α-adrenergic receptors: Sympathetic nervous system - "Sympathetic SHOOTS" hence urethral sphincters contract to inhibit incontinence during ejaculation - primarily found in urethra - *prevent* micturition; *contraction* of urethral - Drugs agonists: ephedrine, imipramine, estrogens - Drugs antagonists: phenoxybenzamine β-adrenergic receptors: Sym. nervous system - *prevents micturition*; relaxation of bladder detrusor muscles hence prevents urination - primarily in the detrusor muscle - Drugs agonists: flavoxate, progestins Cholinergic receptors: Parasympathetic innervation - *enhances micturition* - primarily also in detrusor muscle; *contraction* - Drugs agonists: bethanecol, neostigmine - Drugs antagonists: oxybutynin, propantheline

question

Cystometry Volume Measurements

answer

Post-void residual volume = <50mL Sensation of fullness = 200-225mL Urge to void = 400-500mL Normally a patient should be able to suppress the urge to void. (shown on graph) Involuntary contractions can be seen by watching saline level in the syringe rise/fall; normally there should not be any involuntary contractions

question

Sensory Irritative Incontinence: etiology, history, examination, investigative studies, management

answer

Etiology: - involuntary rises in bladder pressure - results in detrusor contractions - possible causes: infection, stone, tumor, foreign body History: - loss of urine occurs with *urgency, frequency and dysuria* - can take place *day or night* Examination: - suprapubic tenderness may be elicited - pelvic examination normal (no prolapse of any sort) - neurological exam normal (anal contraction reflex normal, S2-3-4; by stimulating labia majora we get a anal contraction) Investigative study: *urinalysis* - bacteria and WBC (infection) - RBC (stone, foreign body, tumor) - positive urine culture (infection) - normal cystometric studies (normal RV with involuntary detrusor contractions present) Management: - antibiotics (infections) - cystoscopy to diagnose and remove stones, foreign bodies, tumors

question

Inhibit voiding Tx: bladder relaxants/antispasmodics

answer

oxybutynin (Ditropan) flavoxate (Urispas)

question

Inhibit voiding Tx: bladder relaxant/anticholinergics

answer

Pro-Banthine

question

Inhibit voiding Tx: bladder relaxant/tricyclics

answer

Imipramine (Tofranil)

question

Inhibit voiding Tx: vesical neck contraction/alpha adrenergics

answer

ephedrine Imipramine Estrogen stimulates alpha receptors Progesterone stimulates beta receptors

question

Which receptors do estrogen stimulate? progesterone?

answer

Estrogen stimulates alpha receptors Progesterone stimulates beta receptors

question

Promote voiding Tx: bladder contraction/cholinergics

answer

Bethanechol (Urecholine) Neostigmine (Prostigmin)

question

Promote voiding Tx: vesicle neck relaxants/alpha antagonists

answer

methyldopa phenothiazines

question

Genuine Stress Incontinence: Etiology, history, examination, investigative studies, management

answer

Etiology: - most common form of true urinary incontinence - rises in bladder pressure because of intraabdominal pressure increase - not transmitted to proximal urethra due to pelvic relaxation and not being a part of pelvic structures anymore - *loss of bladder support* History: - loss of urine occurs in small spurts simultaneously with coughing or sneezing - *Does NOT* take place when patient is sleeping Examination: - cystocele may be seen - Neurologic examination is normal - Q-tip test is positive (q-tip placed within the urethra and patient increases intraabdominal pressure, the q-tip will rotate >30 degrees) Investigative studies: - urinalysis + culture are normal - cystometric studies are normal - *no* involuntary detrusor contractions seen Management: Mostly similar to pelvic relaxation management - Kegel exercises - estrogen replacement (stimulates alpha receptors) - surgical therapy aims to elevate the urethral sphincter (Burch procedure, MML, tension-free vaginal tape procedure)

question

What is the most common form of true urinary incontinence?

answer

Genuine stress incontinence

question

What is the only incontinence that does not result in voiding during the night?

answer

Genuine stress incontinence

question

What is the triad of stress incontinence?

answer

Involuntary loss of urine (large) with coughing and sneezing (increase abdominal pressure) No urine lost at night

question

Motor Urge (Hypertonic) Incontinence: etiology, history, examination, investigative studies, management

answer

Etiology: 'Itty-Bitty Bladder Syndrome' - involuntary rises in bladder pressure from idiopathic detrusor contractions that cannot be voluntarily suppressed History: - loss of urine occurs in large amounts; often without warning - day + night - most common symptom is urgency Examination: - pelvic examination shows normal anatomy - neurologic examination is normal Investigative studies: - urinalysis + culture normal - cystometric studies show normal residual volume - *involuntary detrusor contractions are present even with small volumes of urine in the bladder* Management: - anticholinergic medications - NSAIDS to inhibit detrusor contractions - tricyclic anti-depressants - calcium-channel blockers

question

What is the triad for hypertonic bladder?

answer

Involuntary loss of urine cannot suppress urge to void urine loss day + night

question

Hypertonic incontinence vs. Hypotonic incontinence

answer

Hypertonic: - large volume urine loss - idiopathic detrusor muscle contraction - day + night Hypotonic: - small volume urine loss (until urethral sphincter = bladder pressure) - bladder never empties; detrusor muscle relaxation - day + night

question

Overflow/Neurogenic (Hypotonic) Incontinence: etiology, history, examination, investigative studies, management

answer

etiology: - Rises in bladder pressure occur gradually from over-distended, hypotonic bladder - voiding occurs only when bladder pressure > urethral sphincter pressure - *bladder never empties*; voiding occurs only until bladder pressure = urethral sphincter pressure - may be due to denervated bladder (diabetic neuropathy, MS, or systemic medication) history: - loss of urine occurs intermittently in small amounts* - day + night - pelvic fullness is a common symptom examination: - pelvic examination may show normal anatomy - *decreased pudendal nerve sensation* investigative studies: - urinalysis and culture usually normal; may show infection - cystometric studies show markedly increased residual volume - involuntary detrusor muscle contractions do NOT occur management: - intermittent self-catheterization may be necessary - discontinue the offending systemic medications - bladder contraction stimulation (alpha receptor blocker; cholinergic drugs)

question

What is the triad for hypotonic bladder?

answer

involuntary loss of urine detrusor muscle not contracted urine loss day + night

question

Types of urinary incontinence with irregular detrusor muscle contractions

answer

Hypertonic incontinence

question

Types of urinary incontinence with no involuntary detrusor muscle contractions

answer

Stress incontinence Hypotonic incontinence

question

Fistula incontinence: etiology, history, examination, investigative studies, management

answer

etiology: - normal urethral-bladder mechanism is intact - bypassed by urine leaking out through a fistula from urinary tract history: - *radical pelvic surgery* or *pelvic radiation therapy* - loss of urine occurs continually in small amounts - day + night examination: - normal anatomy and normal neurologic findings investigative studies: - urinalysis and culture are normal - IVP (intravenous pyelogram) will demonstrate dye leakage from urinary tract fistula management: - surgical repair of the fistula

question

Triad for bypass incontinence

answer

involuntary loss of urine history: radical pelvic surgery or radiation urine loss day + night continuously* (small amounts)

question

Vaginal discharge: BV, parasitic, yeast

answer

BV; bacterial vaginosis (most common) - fishy odor - pH↑; thin grayish exudate - no inflammation; endogenous transmission - diagnostic: clue cells - Rx: metronidazole; clindamycin Trichomonas vaginalis - itching, burning "strawberry cervix" - inflammation prominent; pH↑ - green/yellowish frothy discharge - Methylene blue wet mount; mobile flagellates - Rx: Metronidazole Candida albicans - itching, burning - inflammation not as prominent as Trichomonas vaginalis; white "cottage cheese" discharge - pH stays same or ↓ - KOH: pseudohyphae/hyphae - Rx: fluconazole; azole cream Note: metronidazole is safe to use in all trimesters of pregnancy; class B

question

Most common cause of vagina discharge? 2nd? 3rd?

answer

Bacterial vaginosis (50%) Candidiasis (30%) Trichomonas (15%)...STD's

question

What is the predominant bacteria in the vagina?

answer

Lactobacillus Normal flora (70%) in BV it decreases to 15%

question

What is the normal pH of the vagina?

answer

pH < 4.5 estrogen dominance

question

Diagnostic Test: Vaginal Discharge

answer

Visual inspection: the vulva and vagina should be examined for evidence of inflammatory response; check vaginal discharge on speculum Vaginal pH: normal <4.5 Microscopic examination 2 drops of vaginal discharge are placed on glass slide (saline on one side, KOH on the other) looking for clue cells, hyphae, flagellates, WBC's

question

What is a positive "whiff" test in BV?

answer

when KOH is placed on the discharge, releasing a fishy odor KOH is for Candida albicans diagnostics; but it dissolves tissue

question

How does BV most commonly present as?

answer

asymptomatic 50%

question

Rx: Bacterial vaginosis

answer

Metronidazole - safe to use in all 3 trimesters of pregnancy - 250mg - t.i.d. for 7 days - no alcohol for 24-48 hrs Clindamycin - 300mg - b.i.d. for 7 days

question

Trimethylamineuria

answer

Fish odor syndrome AR a rare clinical entity where the patient has an offensive persistent odor that no amount of bathing can correct differential diagnosis with BV

question

What is associated with bubbly vaginal discharge?

answer

Trichomonas vaginalis

question

Trichomoniasis: Men vs. Woman symptoms

answer

Men: 90% asymptomatic Woman: 50% asymptomatic Both needs treatment despite presentations

question

What is associated with strawberry cervix?

answer

Trichomonas vaginalis

question

Rx: Vaginal Trichomoniasis

answer

Metronidazole - 24~48hrs no liquor - recommended: 2g orally in a single dose - alternative: 500mg b.i.d for 7 days - pregnancy: 2g orally in a single dose

question

Rx: Vaginal Candidiasis

answer

Oral fluconazole - 150mg single dose azole cream

question

Physiologic discharge: Sx, risk factors, speculum exam, management

answer

Sx: - most common complaint is increased watery vaginal discharge - no burning or itching Speculum: - columnar epithelium of endocervical canal extends over a wide area of the ectocervix, producing abundant mucus discharge - thin and watery - pH is normal (<4.5) Risk factors: - chronic anovulatory conditions - PCOS, etc. (polycystic ovarian syndrome) Management: - steroid contraception with progestins - convert watery thin discharge into thick sticky progestin-dominant mucus

question

Most common symptom of benign/malignant vulvar lesions

answer

Vulvar itching

question

Premalignant vulvar dermatosis

answer

benign lesions with malignant predisposition - most common symptom is vulvar itching, most lesions are asymptomatic Diseases: - Squamous hyperplasia - Lichen sclerosis - Squamous dysplasia - CIS

question

Squamous hyperplasia : appearance, palpation, histology, management

answer

premalignant vulvar dermatosis Appearance: - lesions appear whitish focal or diffuse areas Palpation: - firm and cartilaginous on palpation Histologically: - thickened keratin - epithelial proliferation Management: - fluorinated corticosteroid cream

question

Lichen sclerosis: appearance, palpation, histology, management

answer

premalignant vulvar dermatosis Appearance: - lesions are bluish-white papula that can coalesce into white plaques Palpation: - thin and parchment-like Histology: - epithelial thinning Management: - Clobetasol cream

question

Vulvar squamous dysplasia: appearance, histology, management

answer

premalignant vulvar dermatosis Appearance: - lesions are white, red, or pigmented, often multifocal in location - almost identical to cervical dysplasia Histology: - cellular atypia restricted to the epithelium without breaking through the basement membrane Management: - surgical excision

question

CIS: appearance, histology, management

answer

premalignant vulvar dermatosis Appearance: - indistinguishable from vulvar dysplasia - white, red, or pigmented, often multifocal lesions Histology: - cellular atypia is full thickness but does not penetrate the basement membrane Management: - laser vaporization and vulvar wide local excision

question

Malignant vulvar lesions

answer

uncommon gynecologic malignancy (4th most common gynecologic malignancy) mean age 65 risk factors: old age, cigarette smoking, HIV, premalignant vulvar dermatosis Diseases: - squamous cell - melanoma - Paget disease

question

Squamous cell (malignant vulvar lesion)

answer

most common type of invasive vulvar cancer (90%) association with HPV Pathogenesis is chronic inflammation (for older woman) and HPV infection (for younger women) Most common stage at diagnosis is Stage 1

question

Melanoma (malignant vulvar lesion)

answer

second most common histologic type of vulvar cancer (5%) most important prognostic factor is the depth of invasion Any dark or black lesion in vulva should be biopsied and considered for melanoma

question

Paget disease (malignant vulvar lesion)

answer

Characteristics: - red lesion - most common in postmenopausal white women Any patient with red vulvar lesion must be considered for the possibility of Paget disease Most common form of Paget disease is intraepithelial process 18~20% of cases invasion of basement membrane is identified association with other cancers (mainly GI, urinary, and breast)

question

Malignant vulvar lesions: diagnosis

answer

Biopsy

question

Malignant vulvar lesions: pattern of spread

answer

starts with local growth and extension that embolizes to inguinal lymph nodes and finally, hemtogenous spread to distant sites

question

Malignant vulvar lesions: staging

answer

Staging is surgical Stage 0: CIS (basement membrane is intact) Stage I: - tumor confined to vulva with size </= 2cm - nodes not palpable Stage IA: invasion 1mm deep Stage II: - tumor confined to the vulva with size >2cm - nodes not palpable Stage III: - Tumor any size with spread to lower urethra, vagina, or anus - unilateral nodes Stage IV: widespread metastasis Stage IVA: involves upper urethra, bladder or rectum, pelvic bone, bilateral nodes Stage IVB: distant metastasis

question

Malignant vulvar lesions: management

answer

1) Wide local excision 2) Modified radical vulvectomy 3) Radical vulvectomy 4) Pelvic exenteration 5) Radiation therapy

question

Management for stage IA malignant vulvar lesions

answer

Wide local excision only

question

Malignant vulvar lesions management: wide local excision

answer

Stage IA only risk of metastasis is negligible No lymphadenectomy is needed

question

Malignant vulvar lesions management: Modified radical vulvectomy

answer

involves radical local excision - Ipsilateral inguinal dissection is used only if stage is IB and unifocal lesion > 1cm from midline AND no palpable nodes (less sexual morbidity) - Bilateral inguinal dissection is used if at least stage IB or a centrally located lesion OR palpable inguinal nodes or positive ipsilateral nodes (lower-extremity edema)

question

Malignant vulvar lesions management: radical vulvectomy

answer

involves removal of labia minora + majora, clitoris, perineum, perineal body, mons pubis seldom performed due to high morbidity sexual dysfunction may result

question

Malignant vulvar lesions management: pelvic exenteration

answer

radical vulvectomy + removal of cervix, vagina, ovaries + lower colon, rectum + bladder create appropriate stomas if necessary seldom indicated or performed due to high morbidity

question

Malignant vulvar lesions management: radiation therapy

answer

only used for patients who cannot undergo surgery

question

Benign vulvar lesions: diseases

answer

1) Mulluscom contagiosum 2) Condylomata acuminata 3) Bartholin cyst

question

Mulluscom contagiosum: at risk group, Sx, transmission, management

answer

Benign vulvar lesion Children, sexually active adults, immunodeficient patients Sx: - spontaneously regressing, umbilicated tumors of skin Transmission: - direct skin contact Management: - observation - curettage - cryotherapy

question

Condylomata acuminata: causative agent, Sx, management

answer

Benign vulvar lesions HPV 6, 11 (no malignant predisposition) Sx: - cauliflower-like vulvar lesions Management: - treat clinical lesions only

question

Bartholin cyst: pathogenesis, management

answer

Benign vulvar lesions obstruction of the Bartholins gland duct may occur due to infection (GC) After immune defenses overcome, duct remains obstructed resulting in cystic dilation of the gland aspiration of the cyst yields sterile fluid Management: - conservative unless pressure symptoms due to size

question

gynecologic cancer rankings 1~4 and age relevance

answer

1. endometrium (61) 2. ovaries (69) 3. cervix (45) 4. vulva (65)

question

What is the type of gynecological cancer occurs earliest in life? Oldest?

answer

Cervical cancer (45) Ovaries (69)

question

Cervical polyps: description, cause, at risk group, findings, management

answer

Description: fingerlike growths that start on the surface of the cervix or originate within endocervical canal/columnar epithelium (more common), can extend out of the cervical os. Cause: - Idiopathic - Associated with chronic inflammation - Associated with increased levels of estrogen (ex: pregnancy) - Associated with thrombosed cervical blood vessels At risk group: - relatively common - older multiparous women more common Findings: - vaginal bleeding, often after intercourse - bleeding occurs between normal menstrual periods - speculum examination: smooth, red/purple, fingerlike projections from cervical canal - biopsy typically reveals mildly atypical cells and signs of infection Management: - polyps can be removed by gentle twisting or by surgical string removal method (electrocautery/laser) - due to infected polyps being common, antibiotic may be given after the removal even if there are no or few signs of infection - although most polyps are benign, pathology exam of biopsy should still be done - regrowth of polyps is uncommon

question

What are cervical polyps associated with?

answer

Associations: - chronic inflammation - increased estrogen levels (pregnancy, etc.) - thrombosed cervical blood vessels - idiopathic

question

What do people with cervical polyps most commonly present with?

answer

vaginal bleeding, mostly after intercourse bleeding between normal menstrual cycles

question

What is the management of cervical polyps?

answer

polyps can be removed by gentle twisting or by surgical string removal method - electrocautery - laser antibiotics given after procedure due to common association of polyps with infection biopsy sent to pathology regardless of nature of polyps

question

Which group of people are at risk for developing cervical polyps?

answer

older women multiparous women

question

Nabothian cysts: description, cause, findings, management

answer

Description: mucus-filled cyst on the surface of the uterine cervix. These endocervical glands can become *covered* by squamous epithelium through metaplasia. Cause: - during the metaplasia and formation of the T-zone, columnar epithelium morphs into squamous epithelium; if the columnar cells beneath did not completely go through metaplasia, they can secrete mucus which can push the squamous epithelium outwards. Findings: - benign condition; rarely large enough to cause clinically relevant problems - pelvic examination reveals small, smooth, rounded lump (or collection of bumps) - rarely, colposcopic exam can be used to distinguish nabothian cysts from other types of cervical lesions Management: - no treatment necessary - Nabothian cysts do not clear spontaneously - Easily cured through electrocautery or cryotherapy

question

The cervical canal is lined by what type of cells? Function?

answer

Glandular cells / columnar epithelium secrete mucus

question

What does the Nabothian cyst present as? How do you treat it?

answer

small, smooth, rounded lump or collection of bumps caused by mucus-fileld cysts on the surface of the cervix (ectocervix) due to incomplete metaplasia of columnar epithelium beneath the T-zone during transformation benign condition No treatment necessary - electrocautery or cryotherapy can easily cure cyst

question

Cervicitis: symptoms, examination, investigative findings, management

answer

Symptoms: - no symptoms most common - vaginal discharge Examination: - most common finding is mucopurulent cervical discharge - friable cervix: endocervical bleeding easily induced by cotton swab palpation of cervical os - No pelvic tenderness noted - Patient is afebrile Investigative findings: DNA probe - Routine cervical cultures are positive for chlamydia or gonorrhea - STDs - WBC and ESR normal (no inflammation) Management: - Oral azithromycin in single dose - Oral doxycycline BID for 7 days

question

What is the most common finding in cervicitis?

answer

mucopurulent discharge from cervix friable cervix no pelvic tenderness or febrile condition

question

How do you manage cervicitis?

answer

Oral azithromycin single dose or Oral doxycycline BID for 7 days

question

Cervical neoplasia: presentation, etiology, risk factors

answer

Presentation: - usually asymptomatic - progression from premalignant to invasive cancer has been reported to be approximately 8~10 yrs (good prognosis for early detection and slow progression) - Most regress (young women) Etiology: - most common* etiology of cervical cancer is HPV - Over 75 subtypes - most common HPV types: 16, 18, 31, 33, 35, 45 - most common for condyloma accuminata: 6, 11 risk factors: - early age intercourse - multiple sexual partners* (strong positive correlation) - cigarette smoking - immunosuppression

question

What is the most common presentation of cervical cancer? What is the most common progression? Associated age groups and types?

answer

most common presentation is asymptomatic progression is most commonly regression, especially in young women - age 14~19 has 33% HPV risk - age 20~29 has 28% HPV risk 65% regress, associated with HPV 6, 11 - young women most commonly regress, 61% within 1 yr, and 91% within 3 years 20% same + 15% progress - associated with HPV 16, 18, 30s

question

What are the risk factors for developing cervical cancer?

answer

early age of intercourse cigarette smoking multiple sex partners immunosuppression

question

What are the most common HPV types for cervical cancer? Order of malignancy? Condyloma accuminata?

answer

CIN: HPV-16, 18, 31, 33, 35, 45 (16>18>45>31>33) Condyloma accuminata: HPV-6, 11

question

What is the most effective medically cancer screening test ever developed?

answer

PAP smear 70~80% decrease of death rate

question

Which HPV is most associated with squamous cell carcinoma of cervix?

answer

HPV-16

question

Which HPV is most associated with adenocarcinoma of the cervix?

answer

HPV-18

question

Rank the most common malignant HPV types that causes cancer in the cervix + association

answer

HPV-16 (squamo)....59% HPV-18 (adeno)....12% HPV-45>31>33....squamo

question

Why do we NOT start PAP smear before age of 21?

answer

Most cases of HPV infection regresses (65%) More so, most cases of HPV infection in young woman regresses completely in 3 years (91%) HPV infection is correlated with sexual intercourse at young age if HPV is going to regress mostly in 3 years there isn't a point of starting PAP smears until after 21yrs old

question

When doing a Pap smear on pregnant women what should you use?

answer

spatula for T-zone *cotton swab for endocervical canal

question

Pap smear should be started at the following ages:

answer

Age < 21: - NO Pap test or screening for HPV, regardless of sexual activity Age 21: start Pap test with cytology alone *without HPV testing; the recommendation is the same whether HPV vaccinated or not

question

What is the frequency of recommended Pap smear for Age groups 21-29? 30-65?

answer

Age 21-29: - repeat Pap every 3 years with cytology alone; do not perform HPV testing in this age group (due to slow progression of the disease) Age 30-65: - Pap every 3 years with cytology but no HPV testing OR - repeat Pap every 5 years if both cytology + HPV (recommended choice)

question

When should Pap smears be discontinued?

answer

After age 65 - if negative cytology and/or HPV tests for past 10 years AND no history of CIN-2, 3, or cervical carcinoma Any age if total hysterectomy and no history of CIN

question

What is the system used to classify Pap smears in the U.S.?

answer

Bethesda system

question

Classification os Bethesda system

answer

Negative: No intraepithelial lesions - may report trichomoniasis, candida, BV, HSV, atrophy, etc. Abnormal squamous cells (99% of abnormal Pap smears) ASCUS: (5%~20%) - atypical squamous cells of undetermined significance - suggestive of LSIL but not adequate - decrease ASCUS findings by making a thinner prep ASCH: - atypical squamous cells can't rule out HSIL - suggestive of but not adequate to label HSIL LSIL: - low-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings of HPV, mild dysplasia, or CIN 1 HSIL: - high-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings of moderate-severe dysplasia, CIN 2, 3, CIS Squamous cell carcinoma: - biopsy expected to show histologic findings of invasive cancer Abnormal endocervical cells (1% of abnormal Pap smears) AGC-NOS: - atypical glandular cells, not otherwise specified AGC-neoplastic: - atypical glandular cells, can't rule out neoplasia - changes suggestive of but not adequate to call AIS or cancer AIS: - adenocarcinoma in situ Adenocarcinoma

question

Describe ASCH on Bethesda system

answer

atypical squamous cells can't rule out HSIL - changes suggestive of but not adequate to label HSIL

question

Describe ASCUS on Bethesda system

answer

atypical squamous cells of undetermined significance - changes suggestive of but not adequate to label LSIL

question

Describe LSIL on Bethesda system

answer

low-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings of HPV, mild dysplasia, CIN1

question

Describe HSIL on Bethesda system

answer

high-grade squamous intraepithelial lesion - biopsy is expected to show histologic findings moderate-severe dysplasia, CIN2, CIN3, CIS

question

Squamous cell carcinoma on Bethesda system

answer

Invasive carcinoma will enter staging instead of CIN numbers Stage 1 is after CIS - <2cm lesion (1a = 1mm deep lesion)

question

Describe AGC-NOS on Bethesda system

answer

atypical glandular cells not otherwise specified

question

Describe AGC-neoplastic on Bethesda system

answer

atypical glandular cells can't rule out neoplasia

question

Describe AIS on Bethesda system

answer

adenocarcinoma in situ

question

High-grade squamous intraepithelial lesions are associated with which histologic findings?

answer

moderate-severe dysplasia CIN-2 CIN-3 CIS

question

Low-grade squamous intraepithelial lesions are associated with which histologic findings?

answer

mild dysplasia HPV CIN 1

question

How often does ASCUS show up on Pap smears? How do you decrease ASCUS diagnosis? What is the management of ASCUS?

answer

<5% but up to 20% Decrease ASCUS findings by: - make a thinner prep or HPV/DNA typing: - if 6, 11 it will most likely regress (low-risk) but repeat Pap within 1 year - if 16, 18, 30s it is high-risk and need colposcopy and biopsy

question

If you find ASCUS on Pap smear, what are the tests you could run? (3)

answer

Accelerate repeat Pap: - 4~6 month intervals until 2 consecutive negative Paps - if a repeat Pap is again ASCUS or worse, this is an indication for colposcopy HPV-DNA testing: - if liquid-based cytology was used on initial Pap smear, it can be used for DNA testing (100% diagnostic) - indications for colposcopy: high-risk HPV types Colposcopy: - uses acetic acid to make vascular patterns more visible - 10~12 times magnification - satisfactory/non-satisfactory - unsatisfactory = t-zone invading into endocervical canal

question

What if you find cells other than ASCUS on a Pap smear, what tests should you run?

answer

Colposcopy and biopsy

question

If you find cells others than ASCUS (ASC-H, LSIL, etc.) on a Pap smear, what is your plan of management?

answer

Colposcopy Endocervical curettage (ECC) - not in pregnancy - ***colposcopy shows T-zone extending into endocervical canal, etc. Ectocervical biopsy - lesions identified on ectocervix by colposcopy*** - mosaicism, punctation, white lesions, abnormal vessels - biopsy and send for histology Compare Pap smear and biopsy - ensure level of severity is comparable with colposcopy - *Pap smear should not be worse than biopsy; means you missed the more malignant area on biopsy Diagnostic Cone biopsy indications: - Pap smear is worse than biopsy - ECC: abnormal cells - Lesions entering endocervical canal*** - Biopsy: microinvasive carcinoma Manage by histology: - observation: CIN1, repeat Pap in 6~12 months, colposcopy and repeat Pap in 12 months, or HPV/DNA testing in 12 months - ablation: CIN1, 2, 3 (cryotherapy, laser vaporization, electrofulguration) - resection: CIN1, 2, 3 (LEEP, cold-knife conization) - hysterectomy: biopsy-confirmed, recurrent CIN2 or 3 only

question

What are the risk of cone biopsy?

answer

incompetent cervix cervical stenosis

question

When Pap smear shows worse dysplasia than ASCUS, you use colposcopy examination and you see metaplastic epithelium entering the endocervical canal, what will you do next?

answer

ECC endocervical canal curettage

question

When Pap smear shows worse dysplasia than ASCUS, you use colposcopy examination and you see ectocervical lesions, what will you do next?

answer

Ectocervical biopsy

question

When Pap smear shows worse dysplasia than ASCUS, you use colposcopy examination and you see lesions entering the endocervical canal, what will you do next?

answer

Narrow cone biopsy

question

What are follow-up options for CIN1?

answer

Observation (repeat Pap, colposcopy and Pap, HPV-DNA) Ablative therapy (cryotherapy, laser, electrofulguration) Excisional procedure (LEEP, cold-knife)

question

What are follow-up options for CIN2?

answer

Ablative therapy (cryotherapy, laser, electrofulguration) Excisional procedure (LEEP, cold-knife cone) Hysterectomy (recurrent CIN2 only)

question

What are follow-up options for CIN3?

answer

Ablative therapy (cryotherapy, laser, electrofulguration) Excisional procedure (LEEP, cold-knife cone) Hysterectomy (recurrent CIN3 only)

question

When is hysterectomy indicated in CIN?

answer

recurrent CIN2, 3

question

CIN follow-up management: Observation

answer

Indicated for CIN1 Repeat Pap in 6~12 months Colposcopy and repeat Pap in 12 months HPV-DNA testing in 12 months

question

CIN follow-up management: Ablative therapy

answer

Indicated for CIN1, 2, 3 Cryotherapy Laser vaporization Electrofulguration Follow-up: repeat Pap smears, colposcopy and Pap smear, or HPV-DNA testing every 4~6 months for 2 years

question

CIN follow-up management: Excision/Resection

answer

Indicated for CIN1, 2, 3 LEEP cold-knife conization Follow-up: repeat Pap smears, colposcopy and Pap smear, or HPV-DNA testing every 4~6 months for 2 years

question

CIN follow-up management: hysterectomy

answer

CIN2, 3 only indicated in recurrent infections

question

What follow-up procedures are required for ablative therapy and excisional procedure patients for CIN?

answer

Follow-up: repeat Pap smears, colposcopy and Pap smear, or HPV-DNA testing every 4~6 months for 2 years

question

If cytologic findings of Pap smear reveals HSIL, what is the next step for patients ages 25-64?

answer

colposcopy + biopsy immediate LEEP**

question

Invasive Cervical Cancer definition

answer

cervical neoplasia that has penetrated through the basement membrane >CIS

question

Cervical cancer: definition, presentation, epidemiology, diagnostic findings

answer

Definition: cervical neoplasia penetrated through the basement membrane Presentation: - normal menstrual cycles - postcoital vaginal bleeding - irregular vaginal bleeding - lower extremity pain and edema in advanced stages Epidemiology: - 3rd most common gynecological carcinoma - ~45 years of age (youngest occurrence) - 250,000 deaths/yr world wide; 10,000/yr in U.S. Diagnostic Tests/Findings: - Cervical biopsy* - Metastatic workup: pelvic examination, chest x-ray, intravenous pyelogram, cystoscopy, sigmoidoscopy - Imaging studies: invasive cervical cancer is the ONLY gynecological cancer staged clinically (CT and MRI cannot be used for clinical staging)

question

What is the only gynecological carcinoma that uses clinical staging?

answer

Cervical cancer

question

Common presentation of cervical carcinoma?

answer

normal menstrual cycle postcoital vaginal bleeding irregular vaginal bleeding

question

Cervical cancer: staging

answer

CLINICAL (only gynecological carcinoma staged clinically) Stage 0: CIS (basement membrane is intact) Stage I: Spread limited to the cervix. *most common* - Ia1: 3mm but 5mm deep (frank invasion) Stage II: spread adjacent to cervix - IIa: involves upper 2/3 of vagina - IIb: invasion of parametria Stage III: spread further from the cervix - IIIA: involves lower one third of vagina - IIIB: extends to pelvic side wall or hydronephrosis Stage IV: spread furthest from cervix - IVA: involves bladder or rectum or beyond true pelvis - IVB: Distant metastasis

question

What is the most common stage of cervical cancer?

answer

Stage 1 limited to the cervix

question

What is the staging for minimally invasive cervical cancer? Management? Management in pregnancy?

answer

Ia1 </= 3mm deep total simple hysterectomy during pregnancy: cone biopsy during pregnancy follow conservatively, deliver vaginally reevaluated and treated 2 months postpartum

question

What is the staging for microinvasive cervical cancer? Management? Management in pregnancy?

answer

Ia2 <3mm but </=5mm deep modified radical hysterectomy during pregnancy: cone biopsy during pregnancy follow conservatively, deliver vaginally reevaluated and treated 2 months postpartum

question

What is the staging for frank invasion cervical cancer? Management? Management in pregnancy?

answer

IB >5mm deep radical hysterectomy or radiation (IIa) during pregnancy: based on gestational age - before 24 weeks: receive definitive treatment as shown above - after 24 weeks: conservative management to 32-33 weeks, after C-section definitive treatment can be done

question

What ist he staging for cervical cancer that has spread adjacent to the cervix? Management? Management in pregnancy?

answer

II IIa: upper 2/3 of vagina involved Management: radical hysterectomy or radiation IIb: invasion of parametria Management IIb or above: radiation therapy and chemotherapy for all ages during pregnancy: based on gestational age - before 24 weeks: receive definitive treatment as shown above - after 24 weeks: conservative management to 32-33 weeks, after C-section definitive treatment can be done

question

Cervical cancer: staging management

answer

Stage Ia1: - 3mm but 5mm frank invasion - IIa: involves upper 2/3 of vagina - radical hysterectomy with/without radiation Stage IIb, III, IV: - radiation therapy and chemotherapy for all ages

question

Cervical cancer: follow-up

answer

All patients with invasive cervical cancer should be followed up with... - Pap smear every 3 months for 2 years after treatment - then every 6 months for subsequent 3 years Patients who have local recurrence can be treated with radiation therapy Patients with distant metastases should be considered for chemotherapy treatment - Cisplatinum

question

What is the most active chemotherapeutic agent for cervical cancer?

answer

Cisplatinum

question

What is the effect of pregnancy in cervical neoplasia

answer

pregnancy does NOT predispose abnormal cytology and does not accelerate precancerous lesions progression

question

Diagnostic tests and findings for pregnant patients in cervical cancer

answer

Pregnant with abnormal Pap smear should be evaluated in the SAME FASHION - owing to increased cervical vascularity ECC is not performed during pregnancy (endocervical canal curettage)

question

What is the plan of management in pregnant patients with cervical cancer in CIN stages?

answer

Pap smear and colposcopy every 3 months during pregnancy 6~8 weeks postpartum the patient should be reevaluated with repeat colposcopy an dPap smear Any persistent lesions can be definitively treated postpartum

question

What is the plan of management for microinvasion cervical cancer in pregnant patients?

answer

evaluated with cone biopsy to ensure no rank invasion patients can be followed conservatively delivery can be vaginal reevaluation and treatment 2 months postpartum

question

What is the plan of management for frank invasion carcinoma in pregnant patients?

answer

Based on gestational age before 24 weeks - definitive treatment based on staging after 24 weeks - conservative management to about 32-33 weeks - C-section - definitive treatment after delivery

question

Gardasil: recommendation, coverage, regimen

answer

Recommendation: - females 8~26; target group 11~12yrs - Efficacy is highest before patient's immune system is exposed to HPV - No point in testing for HPV before vaccination, no easy method of identifying all HPV types - Pap smear continued to guidelines due to >70 types of HPV strains and vaccine covers only 4 most common - sexually active women can receive vaccine, same with women who has previous abnormal cervical cytology or genital warts, just less effective - patients with previous CIN, benefits limited - not recommended for pregnant, lactating, or immunosuppressed women, but no tests has been done to prove clinical relevant harm Coverage: - HPV 6, 11, 16, 18 - covers 70% of cervical cancer and 90% of genital warts of HPV strains Regimen: - initial, 2 months, 6 months - $300

question

What is the target group for Gardasil? Why?

answer

11~12 age group Efficacy best before host immune system is exposed to HPV strains

question

What strains of HPV does Gardasil cover?

answer

HPV 6, 11, 16, 18

question

When is the Gardasil vaccine contraindicated?

answer

Pregnant women Lactating women Immunosuppressed women Not clinically proven to be true

question

How many types of uterine anomalies are there? How are they divided?

answer

7 types by the American Fertility Society (1988) Divided by - failure to form - failure to fuse - failure to dissolve the septum

question

Hypoplasia/Agenesis of Uterus: description, cause, association

answer

description: - may lack a vagina, cervix, fallopian tubes, body of uterus - developmental problem with a section of both mullerian ducts association - urinary tract anomalies - urinary tract embryologically lie close to mullerian ducts

question

Unicornuate uterus: defect, description, complications, symptoms

answer

defect and description: - when ONE of the mullerian ducts fails to form - *sing-horn (banana-shaped) uterus develops from the remainder healthy mullerian duct - single uterus may stand alone complications: - 65% of women with unicornuate uterus, the defected mullerian duct may form an incomplete rudimentary horn - may or may not have cavity in the rudimentary horn but the opening that communicates with the healthy uterus is either small or nonexistent symptoms: if rudimentary horn forms - monthly pain during adolescence because no outlet for menses from rudimentary horn - risk of pregnancy in rudimentary horn, 90% ruptures due to anatomical limitations

question

Didelphys uterus: defect, description, risks

answer

defect and description: - results from complete failure of the 2 mullerian ducts to fuse together (stage 1 development) - each duct develops into a separate uterus - each uterus can have their own cervix or share a cervix - 67% of cases is associated with 2 vaginas separated by a thin wall risks: - preterm delivery is common

question

Bicornuate uterus: defects, description, types, risks

answer

defect and description: - most common congenital uterine anomaly (45%) - results from failure of fusion between the mullerian ducts at the fundus - 'complete' failure to fuse results in 2 separate single-horn uterine bodies sharing 1 cervix* - 'partial' failure to fuse results in fusion at the bottom but not the fundus causing single uterine cavity with 2 distinct horns on top and a shared cervix* Risks: - preterm delivery - malpresentations with pregnancy

question

What is the most common congenital uterine anomaly?

answer

Bicornuate uterus 45%

question

Septate uterus: defect, description, types, risks

answer

defect and description: - failure in degeneration of the median septum - complete failure: 2 single-horned uteri that share one cervix - partial failure: shared cavity at lower portion of uterus with 1 cervix - *external shape of uterus is normal-appearing* risks: - preterm delivery

question

Septate uterus vs. Bicornuate uterus

answer

septate uterus looks normal-appearing single unit exteriorly bicornuate uterus has distinct 2 separate horns at fundus both can result in separate cavity but sharing 1 cervix or partial shared cavity with 1 cervix

question

Arcuate uterus: defect, description, risks

answer

defect and description: - essentially NORMAL in shape - NORMAL in function as well - small midline indentation in the uterine fundus, results from failure to dissolve the median septum completely risks: - essentially none

question

DES uterus: defect, description, cause, risks

answer

defect and description: - *T-shaped cavity - mothers exposed to DES (diethylstilbestrol) which was used 30yrs ago to prevent miscarriages are predisposed to uterine abnormalities and clear cell carcinoma of the vagina, idiopathic risks: - cervical insufficiency

question

What teratogen is associated with predisposition of clear cell carcinoma of the vagina?

answer

DES (diethylstilbestrol) DES uterus + clear cell carcinoma of vagina idiopathic

question

Leiomyoma Uteri: description, at risk group, different locations

answer

Description: benign smooth muscle growth of myometrium causing non-tender asymmetric distortions of the uterus; most common benign uterine tumor At risk group: 5x more common in black women than white women Location: Intramural: - most common location is within uterine wall - asymptomatic and cannot be felt on examination unless enlargement of uterus is altering external contour Submucosal: - located beneath the endometrium and can distort the uterine cavity - since endometrium may not respond appropriately to normal hormonal fluctuation the result is unpredictable, often intermenstrual, bleeding* - *most common symptom is vaginal bleeding and can result in anemia Subserosal: - located beneath uterine serosa; they can distort the external contour of the uterus - pedunculated subserosal leiomyomas can become parasitic fibroids - they break away from uterus and receive their blood supply form another abdominal organ

question

Leiomyoma uteri: natural history

answer

Natural history: - slow growth*: most leiomyomas are small, grow slowly and cause no symptoms - rapid growth: estrogen receptors are increased in leiomyomas resulting in rapid enlargement during times of high estrogen levels, such as pregnancy - degeneration: during rapid growth, myomas may outgrow their blood supply, resulting in ischemic degeneration of a fibroid (hyaline, calcific, red degeneration/carneous degeneration) - Shrinkage: when estrogen levels fall, leiomyomas will typically decrease in size; physiologically (menopause) or through treatment (GnRH agonist suppression of FSH)

question

How does most leiomyomas present clinically?

answer

Slow growth small, grow slowly, and asymptomatic

question

What is the most common form of leiomyoma of uterus?

answer

Intramural leiomyoma found within the uterine wall

question

What is the most common presentation of a submucosal leiomyoma of the uterus?

answer

vaginal bleeding metrorrhagia = irregular bleeding between menses menorrhagia = heavy menses

question

Which type of uterine leiomyoma can become parasitic fibroids?

answer

Pedunculated subserosal uterine leiomyoma Break away from uterus and receive blood supply from another organ in the abdomen

question

Where is the intramural leiomyoma of the uterus found? How does it present?

answer

Most common location of leiomyoma uteri Found within the wall of the uterus Mostly asymptomatic and cannot be felt on examination unless it enlarges to where the normal uterine external contour is altered

question

Where is the submucosal leiomyoma of the uterus found? How does it present?

answer

It is found beneath the endometrium and can distort the uterine cavity It can be pedunculated and extend into the vagina through the cervix Due to overlying endometrium may not respond appropriately to the normal hormonal fluctuations, it results in unpredictable and often intermenstrual bleeding - menorrhagia - metrorrhagia - menometrorrhagia = combined of irregular bleeding between menses and heavy menses Most common presentation is vaginal bleeding

question

Where is the subserosal leiomyoma of the uterus found? How does it present?

answer

It is found beneath the uterine serosa They can distort the external contour of the uterus causing firm, nontender asymmetry Pedunculated subserosal leiomyomas can break away from uterus and form parasitic fibroids receiving blood supply from another organ

question

What are the top causes of uterine enlargement?

answer

1. pregnancy 2. leiomyoma 3. adenomyosis 4. leiomyosarcoma (extremely rare)

question

What is the cause of leiomyoma uteri degeneration? What are the types? Presentations?

answer

Sometimes the leiomyoma outgrows its blood supply and can result in ischemic infarction causing degeneration hyaline, calcified, red degeneration Red degeneration is also called carneous degeneration - cause extreme, acute pain - morphine and narcotics required - this is most common during pregnancy

question

What is the most common type of degeneration of uterine leiomyoma during pregnancy?

answer

Red degeneration

question

When does uterine leiomyoma present with rapid growth?

answer

estrogen receptors are increased in leiomyomas resulting in rapid enlargement during times of high estrogen levels example: pregnancy

question

Leiomyoma uteri: management

answer

Observation: - most leiomyomas can be managed conservatively and followed expectantly with regular pelvic examinations Presurgical shrinkage: - 3~6 months GnRH analog therapy; leuprolide/Lupron - adjuvant to surgical removal - reduction in size up to 60%~70% - decrease in blood loss in myomectomy - makes vaginal hysterectomy possible Myomectomy: - removal of myoma - maintains fertility - laparoscopic or laparotomy - future deliveries through cesarean section Embolization: - catheter placed into vessels supplying myoma - microspheres are injected, causing ischemia and necrosis of myoma - ~10% mortality rate (wrong vessel; uterine necrosis) Hysterectomy: - definitive therapy

question

How can you shrink a uterine leiomyoma before surgery? Purpose?

answer

3~6 months of GnRH (gonadotropin releasing hormone) analog therapy; Lupron (leuprolide) Results in 60%~70% shrinkage in size Not used for definitive cure, due to stoppage of leuprolide can cause regrowth of leiomyoma Mostly used as an adjuvant to surgical removal of myoma; decreases blood loss in myomectomy the decrease in size can also result in vaginal hysterectomy instead of abdominal hysterectomy

question

Uterine leiomyoma: diagnosis methods

answer

Diagnosis: Pelvic examination: enlarged, asymmetric, non-tender uterus in teh absence of pregnancy most common - 20wks gestation size = uterus reaching umbilicus (belly button) - 12wks gestation size = uterus reaching pubis symphysis Sonography: ultrasound, saline infusion sonography is helpful for identifying submucosal myomas Hysteroscopy Histology is only confirmed through surgical confirmation of excised tissue

question

Adenomyosis: definition, presentation, diagnosis, Sx, examination, imaging, management

answer

Definition: ectopic endometrial glands and stroma are located within the myometrium of the uterine wall Presentation: - most common presentation is diffuse involvement of the myometrium - adenomyoma is termed for focal involvement, surrounded by a pseudocapsule Diagnosis: - enlarged, symmetric, tender uterus in teh absence of pregnancy - definitive diagnosis is by histologic confirmation of the surgically excised tissue Sx: - mostly asymptomatic - most common symptoms are secondary dysmenorrhea and menorrhagia Examination: - uterus is globular and up to 2~3x normal size - tenderness is most common immediately before and during menses Imaging: - ultrasound - MRI - *cystic areas found within the myometrial wall Management: - surgery is the definitive treatment - LNG-IUS (levonorgestrel intrauterine system may decrease heavy menstrual bleeding)

question

Primary dysmenorrhea findings

answer

onset 2~3yrs after menarche menarche = 11~16.5 yrs

question

What is the most common presentation of adenomyosis? Otherwise?

answer

Most common is diffuse involvement resulting in symmetric, soft, tender enlargement of the uterus When it becomes focalized and surrounded by a pseudocapsule, it is called adenomyoma

question

What is the most common symptoms of adenomyosis?

answer

mostly asymptomatic most common symptomatic presentation is - menorrhagia - 2° dysmenorrhea

question

When does tenderness most likely occur in patients with adenomyosis?

answer

most common immediately before and during menses

question

What is the most likely diagnosis upon seeing cystic areas found within the myometrial wall and the uterus is symmetrically enlarged?

answer

Adenomyosis

question

What is the management for adenomyosis?

answer

LNG-IUS - levonorgestrel intrauterine system - T-shaped intrauterine device that secretes progesterone into the uterine cavity - decreases heavy menstrual bleeding Surgery - hysterectomy is the definitive treatment

question

Define menopause

answer

3 continuous months of cessation of menses and elevated gonadotropins ~52 years old

question

What is the most common cause of postmenopausal bleeding?

answer

vaginal or endometrial atrophy

question

BMI range

answer

formula = kg/m² 40: obesity class 3 (very severely obese)

question

Synopsis: Postmenopausal bleeding steps of diagnosis and management

answer

Speculum exam: rule out vaginal lesions and cervical lesions Once ruled out... obtaining upper tract tissue: - endometrial biopsy - hysteroscopy and ultrasonography - send biopsy to pathology If finding is... atrophy: - management is estrogen with progestin polyps: - benign - hysteroscopic resection hyperplasia: - simple *without atypia: progestin treatment - complex *with atypia: total vaginal or abdominal hysterectomy carcinoma: - stage & grade - total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH-BSO) + lymph node dissection - according to staging and necessary radiation + chemotherapy

question

Most common cause of endometrial carcinomas?

answer

upposed estrogen without the stabilizing effect of progesterone

question

What are the major risk factors of postmenopausal bleeding?

answer

Obesity***: increased peripheral conversion of androgen to estrogen due to increased adipose tissue hypertension, diabetes mellitus (both points towards obesity) nulliparity: no kids means no exposure to the long period of progesterone during pregnancy; equal to possible unopposed estrogen chronic anovulation conditions (PCOS, etc.): no ovulation means no progesterone

question

What are some the diagnostic tests to confirm cause of postmenopausal bleeding?

answer

Endometrial sampling: - sampling process may miss diagnosis due to localized growth in the endometrium - example: dilatation and curettage of endometrial misses a small section where neoplastic growth is occurring Hysteroscopy: - with hysteroscope, cervical or endometrial polyps can be identified as cause of postmenopausal bleeding Ultrasound: - ultrasonography can be used to measure the thickness of the lining of the endometrium (postmenopausal patients should be <5mm)

question

What is the endometrial lining stripe measurement supposed to be for postmenopausal women?

answer

<5mm Ultrasound

question

Endometrial cancer: staging

answer

Most common cause of gynecological cancer Staging is surgical Stage I: spread limited to the uterus (most common stage at diagnosis) - IA: limited to the endometrium or invasion *less than 1/2 of myometrium* - IB: invasion *more than 1/2 of myometrium* Stage II: extension to teh cervix but not outside the uterus Stage III: Spread adjacent to teh uterus - IIIA: invades serosa or adnexa or positive cytology - IIIB: invasion of vagina - IIIC: invasion of pelvic or para-aortic nodes Stage IV: Spread further from the uterus - IVA: involves bladder or rectum - IVB: distant metastasis

question

What is the management of atrophy of endometrium induced postmenopausal bleeding?

answer

hormone replacement therapy estrogen + progestin

question

Endometrial cancer: management

answer

Stages I~IV: TAH-BSO + lymph node resection - TAH: total abdominal hysterectomy - BSO: bilateral salpingo-oophorectomy After surgery: radiation and chemotherapy - Stage I: none - Stage II: radiation - Stage III + IV: radiation + chemotherapy

question

What is the management for endometrial hyperplasia? What is the most common cause?

answer

Unopposed estrogen can cause hyperplasia of endometrium Simple hyperplasia with no atypia: progestin Complex hyperplasia, no atypia: progestin Complex hyperplasia with atypia: hysterectomy or progestin for non-surgical candidates Endometrial carcinoma: staging + TAH/BSO

question

Which types of hyperplasia can be managed with progestin?

answer

simple hyperplasia with no atypia complex hyperplasia with no atypia

question

How does complex hyperplasia histologically present? Complex hyperplasia with atypia?

answer

decreased stroma with increased glandular tissue atypia will show misshapen nucleus, etc.

question

What are some prevention methods of postmenopausal bleeding? Reproductive age women bleeding? Dietary?

answer

postmenopausal patient: - estrogen replacement therapy with progestin reproductive age women: - most likely due to chronic anovulation (PCOS, etc.) - progestin treatment Dietary - soy: 30~40% reduction of endometrial cancer risk

question

Tamoxifen association with vaginal bleeding

answer

Tamoxifen is used for breast cancer prevention by its estrogen antagonistic effects on the breast However, it has estrogen agonist effects on the uterus It can induce hyperplasia and endometrial polyps

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