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CLINICAL FINDINGS
MODULE 1 Cyanosis
Clubbing of the fingers
CARDIOVASCULAR DISEASES IN PREGNANCY Persistent neck vein engorgement
Systolic murmur greater than Gr III/VI
Circulatory changes during pregnancy Diastolic murmur
Parameter Change Cardiomegaly
Plasma Volume 6 weeks AOG-32 weeks, increase an Sustained arrhythmia
average of 50% over baseline Persistently split S2
Red Cell Volume After 1st trimester, increases 20% Loud P2 (criteria for pulmonary hypertension)
over baseline by term Loud P2 (criteria for pulmonary hypertension)
Blood Volume 6weeks: increases an average 40%
by 32weeks Predicting Cardiac Complications during Pregnancy
- Prior heart failure, transient ischemic attack, arrhythmia, or stroke
Changes in Diagnostic Tests Findings during Pregnancy - Baseline NYHA Class III or greater or cyanosis
normal pregnancy, - Left-sided heart obstruction defined as mitral valve area below 2
functional systolic heart murmurs are common; respiratory effort cm2, aortic valve area below 1.5 cm2, or peak ventricular outflow
is accentuated and at times suggests dyspnea; edema in the lower tract gradient above 30 mm Hg by echocardiography
extremities after midpregnancy is common; and fatigue and - Ejection fraction less than 40%
exercise intolerance develop in most women - most important predictors of complications were prior congestive
1. Cardiac Physical Examination heart failure, depressed ejection fraction, and smoking
Increase in the intensity of first heart sound with exaggerated
splitting Signs and Symptoms of Congestive Heart Failure
- persistent rales at the lung bases – first warning sign of CHF
May have systolic ejection flow murmurs
- sudden diminution of the capacity to work
Diastolic murmurs are rare and would warrant further study
- increasing dyspnea on exertion
2. Chest X-ray Film
- hemoptysis (usually associated with pulmonary hypertension)
Lordosis can create straightening of the left upper cardiac border,
- progressive dyspnea, edema and tachycardia
mimicking left atrial enlargement
- Presence of any of these symptoms warrants admission. Much of
Elevation of the diaphragm causes more horizontal position of
the load on patients occurs at around the second half of
the heart
pregnancy
Pulmonary vasculature appears more prominent
3. Electro-cardiogram
Horizontal position of the heart causes left or right shift of QRS
Group 1 Minimal Risk 01-%
Transient ST-segment an t-wave changes are common
Right axis deviation, RBBB, or ST depression of 1 mm on left
precordial leads
Q waves in lead III, T wave inversion in III, V2 and V3
Small decreases of PR and QT
Rotation of =/- of 15 degrees (QRS axis) ve
Atrial and ventricular premature contractions are relatively
frequent
Pregnancy does not alter voltage findings Group 2A Moderate Risk 5-15%
4. Echocardiogram
allows noninvasive evaluation of structural and functional cardiac
factors Aortic coartation without valvular involvement
Increase in end-diastolic and end-systolic ventricular
measurements with no increase in wall thickness
Mild tricuspid regurgitation may be due to increase volume arfan syndrome, normal aorta
Increased Trivial tricuspid regurgitation (43 to 94% at term)
Pulmonary regurgitation (94% at term)
Increased left atrial size by 12 to 14% Group 2B Moderate Risk 5-15%
Increased LV end diastolic dimensions by 6-10%
Inconsistent increase in LV thickness / left ventricular mass
Pericardial effusions
5. Pulmonary artery catheterization – no change Group 3 Major Risk 25-50%
Control of BP
Goal: is to lower BP gradually because drastic reduction of BP
may compromise placental perfusion.
Emergency parenteral therapy for severe HPN: HIGH NORMAL LOW
Hydralazine(Aprasoline): direct vasodilator-
5 mg IV initial dose,
may be repeated q 10-20min up to a
loading dose of 20 mg (fastest way to lower FT4
BP)
Labetalol: non- selective β1 and £1 blocker, LOW NORMAL
20 mg initial IV bolus,
may give another 40 mg after 10 min if BP
response is inadequate followed by another
80 mg q10 min x 2 doses. HYPOTHYROID SUBCLINICAL
HYPOTHYROIDISM
Total dose should not exceed 220 mg
Nifedipine: Ca channel blocker
10 mg orally may be repeated after 30 min. If the TSH is high, and FT4 is low hypothyroid
drawback: difficult to control; If TSH is high and FT4 is normal subclinical hypothyroidism
may cause severe hypotension
Na Nitroprusside/ Nitroglycerine
seldom used: causes fetal cyanide toxicity SENSITIVE TSH
Verapamil – IV infusion at 5-10 mg/hr
Ketanserin – a selective serotonergic (5HT2A)
Goal: BP 140-150/90-100 mmHg
Treatment
DOTS: Directly Observed Therapy
Isoniazid
o 5mg/kg,not to exceed 300 mg daily
Pyridoxine
o 50 mg daily
Rifampicin
o 10mg/kg ,not to exceed 600 mg daily
Ethambutol
o 5-25mg/kg, not to exceed 2.5 g daily
Figure 46-2 Chest radiographs in a pregnant woman with right lower lobe
pneumonia. A. Complete opacification of the right lower lobe (arrows) is MDR-TB: Multidrug Resistant TB
consistent with the clinical suspicion of pneumonia. B. Opacification (arrows) Four-drug regimen for initial empirical treatment of patients with
is also seen on the lateral projection. symptomatic tuberculosis
Isoniazid, rifampin, pyrazinamide, and ethambutol
Management given until susceptibility studies are performed
Antimicrobial treatment is empirical. Standard treatment with pregnancy: RIPE
AntiTB drugs: chemotherapeutic drugs; just give if there is a high MODULE 2
probability of TB
Therapy maintained for a minimum of 9 months RENAL DISEASES IN OBSTETRICS
If evidence of resistance occurs with any of the three first line
drugs, Pyrazinamide may be considered.
INFECTIONS
Streptomycin, although a first line drug is avoided in pregnancy
o Congenital deafness • asymptomatic bacteriuria: most common
• symptomatic infection
Tuberculosis and Pregnancy – Cystitis: bladder
Without antituberculosis therapy, pregnancy likely has adverse effects on the – Pyelonephritis: renal calyces, pelvis, parenchyma
course of active tuberculosis Etiology
• Escherichia coli strains
Outcomes are dependent on the site of infection and timing of diagnosis in
– nonobstructive pyelonephritis
relation to delivery.
– Adhesins: P- & S-fimbriae enhanced virulence
Effect on pregnancy • promote binding: vaginal and uroepithelial cells
preterm delivery • urinary stasis & vesicoureteral reflux
low-birthweight and growthrestricted
– symptomatic upper urinary infections
• Diabetics: susceptible to pyelonephritis
infants, and perinatal mortality
Glomerulopathies
• Single stimulus (ex poststreptococcal GN)
• Multisystem disease (ex SLE or DM)
• glomerulopathic syndromes:
– acute nephritic
– pulmonary-renal
– Nephrotic
– basement membrane, glomerulovascular, and infectious-
disease syndromes
• Young women, childbearing pregnancy
Pregnancy
• HPN: 50% of women
– Severe
• Proteinuria: worsened in 60 %
• Worst perinatal outcomes:
– impaired renal function
– early or severe hypertension
– nephrotic-range proteinuria
ETIOLOGY: Management:
aberrations of factor VIII complex and platelet dysfunction 1. Iced saline irrigations, topical antacids, and intravenously administered H2-
benign and malignant hematological conditions, solid blockers.
tumors, autoimmune disorders, and medications 2. Transfusions may be needed, and if there is persistent bleeding, then
endoscopy is indicated With persistent retching, the less common, but
Pathogenesis more serious, esophageal rupture—Boerhaave syndrome—may develop
von Willebrand factor series of large plasma multimeric from greatly increased esophageal pressure
glycoproteins that form part of the factor VIII complex.
essential for normal platelet adhesion to Ulcerative Colitis and Pregnancy
subendothelial collagen and formation of a primary Inflammation is confined to the superficial luminal layers of the colon,
hemostatic plug at the site of blood vessel injury. typically beginning at the rectum and extending proximally for a variable
plays a major role in the stabilization of the coagulant distance.
properties of factor VIII. • Endoscopic findings include mucosal granularity and friability interspersed
The procoagulant component is the antihemophilic with mucosal ulcerations and a mucopurulent exudate.
factor or factor VIII:C, which is a glycoprotein • Bloody diarrhea is the cardinal presenting finding.
synthesized by the liver. • Management: 5-aminosalicyclic acid (5-ASA) or mesalamine are used for
von Willebrand precursor, which is present in platelets active colitis as well as maintenance therapy. For recalcitrant disease,
as well as plasma, is synthesized by endothelium and proctocolectomy is performed.
megakaryocytes under the control of autosomal genes There is no evidence to suggest that pregnancy has any significant effects on
on chromosome 12. ulcerative colitis.
The von Willebrand factor antigen (vWF:Ag) is the
antigenic determinant measured by immunoassays. Ulcerative colitis quiescent at conception worsened in approximately a third
of pregnancies
Clinical Manifestations:
considered in women with bleeding suggestive of a chronic Management:
disorder of coagulation Most part is the same as for nonpregnancy
Type Ieasy bruising; epistaxis; mucosal hemorrhage; and Flares may be caused by psychogenic stress and reassurance is
excessive bleeding with trauma, including surger important.
Calcium supplementation is provided because osteoporosis is
DIAGNOSIS: common.
prolonged bleeding time, prolonged partial thromboplastin Maintenance of colitis is continued with 5-ASA derivatives, and
time flares are treated with corticosteroids.
dec. vWF antigen; decreased factor VIII Recalcitrant disease is treated with immunomodulators
Leukocytapheresis
Parenteral nutrition may be necessary for women with prolonged Preinvasive intraepithelial lesions
exacerbations. Diagnosis via biopsy
Colorectal endoscopy is performed as indicated Clinically staged: PE, CXR, intravenous pyelography (IVP) or CT
Colectomy for fulminant colitis may be lifesaving, and it has been and stage does not change based on operative findings
performed during each trimester. “cervical ca=clinically staged;
Most women underwent partial or complete colectomy ovarian/endometrial ca= surgically staged”
decompression colostomy with ileostomy- 10 and 16-week “cervical ca obstruct the kidneys, most px die not because of
pregnancy. cervical ca but with renal problems”
Proctocolectomy improves sexual function and fertility
Women who have had a colectomy and ileal pouch– anal HPV causing cervical CA
anastomosis can safely deliver vaginally. HPV, double stranded DNA viruses replicate w/in the epithelium
Cesarean delivery should be for obstetrical indications Transmission may be by sexual activity
Pouchitis is an inflammatory condition of the ileoanal pouch, Most detected infections cleared w/in a few months although
probably due to bacterial proliferation, stasis, and endotoxin some may persist for as long as 36 months
release. It usually responds to cephalosporins or metronidazole. Compromised immune system may increase risk of infection
Smoking increases risk of CIN3
Ulcerative colitis has minimal adverse effects on pregnancy outcome. 2 vaccines are available and ideally given prior to sexual activity
(Cervarix & Gardasil)
Perinatal outcomes were not substantively different from those in the “Young exposed females to HPV can still remove the virus is the
general obstetrical population. system” at 20’s to 30’s. You can get the virus at an early age but
still can able to remove it s. But with constant contact with
Specifically, the incidences of spontaneous abortion, preterm delivery, and affected male partners until you reach 40’s, virus cannot be
stillbirths were remarkably low. removed anymore”
Inexplicably increased incidence of congenital malformations. PAP SMEAR: every year in the Phil. but in other countries its different
Increased rate of caesarean delivery. Philippine Society of Cervical Pathology and Colposcopy
“based on studies done abroad”:
Crohns Disease Screening should begin approx 3 years after the onset of vaginal
intercourse, but not earlier than 21y/o (applicable in Phil)
Crohn Disease and Pregnancy o “16 y/o sexually active- do not do pap smear”
No evidence that pregnancy affects Crohn disease. o “22 y/o, first sexual intercourse- do pap smear”
One report suggested that disease activity might even be decreased For women aged 21-29 years, screening w/ cytology alone every 3
(Agret and colleagues, 2005). In general, disease activity is related to its years is recommended. Despite the high prevalence of HPV
status around the time of conception. infection in this age group, HPV testing is not recommended due
Management: to the transient nature of the HPV infection (applicable abroad)
Maintenance therapy is similar to that for nonpregnant women. Women aged 35-65 years should be screened with cytology alone
Oral or topical 5-ASA derivatives, usually with azathioprine, 6- every 3 years, or cytology and HPV testing (“co-testing”) every 5
mercaptopurine, or cyclosporine, are continued as they appear to be years. Studies of screening intervals in women with history of
safe during pregnancy negative cytology results show increased risk of cancer after 3
Methotrexate is contraindicated, and recently mycophenolate mofetil year (applicable abroad)
and mycophenolic acid havebeen reported to cause serious congenital Due to the disease burden and low sensitivity of cytology in local
anomalies setting, either screening using conventional cytology (every year)
Monoclonal antibody infliximab- treatment was given in the first or biennial screening with liquid based cytology (every 3 years) is
trimester with no adverse sequelae. recommended (applicable in Phil)
Calcium supplementation is given to combat osteoporosis.
Parenteral hyperalimentation has been used successfully during severe Cervical cytology reporting: The Bethesda System
recurrences. 1. Adequacy of sample
Endoscopy or surgery is performed as indicated. a. Satisfactory
Crohn disease is associated with increased adverse perinatal b. Unsatisfactory
Outcomes usually related to disease activity 2. Squamous cell abnormalities
a. Atypical squamous cells (ASC)
↑ Preterm birth .
i. ASC of undetermined significance
LBW – 2ndary absorption
ii. ASC cannot exclude high grade lesion
b. Low grade squamous intraepithelial lesion
MODULE 3 c. High grade squamous intraepithelial lesion
d. Squamous carcinoma
PREVENTIVE GYNECOLOGY 3. Glandular cell abnormalities
Cervical Cancer a. Atypical glandular cells, specify site or origin, if possible
Abnormal bleeding or brownish discharge b. Atypical glandular cells, favor neoplastic
c. Adenocarcinoma in situ
Signs and Symptoms of Cervical CA d. Adenocarcinoma
Patient presents with abnormal bleeding or brownish foul- 4. Other cancers (ex. Lymphoma, metastatic, sarcoma)
smelling discharge frequently noted following douching or
intercourse and also occurring spontaneously between menstrual FIRST STEP IN EVALUATION OF A WOMAN WITH AN ABNORMAL CERVICAL
periods CYTOLOGY REPORT
Other symptoms: back pain, loss of appetite, weight loss (10%)
are late manifestations Squamous lesions
History of not having Pap smear for years ASC-US: HPV DNA testing for HR types; repeat pap test in 6
40s to 60s median age of 52 years months; colposcopy
ASC-H: colposcopy o Speculum exam
LSIL: colposcopy or HPV DNA testing; ff up cytology in 12 months o Rectovaginal exam
o “Low grade can be pathologic or can be easily o Palpation
removed” o Ultrasound
o In menopause, HPV DNA testing or repeat cytology in
6-12 months is preferred to cytology in some Endometrial Cancer
consensus 50-60 years old
HSIL: colposcopy Compl ex atypical hyperplasia results from increased
estrogenic stimulation of the endometrium and is a precursor to
“COLPOSCOPY – another modality aside from pap smear, just like a big endometrioid endometrial cancer
microscope, uses magnifying lens that can pinpoint pathologies with smallest Some CA develop w/o previous hyperplasia w/c are more poorly
lesion” differentiated and more aggressive
Obesity is a strong risk factor (BMI > 30)
Once you see a lesion, do a biopsy Unopposed estrogen stimulation is strongly associated with
endometrial cancer; risk could be decreased with use of
Glandular lesions: all reports require colposcopy and further evaluation if progestins
negative OCP decreases the risk; protective effect starts after 1 year of use
and lasts approx 15 years after discontinuation
Cervical Biopsy PCOS may also increase risk
(“punch”): small SERM (selective estrogen receptor modulator) also increases risk
tissue samples Most endometrial CA that develop from tamoxifen were
are taken from endometrioid histology and low endometrial CA grade and
the cervix & endometrial CA stage
examined for Screen for endometrial ca: Endometrial biopsy by aspiration or
disease or other endometrial curettage
problems
Role of ultrasound on endometrial CA
“CIN: precancerous lesions of cervical ca. Do not mistake CIN diagnosis with
pap smear. CIN is only done after a biopsy” Cut-off >40mm??? for
post menopausal
Natural history of CIN women, aside from
CIN1 or mild dysplasia result from an infection w/ HPV; may mass seen in UTZ,
resolve spontaneously (benign, can still wait, assess the px after 3- endometrial lining has
6mos, if still persistent do another modality) more contrast??
CIN2 one half to two thirds of the thickness of the epithelium;
reversible, resolve spontaneously in 40%
Endometrial CA risk factors
CIN3 full thickness of the epithelium involved in neoplastic
Increases the risk:
process; severe dysplasia and carcinoma in situ; precursor of
Unopposed estrogen stimulation
invasive CA; 1/3 spontaneously resolve
Treatment Unopposed menopausal estrogen replacement therapy (4-8x)
CIN1 Menopause after 52 yrs (2.4x)
o Treatment is no longer preferred method except in Obesity (2-5x)
patients with lesions that persist >12 month; Nulliparity (2-3x)
treatment < 21 y/o is not recommended except if Diabetes (2.8x)
lesion >24 months Feminizing ovarian tumors
o Manifestation of a transient HPV PCOS
o Require follow up and to ensure patient that lesion will Tamoxifen therapy for breast CA
regress Decreases the risk:
CIN2 Ovulation
o 40% regress spontaneously Progestin therapy
o Follow up patient; if it progress to CIN3 then treat Combination oral contraceptives
patient Menopause before 49 years of age
o <21 y/o no need to treat, follow up Normal weight
CIN3 Multiparity
o Treat and long term follow up
o More related to cervical ca Ovarian CA
Ultrasound remains to be the most helpful imaging examination
CASE for ovarian CA diagnosis with the highest sensitivity (92%)
19 year old
Case in due to vaginal discharge Features highly suggestive of ovarian CA:
Plan of management Complex mass with both solid and cystic components
o Ask for sexual activity o Solid mass= malignant
o Screening modality: Gram stain: get a sample of Papillary excrescences and projections
discharge Internal echoes and septations
o Bacterial Vaginosis- clue cells seen histologically o Mass is probably malignant
36 year old Ascites
Case in due to intermenstrual bleeding o Advanced forms of ovarian ca, for tumors who have
o Do a biopsy metastasized
39 year old Peritoneal metastasis
Case in due to prolonged menses
Plan of management
ACS: every 5 years combined with FOBT is preferable to
sigmoidoscopy alone
Solid tumor
within a cystic Colonoscopy
mass with More specific and sensitive
septations
More expensive
Screening: every 10 years for average risk person
Patients who undergo colonoscopy do not require annual FOBT
Addition of Doppler studies can help in preoperative evaluation
by providing better vascular characteristics of the ovarian masses Double Contrast Barium Enema
o Doppler studies are UTZ that can note the flow of Alternative to Colonoscopy
blood within and outside the mass Less expensive and more readily available
o Higher resistance=benign; Lower resistance= seen Less sensitive and specific than colonoscopy
neovascularization, tumors that are more malignant Abnormalities on DCBE need follow-up with colonoscpoy
have more neovascularization
For epithelial ovarian CA, the combination of CA 125 and Human PEDIATRIC AND ADOLESCENT GYNECOLOGY
epididymal protein 4 (HE-4) provides highest sensitivity in GYNECOLOGIC EXAM IN A CHILD
predicting whether a pelvic mass is benign or malignant components of a complete pediatric examination
For epithelial ovarian CA, the risk of ovarian malignancy algorithm o history
(ROMA) presents a predictive index with different cut-offs for o inspection with visualization of the vulva, vagina, and
premenopausal and postmenopausal women using both CA-125 cervix
and HE-4 o if necessary, a rectal examination
o Premenopausal: ROMA value > 7.4 = high risk; < 7.4% = History = child often ramble, many unrelated facts much- from
low risk parents.
o Postmenopausal: ROMA value >25.3% = high risk; < Young children define their symptomatology on direct
25.3% = low risk questioning.
The risk for malignancy index (RMI) in a woman w/ a pelvic mass Educate = genital area call them “private areas”
includes a scoring system using UTZ, menopause status and CA counsel= age appropriate and potential sexual abuse
125 serum measurements reassure = examination will not hurt.
sense of control and divert the child‘s attention
Ca125 o place the child‘s hand on top of the physician‘s hand
Glycoprotein found on the surface of epithelial cells derived from o give her some choices = doll or toy with her
coelomic epithelium Emphasize = most important part is just looking and theres
Epithelial cells lining the fallopian tube, __?__ (sorry, blurred on conversation during the entire process.
trans), bronchus normally produces Ca125 To successfully examine a child=cooperation of the patient and a
Poor sensitivity medical assistant.
Abnormal in only 50% of women with Stage 1 disease Child‘s reaction - depend on age, emotional maturity, and
High false positive __?__ (sorry, blurred on trans) previous experience with health care providers allowed to
visualize and handle instruments to be used
Colorectal Cancer Primary contact - immunizations= assure that no “shots” involved
Colorectal cancer is a disease in which cells in the colon or rectum assure that adult speculums are not part of the examination
become abnormal and divide without control, forming a mass Occasionally pelvic examination done only until the second visit.
called a tumor. Difficult decision because in the field of pediatric gynecology,
o Risk factor: high meat diet and patients with many errors are errors of omission rather than of commission.
POLYPOSIS Never restrain
The exact causes of colorectal cancer are not known. However, Reassurance and sometimes delay = best approach.
studies show that certain factors increase a person's chance of
Rapport = feel safe to allow a gynecologic exam
developing colorectal cancer.
rarely sedation or general anesthesia to complete an exam
Health care providers may suggest one or more tests for
to ensure cooperation = child as partner and assure her that shots
colorectal cancer screening, including a fecal occult blood test
are not involved.
(FOBT); sigmoidoscopy; regular, or standard, colonoscopy; virtual
colonoscopy; or double contrast barium enema (DCBE).
***Draping = may produce more anxiety
People should talk with their health care provider about when to
begin screening for colorectal cancer, what tests to have, the
handheld mirror = help when discussing specifics of genital
benefits and risks (potential harms) of each test, and how often to
anatomy.
schedule appointments.
have all tools, culture tubes, and equipment within easy reach
New methods, such as the genetic testing of stool samples, to
screen for colorectal cancer are under study.
First phase of the pelvic examination is evaluation of the external genitalia.
Fecal Occult Blood Testing
Not adequate as a screening method Infant - examined on her mother‘s lap
Regular FOBT can reduce mortality by 15-33% Young children = frog leg position
ACS: yearly FOBT with sigmoidoscopy every 5 years is preferable Children 2 to 3 years of age = lithotomy with stirrups.
to FOBT alone Lithotomy = 4 to 5 years of age and older
B. Microscopic Appearance
Histomorphologically similar to endometrium
Four major components:
1. endometrial glands
2. endometrial stroma
3. fibrosis
4. hemorrhage
Clinical Manifestations
Symptoms
o Pain
o progressive dysmenorrhea
o dyspareunia
o Menstrual disturbance
o Infertility
o **Most common- pain and infertility
o Younger age group: pain, dyspareunia. Uterus is fixed:
uncomfortable during sex, because it is adherent to
uterine peritoneum.
o Another hallmarks :adhesions—non patent fallopian
tubes leading to infertility
Signs
o Enlargement of the ovaries, fixed
o Fixed retroversion of the uterus
o Tender nodules within the pelvis
o Cannot be diagnosed by PE/IE alone.
o Should always be considered when patients have
symptoms referable to the pelvic cavity.
**retroversion of the uterus uterus facing down Treatment
25% of pts are asymptomatic and if single infertility is not yet a complain Goal:
Goldstandard: Laparoscopy Relief of PAIN
Restore FERTILITY (Fertility work-up, semen analysis..) o Hyperestrogenemia
Prevent RECURRENCE o Viral transmission
Expectant Therapy: Pathology
Indications: with very limited disease (whose symptoms are Gross Appearance:
minimal or nonexistent) o Globular uterus- bleeds- uterus balloons
If trying to get pregnant, the best way is to do laparoscopic o Usually hyperemic with thickened walls
therapy as early as possible. o The foci are frequently scattered diffusely throughout
Medical Therapy: the myometrium.
Indications: chronic pelvic pain o Occasionally,may be more circumscribed,with the
o severe dysmenorrhea formation of a distinct nodule,an adenomyoma
o no desire to get pregnant Adenomyosis- no distinct nodule
o no ovarian cyst formation Adenomyoma- nodule but with no capsule, no clear border
Hormone–inhibition therapy
GOAL: induction of amenorrhea Clinical Symptoms
Pain Reliever only +infertility drugs- wants to get pregnant Symptomatic adenomyosis occurs primarily in parous women
Drugs: over the age of 40. (30-50y/o)
Danazol:pseudomenopause therapy: (800mg/day)high-dose Classic symptoms:
progestin: 2.5-7.5mg/wk) o secondary dysmenorrhea
GnRH–agonist: medical oophorectomy o abnormal uterine bleeding
o leuprolide acetate 3.75mg IM/mo or 11.25mg IM/3mo Most common physical sign:
o nafarelin acetate 800ug/day o a diffusely enlarged uterus (rarely exceeds 12 weeks
o goserelin acetate 3.6mg/28d SCimplant gestation in size)
add – back therapy : o particularly tender during menstruation
o to reduce vasomotor symptoms, vaginal atrophy, Secondary dysmenorrheal- before wala, ngayon meron na dahil sa
demineralization of bone trauma
30pg/ml estradiol Tender during menstruation
Progestogens:pseudopregnancy therapy Best time to do physical exam- Menstruation (3rd-5th day)
Surgical Therapy (1) (goal: preserve function, to reproduce) ** (+) reproductive age group, secondary dysmenorrhea – dysmenorrhea 3-4
Indications: days prior to onset or after the menses; abnormal uterine bleeding –
o adnexal mass prolonged bleeding, menorrhagia, bleed in the middle of the cycle
o pelvic pain
o infertility Diagnosis
Approaches: History
o trans – abdominal Pelvic examinations
o laparoscopic (advantage is faster recovery) Ultrasonography – large, thick, small cystic s
Surgical Therapy (2) Serum markers:CA-125↑
Methods: **Elicit the symptoms usually seen
o Conservative surgery **IE: slight enlarged uterus and tender
o preserve the fecundity
o preserve the ovarian function Treatment
Definitive surgery: Hormone therapy
o hysterectomy + salpingo–oophorectomy Hysterectomy, the only uniformly successful treatment for
Combination of Medical and Surgical Treament: 3 Step Approach (recurrence adenomyosis, is necessary
are is very high) Uterine Artery Embolization
**rarely will the uterus enlarge for about 14 weeks; if ? do surgery
**Ligate the uterine artery by introducing an emboli, is variably successful
**the only definitve surgery: hysterecomy
MODULE 4
Profuse, Thin
Homogenous
Strawberry Discharge
Cervix
Clue Cells
Trichomonads
Recommended Treatment :
Metronidazole 500 mg BID x 7 days
B. CANDIDIASIS Metronidazole gels
- Caused by a yeast : Candida albicans ,glabrata ,tropicalis Clindamycin creams
- High-risk factors :
o Pregnancy GENITAL ULCERS
o Diabetes A. HERPES GENITALIS
o Oral Contraceptives - Venereal disease caused by : Herpes simplex type II (90% of cases)
o Antibiotic abuse and type I (10% of cases)
- Normal inhabitant of the vagina - Primary infection : s/sxs appear within 3-7days after exposure
- Opportunistic infection - May be asymptomatic
- Clinical Features: - Evolution of HSV Lesions :
o Whitish to yellowish , thick , “cheese-like” or “ curd- Clear vesicles (labia, vulva, perineal area ,vagina and ectocervix ) Vesicles
like” discharge rupture (within 7 days) Ulcer formation (shallow , painful with red borders
o Vulvar pruritus, edema , or erythema ) Secondary infection ( necrosis )
o Dysuria
o Dyspareunia
o Vaginal pH : ~ 4.5
- Diagnosis: KOH wet mount
- Identification of pseudo-hyphae and spores of C. albicans
- Others : Nickerson’s / Sabouraud’s medium; Latex Agglutination
Test ( for nonalbicans sp.)
Thick , Cheese-like
Discharge
Multinucleated
Giant Cell
Pseudohyphae
Recommended Treatment :
- Oral : Fluconazole 150 mg single dose
- Intravaginal Agents : creams , ointments, vaginal tablets or
suppositories
Diagnosis :
Others:
- Usually done clinically +Tsanck or Paps smear
- Butoconazole
- Multinucleated giant cells with nuclear inclusions
- Clotrimazole
- Others : Direct Immunoflourescence of ulcer scrapings
- Miconazole
Viral culture
- Nystatin
- Tioconazole
Recommended Treatment Polymerase or Ligase Chain Reaction
1st episode - Valacyclovir 1 gm PO BID x 7 days
: - Acyclovir 200 mg 5x daily or 400mg TID for 7-10 - Recommended Treatment:
days Doxyxcycline 100 mg BID x 7 days
- Famciclovir 250 mg TID for 7-10 days Alternative Regimens :
Recurrent - Valacyclovir 500 mg PO bID x 5 days - Azithromycin 1 gm PO single dose
Episode - Acyclovir 400 mg TID for 5 days or 800mg BID for - Erythromycin base 500 mg PO QID x 21 days
5 days or 800 mg TID for 3 days - Ciprofloxacin 750 mg PO BID x 3 weeks
- Famciclovir 125 mg BID for 5 days or 1 gm BID for
1 day
Daily - Valacyclovir 500 mg daily (≤ 8 recurrences/yr) or
Suppressive - 1 gm daily or 250 mg BID (> 9 recurrences /yr)
Therapy - Acyclovir 400mg BID
- Famciclovir 250 mg BID
B. CHANCROID
- Caused by : Hemophilus ducreyi bacillus , gm (-) rod in chain
- More frequent in tropical / subtropical countries
- Alternative Regimens
o Trimethoprim-Sulfamethoxazole 80/400 mg BID x 3
weeks or
o Ciprofloxacin 750 mg BID x 3 weeks or
C. LYMPHOGRANULOMA VENEREUM o Erythromycin base 500 mg QID x 3 weeks or
- Caused by Chlamydia trachomatis o Azithromycin 1gm PO q week x 3 weeks
- Sexually transmitted
- Affects males 20x more than females
- Clinical feature :
1. Painless vulvovaginal ulcer
2. Adenitis
3. Inguinal buboes
- Chronic progression
1. ulceration Donovan Body
2. elephantiasis
3. sinus tract formation
4. rectovaginal fistula
5. abscesses
6. rectal strictures
Clinical Features:
- Diagnosis : Clinical + lab tests : syphilis is divided into primary, secondary, and tertiary stages
Biopsy and Culture of Cyclohexamide treated tissues
Complement fixation- Direct Immunoflourescence for Primary syphilis
antibodies A papule, which is usually painless, appears at the site of
Enzyme Immuno-assay inoculation 2 to 3 weeks after exposure.
PROLIFERATIVE INFECTIONS diaphragm
A. Condyloma Acuminatum Nonoxynol 9 - A chemical detergent used in spermicidal preparations
Papillomatous “ cauliflower-like ” lesions on the perianal area, that is also bactericidal and viricidal.
vulva , vagina , or cervix
Synonyms for vulvar condylomata acuminata include genital, ENDOMETRITIS
venereal, or anogenital warts
Management :
1. Podophyllin 0.5% solution BID x 3 days
- may be repeated after 4 days for 4 cycles
Pelvic inflammatory disease
2. Imiquimod cream 5% TID at bedtime for 16 weeks
an infection in the upper genital tract not associated with pregnancy or
3. Cryotheraphy
intraperitoneal pelvic operations
4. Trichloroacetic acid 80-90%
may include infections of: endometrium (endometriris), oviducts
5. Surgical removal
(salpingitis), ovary (oophoritis), uterine wall (myometriris), uterine
6. Laser surgery
serosa and broad ligament (parametriris) and pelvic peritoneum
Salpingitis – most characteristic and the most common component of
PID
o most long-term sequelae of PID result from destruction of the
tubal architecture by the infection
Etiology
o usually a polymicrobial infection caused by organisms
ascending from the vagina and cervix along the mucosa of the
endometrium to infect the mucosa of the oviduct
o two classic STD organisms involved:
N. Gonorrhoeae
C. Trachomatis
atypical or silent PID – an asymptomatic or
relatively asymptomatic,inflammation of the
upper genital tract often associated with
chlamydial infection
With
poikilocytosis Mycoplasma
o role: unclear
o agents: Mycoplasma hominis and Ureaplasma urealyticum
obtained from the majority of young, sexually
active women
o route of spread: via the parametria
the primary upper genital tract infection is in the
parametria and the tissue surrounding the tubes,
NOT in the tubal lumen
AZITHROMYCIN DOXYCYCLINE low success rate of direct tubal cultures
CHANCROID GRANULOMA INGUINALE o histology: does not appear to produce damage to the tubal
METRONIDAZOLE FLUCONAZOLE mucosa
TRICHOMONADS CANDIDIASIS o not highly pathogenic
o may colonize or persist in the endometrial cavity after
INFECTIONS OF THE UPPER GENITAL TRACT complete recover from acute PID
o may be a commensal bacterium rather than a
pathogen in the oviducts
o M. Genitalium
Nonculturable
identified by PRC
associated with cervicitis, endometritis, and
tubal factor infertility
Tuboovarian complexes – more common in women with concurrent
Fitz-Hugh–Curtis Syndrome - A syndrome of perihepatic inflammation bacterial vaginosis or HIV infection
that develops in 5% to 10% of women with acute pelvic inflammatory
disease, originating from transperitoneal or vascular dissemination of
either Neisseria gonorrhoeae or Chlamydia trachomatis.
o diagnosis: laparoscopy
liver capsule will
appear inflamed, with
classic “violin string”
adhesions to the
parietal peritoneum
beneath the
Barriers
o Condom
Protects partnerfrom direct contact with semen, urethral
discharge, or penile lesion
Effective in vitro barrier to Chlamydia, CMV, and HIV, partial
protection with HSV
Protects wearer from direct contact with partner’s mucosal
secretions
Appears to decrease risk of acquiring urethral/cervical GC,
PID, and male urethral Ureaplasma colonization; partial HPV
protection
Effects on risk of acquiring NGU not established
o Spermicide
Chemically inactivates infectious agents
Inactivates gonococci, syphilis spirochetes, trichomonads,
HSC, ureaplasmas, and HIV in vitro.
o Diaphragm
Mechanical barrier covers cervix used with spermicides
Appears to decrease risk of acquiring cervical GC and PID
PELVIC TB
Rare
Chronic salpingits and chronic endometritis
Usually premenopausal (10% postmenopausal)
Immigrants (Asia, Middle East, Latin America).
Organisms:
o Mycobacterium tuberculosis
Primary site: Lungs
Hematogenous spread.
o Mycobacterium bovis.
Oviduct – primary site (GIT – for bovine TB)
Diagnosis of Pelvic TB
o (+) Tuberculin test.
o Endometrial biopsy (secretory phase): Culture and histologic
exam.
Gross Findings : Eversion of
the ends of the oviduct
“ Tobacco pouch ”
o Confirmatory of the Dx: giant
cells and caseation necrosis.
Treatment of Pelvic TB
o Medical (Multi-drug regimen). Outlet resistance is increased by reflex stimulation of the alpha-
INH adrenergic receptors within the smooth muscle of the bladder
Rifampicin neck & proximal urethra.
Streptomycin Stimulation of the striated external urethral sphincter via the
PZA pudendal nerve.
* TB infection should be suspected in women who do not respond to
antibiotic treatment for Acute PID ANATOMY & PHYSIOLOGY OF MICTURITION
o Surgical To maintain URINARY CONTINENCE at the level of the bladder
Reserved for women with: neck & urethra, IUP > IVP (during rest & with stress)
1. Persistent pelvic masses In CONTINENT women: increased IAP (coughing, lifting, straining)
2. Some women with resistant organisms increases IUP equally to the r
3. Women older than 40 other allowing closure pressure to be maintained.
4. Women whose endometrial cultures remain positive.
DIAGNOSTIC PROCEDURES
Methods of Preventing PID 1. Phase I - Provides information to establish diagnosis in 75-80% of
Behavioral : Monogamy patients.
Reduce number of sexual Partners 2. Phase II - More sophosticated urodynamic testing needed in 20-
Barriers Condoms 20% of patients.
Spermicides
Diaphragms BONNEY Test
Vaccines : Hep B Part of phase I
Research in progress : HIV , HSV , indicated in case of a positive stress test associated with a
Gonococcal cystocoele – may manifest as a vaginal mass
Oral Antibiotics : PCN To know if incontinence is due to descent of bladder neck or
Sulfathioazole weakness of the sphincter.
Tetracycline The index and middle fingers are placed on both sides of the
Local Postcoital urination urethra to elevate the bladder neck upwards.
Postcoital washing If no urine escapes on stress it means that the incontinence is due
Postcoital antisepsis to descent of the bladder neck, but if urine still escapes it means
weakness of the sphincter
ACTINOMYCOSIS
o Etiology LOWER URINARY TRACT INFECTIONS
Actinomyces – is rare cause of upper genital tract infection Bacteriuria is quite common in women who are on chronic
agent: Actinomyces israelii catheterization and in women in nursing homes who are chronically
o A. israelii is discovered either by histologic examination or culture from incontinent.
women with tuboovarian abscesses o Asymptomatic bacteriuria is no longer treated, even in the
o risk factor: chronic use of IUD (ave. 8 years) elderly, unless they are undergoing an invasive procedure.
o progression to upper tract infection is highly unlikely to be related o The presence of at least 100,000 organisms per milliliter of
o the decision to remove the IUD to treat a patient is influenced by the urine is generally accepted as evidence for a clinical
presence or absence of clinical symptoms infection.
A. CYSTITIS
Most common UTI in outpatient settings
UROGYNECOLOGY
(+)100,000/ml bacteria concentration in a clean-catch urine specimen
Bladder capacity = 400 – 500 cc
B. URETHRAL DIVERTICULITIS
majority of diverticula seem to occur between the ages of 30 and 50.
Etiology:
o Congenital
o acute/ chronic inflammatory
o Urethral trauma from multiple catheterizations or from
childbirth
o The infectious origin is probably the most common and
the prevalence in women with recurrent UTIs may be
as high as 40%.
s/sx:
o urgency
o frequency
o three “Ds” = dysuria, dyspareunia, postvoid dribbling
o hematuria
o incontinence
o Occasionally, patients have urinary stones within the
diverticula or discharge or pus from the urethra.
PHYSIOLOGIC BLADDER FILLING: Dx: Diagnosis is generally suggested by physical examination.
Little or no increase in IVP is observed, despite large increases in Tx: marsupialization
urine volume.
As filling increases, detrusor muscle contractility is inhibited by URINARY INCONTINENCE
activation of a spinal sympathetic reflex. Types
Results in inhibition of parasympathetic ganglion transmission & Genuine stress incontinence
stimulation of beta-adrenergic receptors in the bladder body. Detrusor instability
Mixed (GSI and DI)
Overflow
Fistulae (True Incontinence) SURGICAL TREATMENT
It is the primary treatment of stress incontinence.
Genuine stress incontinence The operation is done vaginally, abdominally, or abdominovaginally.
Is the involuntary loss of urine in the absence of a detrusor contraction,
the intravesical pressure exceeds the urethral pressure. INFERTILITY
There is not an associated desire to void. Primary infertility : identified in couples in whom a pregnancy has
never been established.
Detrusor instability Secondary infertility : identified in couples who have previously
Involuntary detrusor contractions either spontaneous or provoked conceived but are currently unable to do so.
which cannot be suppressed and may cause incontinence.
It is associated with a strong desire to void. Examples of some of the principal dysfunctions for each component of
Abnormal nerve supply to bladder (spinal cord injury, spina bifida) - the reproductive system are :
detrusor hyperreflexia. o Sperm :
childhood mumps
MIXED INCONTINENCE: GSI +DI testicular injury/sexually transmitted diseases
Presence of both GSI & DI varicocele
Address foremost one component, preferable the worse one. sexual dysfunction
exposure to toxins endocrinopathies
Overflow incontinence CAUSES OF INFERTILITY:
Is an involuntary loss of urine associated with over distension of the 1. Anovulation
bladder 2. Fallopian tube is non functional or not patent
May present as SI or dribble. 3. Spermatozoa are not present or not functional
Due to bladder outlet obstruction or impaired detrusor contraction. 4. Coitus is either not timely or is not performed properly
More common in males. 5. Unfavorable cervical mucus
6. Unreceptive endometrium
True incontinence
In this case, urine escapes continuously by day and by night. Hysterosalpingogram
It is caused by: o Fluoroscopic and radiographic visualization of the interior of
a. Urinary fistulae as vesicovaginal fistula – MOST COMMON the female upper genital tract after instillation of
b. Ectopia vesica. radiopaque dye.
o Schedule the HSG during the week following the end of
MANAGEMENT menses to avoid irradiating a possible pregnancy
1. Prophylactic o can assess proximal or distal occlusion of an oviduct by
2. Conservative (non-surgical) outlining internal anatomy through infusion of a radio-
3. Surgical opaque medium.
o Patency is confirmed by extrusion of media into the cul-de-
PROPHYLACTIC TREATMENT sac.
1. During labor, the bladder should be kept empty. o Often, performing an HSG results in pregnancy; the
2. Episiotomy is performed if necessary. procedure may break fimbrial adhesions.
3. Physiotherapy. o Premedication with prophylactic doxycycline and
prostaglandin synthetase inhibitors can prevent
* Pelvic floor exercises are started after delivery. exacerbation of previous PID and stimulation of painful
* These include repeated stoppage of the urinary stream during micturition uterine cramping.
and repeated contractions of the pelvic floor muscles.
CONSERVATIVE TREATMENT
Indications:
1. Mild stress incontinence.
2. The patient not completed her family as vaginal delivery may
damage a bladder neck repair
3. Patient is unfit for surgery or refuses surgery.
4. When stress incontinence is combined with detrusor instability.
* The latter should be treated at first before surgery is done for stress
incontinence. Luteal phase deficiency
o Deficient progesterone secretion or action resulting in a
Physiotherapy: Kegel perineometer delay of normal endometrial development.
Faradic current stimulation of the levator ani muscles Ovarian hyperstimulation syndrome
Vaginal cones: 5-9 o Mild – abdominal pain, distention, and weight gain
Estrogen therapy for menopausal patients o Moderate – >10 cm ovarian enlargement, ascites, nausea,
Alpha-adrenergic stimulants vomiting
Large vaginal diaphragms, Hodge pessary - to elevate and support the o Severe – hemoconcentration, oliguria, elevated serum
bladder neck creatinine. Pleural effusion and ascites can be present.
Reduction of weight in obese patients to reduce intra-abdominal Post-coital test – examination of the cervical mucus to evaluate the
pressure. presence of sperm several hours after sexual intercourse.
Stop caffeine (to avoid diuresis) and smoking (to avoid coughing) o 20 forwardly progressive sperm should be seen per high-
Injection of Teflon or bovine collagen in the submucosal layer in the power field.
region of the bladder neck.
o This leads to narrowing of the urethral lumen and increased
urethral resistance.
Dx of ANOVULATION
a) A basal body temperature (BBT) is based on the thermogenic effect of
progesterone. The BBT should remain increased 0.5° to 0.8°F for at
Management is based on the following abnormal findings: least 11 days during the luteal phase.
1. If sperm are absent, coital technique (e.g., use of sexual lubricants, b) Serum progesterone > 3 ng/ml provides indirect evidence of ovulation.
post-coital douching) should be investigated. c) Endometrial biopsy may reveal a luteal phase defect, which is a
The woman should difference of 2 or more days on endometrial histology compared with
be advised to remain the known cycle day.
supine for 15
minutes after coitus Intrauterine Insemination (IUI)
with her knees bent Placement of spermatozoa that
to enhance cervical have been separated from the
mucus contact with seminal fluid into the
the seminal pool. endometrial cavity through
2. If the mucus is of poor quality, small catheter.
and the sperm have poor Effective for couples in which
motility but adequate numbers, the male has a low sperm
the timing within the cycle should be assessed. Mid-cycle exogenous count.
estrogen may improved mucus quality. Donor insemination is a last resort.
3. If the mucus is of good quality, and there are adequate sperm numbers,
the woman should be evaluated for sperm antibodies. Immunobead Test
Type of male fertility test that can help assess common male fertility
If the woman is having regular menstrual cycles, a serum progesterone problems.
level should be measured in the mid-luteal phase to provide indirect This preliminary male fertility test looks for the presence of antisperm
evidence of ovulation as well as normal luteal function. antibodies, which can have a negative effect on the reproductive
o A se prog level of 10 ng/ml = indicative of adequate luteal health of both men and women, thereby reducing fertility.
function.
Serum motility begins to decline 2 hours after ejaculation, and it is best Management
to examine the specimen within this time period. 1. Clomiphene citrate is the usual initial agent used
Documentation of anovulation: TV UTZ
Characteristic Value Done on 10th day of cycle every 2 days
Observe for: Mature ovarian follicle
Semen volume 2 – 5 ml
Sperm count > 20 million / ml Px does not ovulate on her own.
Sperm motility > 50% Day 3-7: clomiphine citrate
Normal forms > 30% Increase in dosage every cycle until ovulation is achieved
Forward progression >2 (scale 0-4)
Normal morphology >50% normal 2. Human menopausal gonadotropin (hMG) stimulation
which triggers ovulation
used for patients who are resistant to clomiphene.
Measurement of TSH and Prolactin in ovulatory women
Ovarian response must be monitored closely by:
o If women with anovulation have hypothyroidism or
o serum estrogen levels and
hyperprolactinemia, tx with thyroid replacement or
o sonographic assessment of follicle number
dopamine agonists
Ovulation is successful in 90% of women
Luteal deficiency
o pregnancy rate of 50%.
o Diagnosis of luteal deficiency can be determined by finding
Very expensive
serum progesterone levels consistently below 10 ng/ml a
Starts at day 6 until the px has a mature follicle at a size of 1.6- 1.8
week before menses
Seen via transvaginal ultrasound
*eto yung galing sa mga nun. Wala silang sexual intercourse kaya yung
Most Couples Will Achieve Conception Within :
sa kanila ang kinukuha.
1 month : 25%
6 months : 60% 3. Hyperstimulation
9 months : 75% Excessive stimulation can produce large theca lutein cysts with
1 year : 80% transudation of ovarian fluid, resulting in ascites and
18 months : 90% hemoconcentration (OHSS).
o Treatment is conservative, allowing spontaneous
involution. Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum* :
4. Assisted reproductive technology (ART) CDC 2010
refers to all techniques, in lab or hospital, involving direct retrieval Recommended Ceftriaxone 250 mg IM in a single dose
of oocytes from the ovary. Regimens or
Cefixime 400 mg orally in a single dose or 400 mg by
They may be used when conventional infertility therapy has suspension (200 mg/5ml)
failed. or
Single dose Cephalosporin regime IM
*More prone to multifetal pregnancy: implantation of multiple fertilized PLUS
ovum are all successful Azithromycin 1 gm oral single dose or
In-Vitro Fertilization (IVF) Doxicycline 100 mg orally BID x 7 days
Involves extraction of Alternative Spectinomycin 2 g in a single intramuscular (IM)
oocytes, fertilization on the Regimens dose
laboratory, and transcervical OR
transfer of embryos into the Single-dose cephalosporin regimens
uterus.
Uncomplicated Gonococcal Infections of the Pharynx* : CDC 2010
Recommended Regimens Ceftriaxone 250 mg IM in a single dose
PLUS
Azithromycin 1 gm single oral dose or
Doxicycline 100 mg BID x 7 days
Gamete intrafallopian transfer
(GIFT)
Placement of human ova and
Disseminated Gonococcal Infection(DGI) : CDC 2010
sperm into the distal end of
Recommended Regimens Ceftriaxone 1 g IM or IV every 24 hours
the oviduct.
Refers to placement of
oocytes and sperm directly
into the fallopian tube. Alternative Regimens Cefotaxime 1 g IV every 8 hours
Used if the infertile woman OR
has a functioning oviducts Ceftizoxime 1 g IV every 8 hours
Modifications include zygote Fitz- Hugh- Curtis Syndrome:
intrafallopian transfer (ZIFT) Transperitoneal or vascular dissemination of Neisseria or
and tubal embryo stage Chlamydia- perihepatic inflammation-
transfer (TEST) “violin strings”
ZIFT the oocytes are
fertilized in vitro and
transferred 24 hours later.
(TET) is similar to ZIFT
except the embryos are
transferred 8 to 72 hours
after fertilization
Symptoms:
o PID sxs (abdominal tenderness, cervical motion
Intracytoplasmic sperm injection tenderness, adnexal tenderness) + RUQ pain+ pleuritic
(ICSI) pain
Sperm (single spermatozoa) o Treatment same as PID
is placed inside the egg by Management Guidelines for PID
microinjection
Partners of women with PID should also be given tx 250 mg
Ceftriaxone IM plus Doxyxycline 100 mg BID for 7 days OR
A single spermatozoon is
Azithromycin 1 gm PO single dose
injected into the cytoplasm of
25 % recurrence within 10 weeks if male partner is not treated
an ovum.
Oral Treatment for Acute PID
(CDC 2010)
UPPER GENITAL TRACT INFECTIONS
Ceftriaxone 250 mg IM in a single dose
Risk factors for PID: PLUS
Young Menstruating Female Doxycycline 100 mg orally twice a day for 14 days
Multiple Sex partners WITH or WITHOUT
No Contraceptive use: Metronidazole 500 mg orally twice a day for 14 days
o OCP’s Decrease risk of STD’s due to: OR
Thicker cervical mucus Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered
Shorter duration and amount of menstrual concurrently in a single dose
flow PLUS
o Condoms, diaphragms and spermicides Doxycycline 100 mg orally twice a day for 14 days
Provide mechanical and chemical barriers
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or
cefotaxime) CIN is graded in three steps:
PLUS a) CIN 1 – little or no clinical consequence as it usually
Doxycycline 100 mg orally twice a day for 14 days result of a transient HPV infection only. In the past,
WITH or WITHOUT referred to as mild dysplasia.
Metronidazole 500 mg orally twice a day for 14 days b) CIN 2 – cellular changes are more extensive and include
one-half to 2/3 of the thickness of the epithelium
c) CIN 3 – full thickness cellular changes; includes those
Pelvic Inflammatory Disease (PID) changes previously referred to as severe dysplasia and
CDC 2010 carcinoma in situ.
Recommended Parenteral Regimen A CIN I
Cefotetan 2 g IV every 12 hours No penetration of Basement
OR membrane and do not extend
Cefoxitin 2 g IV every 6 hours more than half
PLUS
Doxycycline 100 mg orally or IV every 12 hours CIN II
Recommmended Parenteral Regimen B
Acetic acid makes the specimen dark; while Lugol’s make it bright
COLPOSCOPY Large Cell Nonkeratinizing
A colposcope is used to magnify abnormal cervical areas that
require biopsy
Abnormal Pap smear results are usually referred for colposcopy/
any abnormal screening test.
Solutions Used:
a. Normal Saline – remove cervical mucus and allows vascular and Small Cell Ca
surface features of lesion to be initially assessed
b. Acetic Acid – is 3-5% preparation serves as a mucolytic agent
that reversibly clumps nuclear chromatin causing various shade
of white depending on the degree of abnormal chromatin
density Adenocarcinoma
c. Lugols Iodine – stains mature epithelial cells mahogany in
estrogenized women due to high cellular glycogen content
Adenosquamous
(mosaicsism)
Clear cell CA
CRYOTHERAPY **signet ring appearance
Freeze the lesion
Has largely been supplanted by LEEP. If patients are carefully
selected, the success rate is approximately 95%.
Larger CIN lesions have higher failure rates, most likely because CLINICAL PRESENTATION
the whole lesion is not covered by the cryoprobe. It is not EARLY SYMPTOMS
appropriate to use cryotherapy if the lesion extends into the 1. Vaginal bleeding - most important symptom
endocervix. Induced by sexual intercourse or internal examination
procedure is simple. After colposcopy and sampling has shown Intermenstrual
that the lesion is confined to the exocervix, a probe is selected that 2. Vaginal discharge
will cover the entire lesion, in most systems, N2O is used as the LATE SYMPTOMS
refrigerant 1. Pelvic/flank pain
Probe is applied to the cervix and the system is activated. The 2. Bone pain
cervix will freeze quickly, but the probe must remain in place until 3. Urinary disturbances: dysuria, hematuria
the ice ball that forms extends to at least 5 mm beyond the edge 4. Bowel disturbances: rectal bleeding
of the instrument. 5. Lower extremity edema
Most cases, this takes 3 to 4 minutes 6. Signs/symptoms of uremia
Refrigerant is then turned off, and the probe allowed to thaw and
separate from the cervix FIGO STAGING OF CERVICAL CANCER
Because the tissue that was destroyed remains on the cervix, Stage 0 Carcinoma in situ (preinvasive carcinoma)
within a few hours to a day, the patient will begin to experience Stage 1 Carcinoma strictly confined to the cervix; extension to the
vaginal discharge uterine corpus should be disregarded.
As the tissue sloughs, the amount of discharge increases, and Stage 1A Invasive cancer diagnosed only by microscopy.
malodor is common. It may take as long as 3 weeks for the All macroscopically visible lesions even with superficial
discharge to stop invasion are stage Ib cancers. Invasion is limited to
The patient should be cautioned to place nothing in the vagina for measured stromal invasion with a maximum depth of 5
at least 3 weeks after the procedure to avoid causing dislodgment mm* and no wider than 7 mm.
of the eschar. Stage 1A1 Stromal invasion is no greater than 3 mm in depth and no
First follow-up should occur in approximately 4 to 6 months and wider than 7 mm in horizontal spread.
include cytology and colposcopy. The cytology sample should Stage 1A2 Stromal invasion >3 mm but 5 mm in depth and with
include the endocervix
horizontal spread of 7 mm.
CERVICAL CANCER
In the US is the 3rd most common malignancy of the lower female
genital tract after endometrial and ovarian cancers
In the Philippines is the reverse, it is the #1
PHMS are derived from paternal and maternal chromosomes, resulting in
triploid genotype. Absence of the immunohistochemical nuclear stain p57 (a
maternally expressed gene) suggest paternal origin and can be used to
differentiate between CHM and PHM
PARTIAL COMPLETE
Karyotype 69XXX, 69XXY 46XX, 46XY
*with maternal
Pathology
Stage 1B Clinically visible lesions confined to the cervix or microscopic -embryo/fetus Often present Absent
lesions greater than stage IA2. -amnion/fetal rbc Often present Absent
Stage 1B1 Clinically visible lesions no greater than 4 cm in greatest -villous edema focal Diffuse
dimension. -tropho proliferation Variable, focal to slight to Variable, Slight to
Stage 1B2 Clinically visible lesions > 4 cm in greatest dimension. moderate severe
Clinical Presentation
-diagnosis Missed abortion Molar gestation
(1-3%)
-uterine size Small for dates 50% large for dates
-theca lutein cyst rare 25-50%
-medical complication rare frequent
-persistent trophoblastic 1-5% 15-20%
disease
Stage 2 Tumor extends beyond the cervix but has not extended
onto the pelvic wall. The carcinoma involves the vagina, but
Clinical Presentation: same for Partial and Complete
not as far as the lower third.
Vaginal bleeding – most common
Stage 2A No obvious parametrial involvement. Involvement of up to
Size greater than dates
the upper two-thirds of the vagina.
Anemia
Stage 2B Obvious parametrial involvement, but not onto the pelvic
sidewall.
*Due to B hCG:
o Preeclampsia
o Hyperemesis
o Hyperthyroidism
o Respiratory Distress
B-hCG
Stage 3 Tumor extends to the pelvic sidewall and/or involves the
lower third of the vagina and/or causes hydronephrosis or
nonfunctioning kidney. *the bigger the size the higher the value
On rectal examination, there is no cancer free space -releasing hormone
between the tumor and the pelvic sidewall.
Stage 3A No extension to the pelvic sidewall but involvement of the
lower third of the vagina.
Stage 3B Extension to the pelvic sidewall or hydronephrosis or THECA LUTEIN CYST
nonfunctioning kidney. Regress spontaneously 8 to 12 weeks post evacuation
Torsion rupture
CERVICAL CANCER IN PREGNANCY *do not remove, regress spontaneously
The diagnosis of invasive carcinoma of the cervix during *remove if there is rupture/torsion/hemorrhage
pregnancy is managed in much the same fashion as the non- Diagnosis:
pregnant patient. In pregnancy, the treatment method depends Ultrasound – Gold standard
on the patient’s wishes with respect to pregnancy continuation.
If fetal viability has not been achieved and the lesion is Stage I or HUMAN CHORIONIC GONADOTROPHIN
IIA, treatment may be with radical hysterectomy and pelvic Pregnancy hormone
lymphadenectomy with the fetus left within the uterus. Glycoprotein with the highest carbon in human hormone
If close to fetal maturity, if after discussion with the patient, the 2 subunits:
patient wishes to continue with the pregnancy, then cesarean Alpha – LH, FSH, TSH
radical hysterectomy and bilateral pelvic lymphadenectomy is the Before 5 weeks- both cytoT and syncytioT
treatment of choice for early lesions. More advanced disease is Later gestation – only syncytioT
generally treated with radiotherapy. 7 to 9 days after LH surge – detectable in the plasma of pregnant
women
GESTATIONAL TROPHOBLASTIC DISEASE hCG enters the maternal blood at the time of blastocyst
Complete Mole implantation
Abnormality in chorionic villi 8 to 10 weeks- maximum level (doubles every 2 days)
Trophoblastic proliferation 10 to 12 weeks – begins to decline
Edema of the villous stroma 16 weeks- nadir
CHMS = completely derived from paternal origin, >90% is 46, XX genotype,
produced by fertilization of an empty (anuclear) ovum by a single haploid Diagnostic – *e.g. patient : 5 mos after NSD with bleeding, no contraceptive
(23, X) sperm, which then duplicates (w/o cell division) in the ovum use: initial dx: pregnant again, normal menstruation; diff dx: ectopic preg,
(androgenesis). A small percentage of CHMS have a 46,XY genotype, abortion
produced by dispermy 10%, in which a 23,X sperm and a 23,Y sperm fertilize Prognostication – *the higher the level, mas pangit
an empty ovum risk factor is 4 , high risk already
Treatment response – *chemotherapy, serial B hCG is done to see tx
response
Concentration in serum and urine : on
HCG plasma level parallels urine level
1 IU/ml by 6 weeks after LMP *normal B hCG for nonpreganant = 0-5
100,000 m IU/ml : 60th – 80th days after LMP
*100,000-200,000 B hCG – normal; If px has 300,000, most CHORIOCARCINOMA, GESTATIONAL
probably it’s molar pregnancy
o Rescue and maintenance of corpus luteum in early pregnancy (continued
progesterone production)
e syncytioT
1. Suction curettage
*eto yung mga nasa male, testicular chorioCa; ovarian chorioCa w/o
pregnancy; same histologic appearance; not responsive to chemoRx
– Preop dilator
Placental Site Trophoblastic Tumor
– oxytocin
*how would you treat patient with Molar pregnancy? Evacuate by SUCTION
CURETTAGE AND REGULAR FOLLOW-UP
*no syncytioT which produces B hCG, so very low B hCG, dignosed by
immunostaining
2. Hysterectomy
Completed family size
Classification and Staging FIGO STAGING SYSTEM
Adjunctive therapy : decrease local persistence
STAGE I Disease confined in the uterus
*when do you do hysterectomy? High risk px, under medical complication,
STAGE II Disease extends outside the uterus but
thrombosed molar malignancy
confined to pelvic area
*42y/o px G6, 3 mos pregnant, uterine size is for 4 mos, suction or
hysterectomy? Preferred method is SUCTION CURETTAGE STAGE III Pulmonary metastasis
STAGE IV Metastasis to other sites
*Do you infuse Oxytocin prior to curettage? NO, but once evacuated that’s WHO PROGNOSTIC FACTORS
the time you put oxytocin 0 1 2 4
*when do you do hysterogram in molar px? After evacuation, because the Prognostic factors
uterus of Molar px is very soft, so do not do before or during. age <40 >40
*closed cervix is dilated by laminaria- toothpick /bamboo stick-like inserted Antecedent mole abortion Term
in the cervical canal, after 24hrs, it will dilate, absorbs water. pregnancy
*Do you do hysterotomy in molar preg? NO Pregnancy interval <4mos 4-7 7-12 >12
*when you do suction curettage, your left hand should be in the fundus, to B hCG <1000 1000- 10,000- >100,000
prevent perforation and at the same time you massage the uterus. 10,000 100,000
*benefit of hysterectomy: may lessen the local invasion but not the distal so
serial monitoring is still needed Largest tumor <3cms 3-4 >5
Site of metastasis lungs Spleen/kidney GIT Liver/brain
High Risk Patients: *(memorize)
# of metastasis 1-4 5-8 >8
Prior chemotherapy Single agent 2 or more
Diagnosis:
ths Consideration for the possibility – most important factor
Only by B hCG determination
No histopath diagnosis neede
*after 1 year, can get pregnant again Quantitative B hCG
Complete physical exam
Quiescent Gestational Trophoblastic Disease CBC
-212 IU/L) of B hCG for 3 mos or longer with no Renal function test
obvious decrease in level trend Thyroid function test
Utrasound, Doppler Low Risk GTD
Chest Xray – for baseline purposes, for comparison if px is high
risk more cycles
CT of the thorax – if negative for chest Xray, possible metastasis
CT or UTZ of the abdomen
MRI/CT of the brain – needed if postive for micrometatsasis in o Achieved by diligent follow-up and
lungs o Salvage therapy for failures
o II. Repeat the metastatic evaluation dysfunction, either transient or eventually premature ovarian failure,
o III. Consider hysterectomy if disease confined to uterus particularly those in their 30s or 40s.
o IV. Multiagent therapy with EMA-CO creased risk of molar pregnancy, from 1/1000 pregnancies to 1/100.
FIBROMA
Most common benign solid tumor of the vulva
Arises from deep connective tissue
Treatment is excision- TOC
CERVICAL POLYPS
Most common benign neoplastic growth of the cervix
Common 40-50s age group
Tx- polypectomy (forceps grasp the base of the polyp because the
pedicle is soft and friable then squeeze to remove the polyp
ENDOMETRIAL POLYP
Localized growth of the endometrial glands and stroma beyond
the surface of the endometrium A unilocular or multilocular cyst of ovary lined by tall columnar
Peak incidence 40-49 yr epithelium resembling that of the cervix or large intestine
Softer than myoma It is usually large and may reach immense proportions, occupying the
Sx bleeding, infertility whole peritoneal cavity and compressing other organs.
It may occur at any age.
LEIOMYOMA primary during reproductive years
3 most common types May become huge >300lbs
o Intramural Rupture may occur and seeding of the epithelium on the
o Subserous peritoneal surface may cause pseudomyxoma peritonei.
o Submucous Pseudomyxoma Peritonei
o transformation of peritoneal mesothelium to a mucin
secreting epithelium
o Continuous secretion of mucuc resulting in Staging The Federation Internationale de Gynecologie
accumulation in peritoneal of gelatinous material et d'Obstetrique (FIGO) and the American Joint
o Evaluation at operation os followed by reaccumulation Committee on Cancer (AJCC) have designated staging.
TX: repetitive surgical evacuation; long term nutritional support
Stage I ovarian cancer limited to the ovaries
SEROUS CYSTADENOMA Stage 1A tumor limited to 1 ovary,
They are the most common benign epithelial tumors and form the capsule is intact,
20% of all ovarian neoplasm. no tumor on ovarian surface and no malignant
cells in ascites or peritoneal washings.
SEROUS CYSTADENOCARCINOMA Stage 1B tumor limited to both ovaries,
This is by far the most common primary carcinoma, accounting for capsules intact,
60% of all cases, and in over half the cases it is bilateral. no tumor on ovarian surface and no malignant
cells in ascites or peritoneal washings
Endometrioid Carcinoma of the Ovary Stage 1C tumor is limited to 1 or both ovaries with any of
It is now recognized that carcinoma of the ovary may be of the following:
endometrial type, sometimes arising in endometrioma. capsule ruptured,
Attacks of pain, unusual with ovarian cancer, are common. tumor on ovarian surface,
Sometimes there is uterine bleeding in post-menopausal cases. malignant cells in ascites or peritoneal washings.
Usually the lesion is cystic and chocolate brown in color. Stage II ovarian cancer tumors involving 1 or both ovaries with pelvic
If such a cyst ruptures spontaneously, malignancy should be extension and/or implants
suspected. Stage 2A extension and/or implants on the uterus and/or
Clear Cell Carcinoma fallopian tubes.
It is doubtful if this exists as a distinct entity. No malignant cells in ascites or peritoneal
Clear cells may be seen in almost any variety of ovarian washings.
carcinoma, but occasionally a carcinoma, usually solid, consists Stage 2B extension to and/or implants on other pelvic
almost entirely of polygonal cells with clear cytoplasm. tissues.
It behaves in the same way as any other solid carcinoma and has No malignant cells in ascites or peritoneal
the same prognosis. washings
Contain cells with abun-dant glycogen and so-called hobnail cells, Stage 2C Pelvic extension and/or implants (stage IIA or
in which the nuclei of the cells protrude into the glandular lumen.
stage IIB) with malignant cells in ascites or
Tumors with identical histologic features are found in the peritoneal washings.
endometrium, cervix, and vagina, the latter two often associated
Stage III ovarian tumors involving 1 or both ovaries with
with intrauterine diethylstilbestrol exposure
cancer microscopically confirmed peritoneal implants
They occur primarily in women 40 to 70 years of age and are
outside the pelvis.
highly aggressive.
Superficial liver metastasis equals stage III.
Dysgerminomas
Stage 3A microscopic peritoneal metastasis beyond pelvis
Dysgerminomas are the most common type of malignant germ
(no macroscopic tumor).
cell tumors.
Stage 3B macroscopic peritoneal metastasis beyond pelvis
The tumor can be discovered during pregnancy. Some arise in
less than 2 cm in greatest dimension
dysgenetic gonads
Stage 3C peritoneal metastasis beyond pelvis greater than 2
Granulosa-Theca Cell Tumors cm in greatest dimension and/or regional lymph
Incidence node metastasis
consist primarily of granulosa cells and a varying proportion of Stage IV ovarian tumors involving 1 or both ovaries with distant
theca cells or fibroblasts or both cancer metastasis. Parenchymal liver metastasis equals
One characteristic microscopic pattern is which demonstrates the stage IV
so-called Call Exner Bodies, eosino-philic bodies surrounded by
granulosa cells General Rule
Functional granulosa cell tumors are primarily estrogenic Benign ovarian over 10 cm in diameter must be removed, but
For women who have completed childbearing, abdominal clinical and ultrasonically diagnosed cysts under 10 cm (the size of
hysterectomy and bilateral salpingo-oophorectomy are a lemon) in women under 35 years may be reviewed in a few
recommended. months if there is no suspicion of malignancy.
A follicular or luteral cyst may resolve spontaneously.
Androblastoma
tumors are very rare General Principle
Sertoli (sex cord) and Leydig (stromal) cells are present in varying Ovarian carcinoma is staged surgically, so laparotomy is an
amounts,and the tumor may consist almost entirely of either essential part of management for most patients.
Sertoli or Leydig cells
These tumors tend to occur in young women of reproductive age GENERAL GUIDELINES:
and frequently are the cause of masculinization and hirsutism. Standard treatment is surgery (staging and optimal debulking)
followed by adjuvant chemotherapy in most cases.
OVARIAN CANCER Stage I
Screening and Early Detection Tools Generally a total abdominal hysterectomy, removal of both
Periodic pelvic examination ovaries and fallopian tubes, omentectomy, biopsy of lymph nodes
Sonography and other tissues in the pelvis and abdomen is done.
Biomarkers (eg CA125) Young women whose disease is confined to one ovary are often
Conclusion: there is no evidence available yet that the treated by a unilateral salpingo-oophorectomy without a
current screening modalities can be used effectively hysterectomy and removal of the opposite ovary being performed
for widespread screening for ovarian cancer Depending on the pathologist's interpretation of the tissue
removed, there may be no further treatment if the cancer is low
grade, or if the tumor is high grade the patient may receive No primary malignancy uncovered – wide excision of the affected
combination chemotherapy. area
Stage II
Treatment is almost always hysterectomy and bilateral salpingo- Carcinoma in Situ (VIN III)
oophorectomy as well as debulking of as much of the tumor as Irritation and itching- common
possible and sampling of lymph nodes and other tissues in the Full thickness - abnormal
pelvis and abdomen that are suspected of harboring cancer.
Prevention
Diet: a high-fat diet may play a role in the etiology of ovarian
cancer.
Oral contraceptives appear to reduce the risk of ovarian cancer
for up to 10 years following cessation of use.
Patients who have used fertility drugs should be counselled as to
their possible increase in risk of ovarian cancer.
Full
CARCINOMA OF THE VULVA AND VAGINA Thickness
VULVAR CARCINOMA
5% of malignancies of the lower genital tract
Premalignant and malignant lesions grow on multifocal areas Colposcopy
Biphasic age distribution
Most in their 60-70s magnification of the colposcope may be used to help follow
Itchiness patients with VIN as well as to identify the discrete whitish or
Drain: inguinal/pelvic nodes/femoral nodes pigmented areas that warrant biopsy
2cm lateral to midline of vulva-ipsilateral spread!
Vulvectomy done in the past (but not in the present)
Many lesions of intraepithelial neoplasia of the vulva tend to be
VULVAR ATYPIA posterior, predominantly in the perineal area
Lichen Sclerosus VULVAR CARCINOMA: FIGO 2008
60-70s Stage I Tumor confined to the vulva
Thinned out skin, smooth Stage 1A Lesions ≤2 cm in size,
Chronic itching confined to the vulva or perineum and with
markedly thinned with a loss or blunting of the rete ridges stromal invasion ≤1.0 mm⁎,
no nodal metastasis
Lichen Sclerosus Stage 1B Lesions N2 cm in size or with stromal invasion N1.0
mm⁎,
confined to the vulva or perineum,
with negative nodes
Stage II Tumor of any size with extension to adjacent
perineal structures (1/3 lower urethra, 1/3 lower
vagina, anus)
with negative nodes
Stage III of any size with or without extension to adjacent
Tumor perineal structures (1/3 lower urethra, 1/3 lower
vagina, anus) with positive inguino-femoral lymph
nodes
Paget’s Disease Stage 3A (i) With 1 lymph node metastasis (≥5 mm), or
(ii) 1–2 lymph node metastasis(es) (b5 mm)
Stage 3B (i) With 2 or more lymph node metastases (≥5 mm),
or
(ii) 3 or more lymph node metastases (b5 mm)
Stage 3C With positive nodes with extracapsular spread
Stage IV Tumor invades other regional (2/3 upper urethra,
2/3 uppervagina), or distant structures
Stage 4A Tumor invades any of the following:
(i) upper urethral and/or vaginal mucosa, bladder
mucosa rectal mucosa, or fixed to pelvic bone, or
(ii) fixed or ulcerated inguino-femoral lymph nodes
Stage 2 Tumor extends beyond the cervix but has not b) Internal Radiotherapy/Brachytherapy
extended onto the pelvic wall. The carcinoma Brachytherapy involves the temporary placement of
involves the vagina, but not as far as the lower intrauterine tandem and intravaginal ovoid that are
third. afterloaded with radioactive material.
Stage 2A No obvious parametrial involvement. is associated with the most severe and difficult to
Involvement of up to the upper two-thirds of manage complications, notably pelvic fistulas.
the vagina.
Stage 2B Obvious parametrial involvement, but not onto CERVICAL CANCER IN PREGNANCY
the pelvic sidewall. The diagnosis of invasive carcinoma of the cervix during
pregnancy is managed in much the same fashion as the non-
pregnant patient. In pregnancy, the treatment method depends
on the patient’s wishes with respect to pregnancy continuation.
If fetal viability has not been achieved and the lesion is Stage I or
IIA, treatment may be with radical hysterectomy and pelvic
lymphadenectomy with the fetus left within the uterus.
If close to fetal maturity, if after discussion with the patient, the
patient wishes to continue with the pregnancy, then cesarean
radical hysterectomy and bilateral pelvic lymphadenectomy is the
treatment of choice for early lesions. More advanced disease is Lead to pseudomyxoma peritonei
generally treated with radiotherapy. o Adenofibroma
epithelial component may be serous, mucinous,
clear-cell, or endometrioid
Neoplastic diseases of the ovary have fibrous component
o Brenner tumor
A. EPITHELIAL STROMAL TUMORS rare and often incidental findings
o 2/3 of ovarian neoplasms occur in women in their 40s and 50s
o Serous tumors: MC ovarian epithelian tumor almost always benign
o Mucinous tumors: epithelial cells filled with mucin oophorectomy
o Endometrioid tumors: epithelial cells resembling the
endometrium b. Intermediate
o Clear cell tumors: cells with abundant glycogen and hobnail o Occur in women 30-50
cells o BRCA1 highly expressed in ovarian borderline carcinoma
o Brenner tumors: resemble transitional epithelium of the o Excellent prognosis
bladder and walthard nests if the ovary o do not invade the stroma of the ovary
o UTZ o occur in young women during the reproductive years
define criteria to allow conservative follow-up and the o Mucinous Borderline: excellent prognosis
risk of malignancy of some adnexal masses widespread growth of mucin-producing cells in the
addition of a CA 125 serum assay to their ultrasound peritoneum (pseudomyxoma peritonei).
criteria in postmenopausal women increased the o Treatment:
accuracy of preoperative evaluation Unilateral oophorectomy, if:
malignancy rates were 8% for multilocular cysts, 65% tumor is confirmed to be at stage IA
for multilocular solid tumors, and 39% for solid ovarian histologic sampling of the tumor confirms it to be a
masses borderline tumor
unilocular cysts smaller than 10 cm in diameter are contralateral ovary appears normal
rarely malignant biopsy specimens of areas of omental or peritoneal
nodularity are negative
o Socring systems for malignancy of peritoneal cytologic tests are negative for tumor
Is the finding a simple (unilocular) or complex cells
(multicystic/multilocular with solid components) cyst? Radiation and chemotherapy
Are there papillary projections?
Are the cystic walls and/or septa regular and smooth? c. Malignant
What is the echogenicity (tissue characterization)? o Women older than 40
o Ovarian carcinomas are usually diagnosed by detection of
o Transvaginal color Doppler an adnexal mass on pelvic or abdominal examination
resistance index: measures resistance to flow in the o serous carcinomas:
vessels, low in malignant tumors MC invasive epithelial CA
o Borderline and Stage I: larger, contained more papillary worst prognosis
projections, and more often were multilocular without o transitional cell carcinoma: rare but chemosensitive
solid components but were less often purely solid and less o Endometrioid: endometrial CA
likely to be associated with ascites o diagnosis is made from radiographic survey executed for
evaluation of nonspecific gastrointestinal symptoms
o Ovarian Cancer Screening o infiltrate the peritoneal surfaces of both the parietal and
Physical exam: least sensitive intestinal areas
Biomarkers
o CA 125
UTZ DYSGERMINOMA
o most common type of malignant germ cell tumors
a. Benign o consist of primitive germ cells with stroma infiltrated by
o Occur mostly in the reproductive years lymphocytes
o Age and menstrual status should be considered in o analogous to seminoma in the male testis
evaluating an ovarian mass o occur primarily in women younger than the age of 30
o Those taking OCP’s should be monitored carefully o can be discovered during pregnancy
o Unilocular 5-8 cm cysts are likely to be functional o Some arise in dysgenetic gonads
o Multilocular or partly solid more likely neoplastic o bilateral in approximately 10% of cases
o CA 125: expressed by approximately 80% of ovarian o 15% of dysgerminomas produce human chorionic
epithelial carcinomas gonadotropin
o Increased in endometrial and tubal carcinoma (>35
U/ml) SEX CORD STROMAL TUMORS
o increased in 22% of cases of benign masses o Derived fromsex cords of the ovary and the specialized stroma
o Benign conditions where CA 125 is elevated of the developing gonad
Endometriosis o elements can have a male or female differentiation
Peritoneal inflammation, PID o can be hormonally active
Leiomyoma o sex cord component is the granulosa cell, and the stromal
Preagnancy component is the theca cell or fibroblast (female)
Hemorrhagic ovarian cyst o Sertoli cell and the Leydig cell (male)
Liver disease
o Most are asymptomatic a. Granulosa Theca Cell Tumor
o Mucinous tumors: >30 cm o consist primarily of granulosa cells and a varying proportion
Can perforate and rupture of theca cells or fibroblasts or both
o Call Exner bodies o poorly differentiated: poor prognosis, metastasis
eosino-philic bodies surrounded by granulosa cells o Treatment
o Functional granulosa cell tumors are primarily estrogenic Surgery: excision
o 5% occur before puberty Adjuvant chemotherapy
Can cause precocious puberty symptoms of virilization usually regress after tumor
o Iproduce increased levels of blood estrogens, uterine removal, but temporal hair recession and a deeper voice
bleeding, and occasionally endometrial carcinomas in tend to remain.
postmenopausal women
o functional granulosa cell tumor can produce abnormal
menstrual patterns, menorrhagia, and even amenorrhea. Most patients with malignant ovarian germ cell tumors can be treated
o can become large and may present as a ruptured mass, successfully with fertility-sparing surgery followed by BEP chemotherapy.
leading to laparotomy for an acute abdomen with
Patients who clearly do not require postoperative chemotherapy include
hemoperitoneum
o 90 % present as stage I those with stage IA dysgerminoma and stage IA grade 1 immature teratoma.
o Advance clinical tage present with tumor rupture, a large However, there is a trend toward the study of surveillance rather than
primary tumor (>15 cm), and a high mitotic rate chemotherapy for patients with stage I tumors of any histologic subtype
o granulosa cell tumors can be confused histologically with
poorly differentiated adenocarcinomas MODULE 6
o Juvenile granulose cell tumor (found in females younger
than 20) PRE-MALIGNANT AND MALIGNANT DISEASES OF THE ENDOMETRIUM
o Treatment
Surgical removal
ENDOMETRIAL HYPERPLASIA
unilateral adnexectomy or salphingo-oophorectomy
Classification Sample Image
Unilateral salphingo-oophorectomy have high
Simple Hyperplasia
reccurence rate—close follow-up
For women who have completed childbearing,
abdominal hysterectomy and bilateral salpingo-
oophorectomy are recommended
Radiotherapy
VAC regimen
Combination of ciplastin, doxorubicin and
syclophosphamide for metastatic tumors
Patients with stage II-IV and those with recurrent Complex Hyperplasia
tumors should undergo post op therapy
Hormone Therapy for metastatic tumors
medroxyprogesterone acetate
gonadotropin-releasing hormone antagonists
Thecoma
o benign tumors that consist entirely of stroma (theca) cells Atypical Hyperplasia
o occur in women in the perimenopausal and menopausal
years
o can be associated with estrogen production
o Treatment
Removal of the tumor for women in the reproductive
years
total abdominal hysterectomy and bilateral salpingo-
oophorectomy for older women
WHO Classifications of Endometrial Hyperplasia
Fibroma 1. Simple Hyperplasia
o most common benign solid ovarian tumor defines an endometrium with dilated glands that may
o can occur at any age but is more common in older contain some outpouching and abundant endometrial
women stroma
o does not secrete hormones Glands cystically dilated and focal crowding
o contain spindle cells and can grow to a large size Lined by psuedostratified tall columnar epithelium
o excision is adequate treatment Glands separated by abundant cellular stroma
o associated with ascites in approximately 40% of cases if term cystic hyperplasia has been used to describe
the tumor exceeds 10 cm dilation of the endometrial glands, which often occurs
o Meigs’ Syndrome: hydrothorax and benign ascites which in a hyperplastic endometrium in a menopausal or
regresses following tumor removal postmenopausal woman (cystic atrophy). It is
considered to be weakly premalignant.
c. Sertoli-Leydig Cell Tumors (Androblastoma) 2. Complex Hyperplasia (without atypia)
o Rare this condition, glands are crowded with very little
o consist almost entirely of either Sertoli or Leydig cells endo-metrial stroma and a very complex gland pattern
o occur in young women of reproductive age and outpouching formations
o frequently cause masculinization and hirsutism This is a variant of adenomatous hyperplasia with
o also to have estrogenic activity moderate to severe degrees of architectural atypia but
o behave as low-grade malignancies with no cytologic atypia.
o well differentiated: benign 3. Atypical Complex Hyperplasia
refers to hyperplasias that contain glands with
cytologic atypia and are considered premalignant
an increase in the nuclear/cytoplasmic ratio with
irregularity in the size and shape of the nuclei
Cytologic atypia occurs primarily with complex
hyperplasia, and simple hyperplasia with atypia is
rarely seen.
Has the greatest malignant potential.
Crowding of glands with disparity in their size and
irregularity in their shape.
Budding with fingerlike outpouching in the adjacent
endometrial stroma
4. Atypical Simple Hyperplasia
**wulei sa trans/ppt to
Simple hyperplasia - 1% rate of progression to cancer
Complex hyperplasia without atypia - 3% rate of progression to cancer
Complex atypical hyperplasia had a 29% rate of progression to cancer.
c
Schematic Diagram of Endometrial Management for Reproductive Patients
c c
c FIGO STAGING
Stage I: The tumor is confined to the body of the uterus.
Stage IA: The tumor is limited to the endometrium
Stage IB: The tumor invades less than ½ of the myometrium
Stage IC: The tumor invades more than 1/2 of the myometrium
Stage II: The tumor extends to the cervix (the lower part of the uterus).
Stage IIA: Cervical extension is limited to the endocervical glands
Stage IIB: Tumor invades the cervical stroma
Stage III: There is regional tumor spread.
IIIA:The tumor invades the uterine serosa or adnexa or both, or
(+) peritoneal cytology , or both
IIIB:Vaginal metastases
c IIIC:Metastases to pelvic or para-aortic lymph nodes , or both
Stage IV: There is bulky pelvic disease or distant spread.
IVA: Tumor has spread to the bladder or bowel mucosa , or both.
IVB:Distant metastases are present.
Histologic Grade DOES NOT change the Stage (from book and ppt)
c Grade 1 : Well differentiated: <6% solid components
Grade 2 : Moderately differentiated: 6-50% solid components
Grade 3 : Poorly differentiated: >50% solid components
Pathologic Features
75% of Endometrial Ca are pure ADENOCARCINOMAS
Less often types but carries a worse prognosis : CLEAR CELL ,
SQUAMOUS , SEROUS CA
Adenocarcinoma
ENDOMETRIAL CARCINOMA
Risk Factors:
• Diminishes the Risk
Ovulation
Progestin therapy Clear Cell Carcinoma
Combination oral contraceptives
Menopause prior to 49 years
Normal weight
Multiparity
Pattern of Spread
Most common : Direct extension of tumor to the adjacent
structures
Exfoliated cells may pass through the FT and implant on the • Fleshy outgrowth, soft, smooth, friable, red
ovaries , visceral or parietal peritoneum or the omentum • Postmenopausal
Lymphatic spread : common in pxs with deep myometrial
• Caused by: Chronic irritation or infection
involvement
•
Pelvic lymph nodes
Para-aortic lymph nodes • URETHRAL CARCINOMA: SCC
o Elderly
Hematogenous route : uncommon; may result in parenchymal
metastases (lungs , liver, or both) • Biopsy: if benign, oral/topical estrogen
• Surgical management: cryoTx, laser tx, excision
Clear Cell Carcinoma NOTES:
Resemble clear cell adenocarcinoma of the ovary, cervix and vagina -when you see this mass, differentiate benign from malignant
Tend to develop in postmenopausal women - oral and topical applied twice a day-> regress
Prognosis much worse than typical endometrial adenocarcinoma
FIBROMA
Survival rates of 39% - 55% have been reported, much less the 65% or
better usually recorded for endometrial carcinoma
Prognostic Factors
I. Clinical determinants:
patient age at diagnosis: older > young
race: white > black
clinical tumor stage
UTERUS
ENDOMETRIAL POLYPS (etiology: Unopposed estrogen)
Clinical Manifestation:
Most common symptoms:
• pressure from an enlarging mass
• pain including dysmenorrheal
• acquired dysmenorrheal is one of the most frequent complaints
• Origin:
• abnormal bleeding-
o each tumor develops from a single muscle cell a progenitor
o 30% of patients with myomas
myocyte- may undergo somatic mutation
o Most common is menorrhagia
o Cytogenetic analysis demonstrated that myomas have
o Intermenstrual spotting and disruption of normal
multiple chromosomal
pattern-frequent complaints
o abnormalities affecting regulation of growth inducing
o Exact cause is poorly understood
proteins and cytokines
• severity of symptoms depend on the number, location, and size of
• Current theory:
the myoma
- neoplastic transformation from normal myometrium to
• 2/3 are asymptomatic
leiomyomata is the result of a somatic mutation in the single
• Pelvic pain
progenitor cell affecting cytokines that affect cell growth. The
• Pelvic discomfort- described as pelvic heaviness or a dull, aching
growth may be influenced by estrogen and progesterone levels
sensation, that may be secondary to an edematous swelling in the
- Guidelines- can be treated with OCP (estrogen and progesterone
myoma
can decrease size), but do not give Progesterone only pill/
• Abdominal girth increasing without appreciable change in weight
injectables
• Anterior myoma pressing on the bladder- urinary frequency and
Clinical Characteristics:
urgency
• rare before menarche, diminish in size after menopause with the
• rapid growth after menopause -consider leiomyosarcoma- classic
reduction of a significant amount of circulating estrogen
symptom
• enlarges during pregnancy and occasionally during OCP use
o very uncommon
• Medically induced hypoestrogenic states decreases myoma size
o like term pregnancy
• Women who smoke cigarettes- relatively estrogen deficient- lower
o must have total abdominal hysterectomy
incidence of myomas
Diagnosis:
Gross Appearance
• lighter in color than the normal myometrium • PE – internal examination, palpation of an enlarged, firm, irregular
• cut surface: glistening, pearl white with smooth muscle arranged in uterus, asymmetrically enlarged
trabeculated or whorl configuration -other differentials:
Histologic Appearance: pregnancy
- with proliferation of mature smooth muscle cells adenomyosis
- nonstriated muscle fibers are arranged in interlacing bundles with ovarian neoplasm
variable amount of fibrous connective tissue in between - mobility of the pelvic mass and whether the mass moves
- amount of fibrous tissue proportional to extent of atrophy and independently or as part of the uterus may be helpful
degeneration diagnostically
• Utrasound- diagnostic, whorled
• Hysteroscopy
• CT Scan or MRI- MRI is helpful in differentiating adenomyosis or
an adenomyoma from a single, solitary myoma, especially in a
woman desiring preservation of her fertility
Management:
• Observation – for small, may be multiple but still asymptomatic,
tumor first discovered
o appropriate to perform a pelvic examination, serial UTZ at 6-
12 month intervals to determine the rate of growth
Majority of women will not need an operation, especially Vaginally
perimenopausal- condition improves with diminishing estrogen levels. - Hysterectomy
Cases of abnormal uterine bleeding and leiomyomas should be o >90% patient satisfaction
investigated thoroughly for concurrent problems such as endometrial o Higher rate of Urinary tract injuries (abdominal
hyperplasia, if symptoms do not improve with conservative hysterectomy)
management, operative management may be considered o E.g Late 50’s
• Medical o Indications:
- Causing symptoms Same as myomectomy
- medical treatment majority of the reduction in size occurs Asymptomatic myomas that has reached
within the first 3 months the size of a 14 to 16 week gestation
- GnRH agonist – danazol Rapid growth
o Block production of estrogen - Prolapse of a myoma through the cervixs is optimally treated with
o Hypoestrogenic state vaginal removal and ligation of the base of the myoma
o May reduce blood loss at the time of hysterectomy and - choice between myomectomy and hysterectomy depends on the
myomectomy patient’s age, parity, and MOST IMPORTANT, future reproductive
- Medroxyprogesterone acetate – RU 486 plans
o Significant reduction in soze, bleeding and
improvement of quality of life Uterine Artery Embolization
Advantages and Disadvantages of Preoperative GnRH Agonist • Gelatin sponge (gelfoam) silicon spheres (multiple embolic materials)
Treatment (read daw) • Polyvinyl alcohol (PVA) particles
Advantages: • Metal coils
May allow vaginal hysterectomy • Gelatin microspheres
May decrease intraoperative blood loss
May allow Pfannenstiel incision *Complication of Uterine Artery Embolization
May facilitate endoscopic myomectomy • Post embolization fever
Advantages gained by induction of Amenorrhea: • Sepsis from infarction of the necrotic myometrium
May correct hypermenorrhea–menorrhagia-associated anemia • Ovarian failure
May improve ability to donate blood • Abdominal pain- postprocedural, common, in the first 24 hours up
May decrease need for nonautologous blood transfusion to 2 weeks
May atrophy endometrium, facilitating hysteroscopic resection of •
submucosal tumors Associated Rare Disease:
Disadvantages: • Intravenous Leiomyomatosis
Delay to final tissue diagnosis o benign smooth muscle fibers invade and slowly grow
Degeneration of some leiomyomas, necessitating piecemeal into the venous channels of the pelvis
enucleation at o grossly appears like a “spaghetti” tumor
myomectomy • Leiomyomatosis peritonealis dessiminata (LPD)
Hypoestrogenic side effects (e.g., trabecular bone loss, vasomotor o benign multiple small nodules over the surface of the
flushes) pelvis and abdominal peritoneum
Cost o usually associated with recent pregnancy
Need to self-administer or receive injections in many cases o management: progestational therapy
Vaginal hemorrhage in approximately 2% of patients
GnRH, gonadotropin-releasing hormone. ADENOMYOSIS
fdiJrrsFFeeoooagnnAUmm:ldhiitrrrseeooooaagnnnpm- • Often been referred to as endometriosis interna
• Operative: • Term is misleading because endometriosis and
-failed medical management, too large myomas • adeno-myosis arediscovered in the same patient in less than 20%
- Myomectomy of women.
o Longer hospital stays • only common feature is the presence of ectopic endometrial
o Reproductive years glands and stroma in the endometrium
o More pelvic adhesions • Adenomyosis is derived from:
o 80% resolution of symptoms -aberrant glands of the basalis layer of the endometrium
o CS is recommended for all degrees of myomectomy -glands do not usually undergo the traditional proliferative and
other than removal of pedunculated leiomyomata, or secretory changes that are associated with cyclic ovarian hormone
small hyteroscopic resection production. (not responsive to hormonal stimulation)
o Indications for myomectomy: • The symptoms of menorrhagia and dysmenorrhea form a
Persistent abnormal bleeding, pain or spectrum and are subjective, thus delineating an incidence of
pressure associated symptomatology with adenomyosis is problematic.
Enlargement of asymptomatic myoma to • Diagnosed incidentally by the pathologist examining histologic
more than 8 cm in a woman who has not sections of surgical specimens
completed childbearing
• a common incidental finding during autopsy
o Contraindications:
Disease is associated with:
Pregnancy
• increased parity
Advanced adnexal disease
• particularly uterine surgeries and traumas
Malignancy
• higher rates of induced abortion with presumed curettage with
Situation in which enucleation of the
adenomyosis
myoma would severely reduce the
• Pathogenesis of adenomyosis is unknown but is theorized to be associated
endometrial surfaceso that the uterus
with disruption of the barrier between the endometrium and myometrium as
would not be functional
an initiating step
o Myomectomy maybe performed through:
Pathology:
Laparosopy
• Two distinct Pathologic presentations:
Hysteroscopy
o Focal area or adenomyoma- do not confuse with myoma
Laparotomy
uteri.
Results in asymmetrical uterus • acquired dysmenorrhea becomes increasingly more severe as the
No pseudocapsule- cannot remove mass disease progresses.
o Most common is a diffuse involvement of both anterior and • Occasionally the patient complains of dyspareunia, which is
posterior walls, posterior wall is usually involved more than midline in location and deep in the pelvis.
the anterior wall. Pelvic examination:
Usually show symptoms such as severe and • Uterus is diffusely enlarged, usually two to three times normal
progressing pelvic pain during menses and size.
menorrhagia(AUB) • It is most unusual for the uterine enlargement associated with
Palpate the uterus- globular, symmetric adenomyosis to be greater than a 14-week-size gestation unless
enlargement and tender the patient also has uterine myomas.
Found in 2/3 of cases • The uterus is globular and tender immediately before and during
Diffuse type of adenomyosis the uterus is menstruation
uniformly enlarged, usually two to three times Diagnosis
normal size. • adenomyosis is usually confirmed following histologic examination
often difficult to distinguish on physical of the hysterectomy specimen.
examination from uterine leiomyomas. • Traditionally the patient will have endometrial sampling to rule
Gross: out other organic causes of abnormal bleeding.
• Adenomyosis may coexist with both endometrial hyperplasia and
endometrial carcinoma
• Approximately2/3 women with adenomyosis have coexistent
pelvic pathology, most commonly myomas but also
endometriosis, endometrial hyperplasia and salpingitis nodosa.
• When the myometrium is transected by a knife, the cut surface • Ultrasound and MRI are useful to help differentiate between
protrudes convexly and has a spongy appearance adenomyosis and uterine myomas in a young woman desiring
• cut surface of a uterus with adenomyosis is darker than the white future childbearing.
surface of a myoma • T2-weighted images are superior in making the diagnosis and
• Sometimes there are discrete areas of adenomyosis that are not documenting widened junctional zones.
densely encapsulated and contain small, dark cystic spaces. o Poorly defined junctional zones markings in the
• There is not a distinct cleavage plane around focal adenomyomas as endometrial-myometrial interface help confirm the
there is with uterine myomas diagnosus
o These bands most likely represent the glands and
Histologic examination: hypertrophied muscle of adenomyosis.
• MRI is used fro those who may choose uterine artery
embolization for treatment of myomata.
Management:
• There is no satisfactory proven medical treatment for
adenomyosis
• patients with adenomyosis are treated with GnRH agonists,
progestogens, progesterone containing IUD, cyclic hormones, or
• benign endometrial glands, and stroma are within the prostaglandin synthetase inhibitors for their abnormal bleeding
myometrium. and pain.
• glands rarely undergo the same cyclic changes as the normal • Hysterectomy is the definitive treatment if this therapy is
uterine endometrium. appropriate for the woman's age, parity, and plans for future
• standard criterion used in diagnosis of adenomyosis is the finding reproduction.
of endometrial glands and stroma more than one low-powered • Size of the uterus, degree of prolapse, and presence of associated
field (2.5 mm)n from the basalis layer of the endometrium. pelvic pathology determine the choice of surgical approach.
• small areas of adenomyosis have the same general appearance as • Women in their late 40’s- ovaries, menopausal are often removed
the basalis layers of the endometrium general there is a lack of as a risk reducing measure against ovarian carcinoma
inflammatory cells surrounding the fossae of adenomyosis. • Increased risk for complications for those who are pregnant with
• Some fossae of adenomyosis undergo decidual changes either adenomyosis
during pregnancy or during estrogen–progestin therapy for o Increased premature labor and dlivery
endometriosis. o Low BW
• The reaction of the myometrium to the ectopic endometrium: o Preterm PROM
o Hyperplasia
o hypertrophy of individual muscle fibers PARATUBAL CYST
• Surrounding most foci of glands and stroma are localized areas of • Frequently incidental
hyperplasia of the smooth muscle of the uterus. • Often multiple, vary from 0.5 to >20 cm in diameter
• change in the myometrium produces the globular enlargement of • Most cysts are small, asymptomatic, and slow growing, discovered
the uterus on the 3rd-4th decade of life
Clinical Diagnosis: • May rupture, on examination or vigorous coitus
• Over 50% of women with adenomyosis are asymptomatic or have • Pedunculated Paratubal cysts- near the fimbrial end, they are
minor symptoms called Hydatid cysts of Morgagni
• attribute the increase in dysmenorrhea or menstrual bleeding to • Cysts near the oviduct may be of mesonephric, mesothelial, or
the aging process and tolerate the symptoms. paramesonephric in origin.
• Symptomatic adenomyosis usually presents in women between • Cysts are translucent, and contain clear or pale yellow fluid
the ages of 35 and 50.
• severity of pelvic symptoms increases proportionally to the depth
of penetration and the total volume of disease in the myometrium.
• classic symptoms of adenomyosis:
o secondary dysmenorrhea
o menorrhagia.
o associated with nausea and vomiting in two thirds of
the cases.
o pelvic pain, secondary to hypoxia, is so intense-
difficult to perform an adequate pelvic exam.
• histogenesis of the majority of paratubal cysts had been believed • Twisted mass or paratubal cyst
to be from the mesonephric duct, with the cysts arising from the • SIZE matters- bigger- torsion
main duct or accessory tubules. • Unless there is associated torsion of the ovary, a specific mass is
o These latter cysts often develop between the leaves of usually not palpable on pelvic examination.
the broad ligament in the mesosalpinx, with the ovary • number of cases diagnosed preoperatively
being separate. • has increased dramatically with the use of vaginal
• Occasionally there is a papillomatous proliferation on the internal ultrasonography
wall • Because of the severity of the pain, a wide differential diagnosis of
• Low grade malignant cysts- were in women of reproductive age abdominal and pelvic pathology must be considered.
who had cysts greater than 5 cm in diameter with internal • The differential diagnosis includes :
papillary projections o acute appendicitis
• Inflammatory cysts of the peritoneum may be found anywhere in o ectopic pregnancy
the pelvis. o pelvic inflammatory disease
• majority of paratubal cysts are asymptomatic and are usually o rupture or torsion of an ovarian cyst.
discovered incidentally during ultrasound or during gynecologic • Exploratory operation determines the extent of hypoxia and the
operations. choice ofoperative techniques.
• symptomatic paratubal cysts- generally produce a dull pain. • EMERGENCY case
• During a pelvic examination it is difficult to distinguish a paratubal • tubal torsion- usually the tubes are gangrenous (eg. In delayed
cyst from an ovarian mass. management) and must be excised.
• Do not assume that it benign,(paratubal cysts) specially in the • The twisted tube is usually filled with a bloody or serous fluid
elderly, as much as possible do not aspirate- spilling of cancer cells • may be possible to restore normal circulation to the tube by
• practice of aspirating cysts via the laparoscope should be limited manually untwisting it.
to cysts that are completely simple and associated with normal • The tube is usually sutured into a secure position to prevent
cancer antigen-125 (CA-125) levels recurrence
• Paratubal cysts may grow rapidly during pregnancy, and most of
the cases of torsion of these cysts have been reported during Ovary
pregnancy or the puerperium. FOLLICULAR CORPUS LUTEUM THECA LUTEIN CYSTS
• Menopausal-hysterectomy CYSTS CYSTS
• Treatment is simple excision. Most frequent Most clinically Least common
relevant
TORSION Dependent on >3cm Bilateral, moderate
• Acute torsion of the oviduct is a rare event; however, it has been gonadotropins for to massive
reported with both normal and pathologic fallopian tubes. growth enlargement
• Pregnancy Predisposes to this problem. Prolonged
• Tubal torsion usually accompanies torsion of the ovary- they have exposure/inc
a common vascular pedicle. sensitivity to
• Torsion of the fallopian tube is secondary to an ovarian mass in gonadotropins
approximately 50% to 60% of patients. Reproductive age Mature Graafian Pregnancy, ovarian
• right tube is involved more frequently than is the left follicles hyperstimulation
• degree of tubal torsion varies from less than one turn to four Asymptomatic Dull, unilateral, Pressure sxs, ascites,
complete rotations. LAb pain abdl enlargement
• Torsion is usually seen in women of reproductive age. May delay menses
• it occurs also in preadolescent children, especially when part of Intraperitoneal
the tube is enclosed in the sac of a femoral or inguinal hernia. bleeding
• Tubal torsion may be divided into intrinsic and extrinsic causes: Transparent, thin- Small, purplish- Thin-walled,
o Intrinsic: walled red/brown hemorrhagic
Congenital abnormalities- such as increased “Follicular Halban’s classic Hyperreactio
tortuosity caused by excessive length of the hematomas” triad luteinalis
tube Ovarian cortex Secretes Luteoma of
Pathologic process- hydrosalpinx, progesterone pregnancy
hematosalpinx, tubal neoplasma, previous
Observation Pregnancy test UTZ
operation- specially tubal ligation (usually at
OCPs x 4-6 weeks UTZ Regresses
the distal end)
Cystectomy Cystectomy spontaneously
o Extrinsic
**Corpus Luteum Cyst:
Ovarian, peritubal tumors
Differentials include: Ectopic pregnancy, Ruptured Endometrium, Adnexal
Adhesions
Torsion
Trauma
pregnancy
FOLLICULAR CYSTS
• The most important symptom of tubal torsion is acute lower
• By far the most frequent cystic structures in normal ovaries.
abdominal and pelvic pain.
• May be young as early as 20 weeks gestation in female fetuses and
• Pain
throughout a woman’s reproductive life
o Severe hypogastric pain
• Frequently multiple and may vary from a few millimeters to as large as
o May be gradual or sudden
15 cm in diameter.
o Located in the iliac fossa with radiation to the thigh
• A normal follicle may develop into a physiologic cyst.
and flank
• A minimum diameter to be considered as a cyst is between 2.5 and 3
o duration of pain is generally less than 48 hours
cm.
• Follicular cysts are not neoplastic and are believed to be dependent on • The majority of follicular cysts disappear spontaneously by either
gonadotropins for growth. reabsorption of the cyst fluid or silent rupture within 4 to 8 weeks of
• Clinically they may present with the signs and symptoms of ovarian initial diagnosis
enlargement -must be differentiated from a true ovarian neoplasm. • ,a persistent ovarian mass necessitates operative intervention to
• Functional cysts may be solitary or multiple. These cysts are found most differentiate a physiologic cyst from a true neoplasm of the ovary.
commonly in young, menstruating women. • Endovaginal ultrasound examination is helpful in differentiating simple
• Solitary cysts may occur during the fetal and neonatal periods and from complex cysts and is also helpful during conservative management
rarely during by providing dimensions to determine if the cyst is increasing in size.
• childhood, but there is an increase in frequency during the • When the diameter of the cyst remains stable for greater than 10
perimenarcheal period weeks or enlarges- neoplasia should be ruled out.
• CA-125 may be used to evaluate large cysts in pregnancy, values for CA- • Oral contraceptives may be prescribed for 4 to 6 weeks for young
125 should be within the normal range past 12 weeks' gestation women with adnexal masses
• Multiple follicular cysts in which the lining is luteinized are associated - This therapy removes any influence that pituitary gonadotropins
with either intrinsic or extrinsic elevated levels of gonadotropins. may have on the persistence of the ovarian cyst
• Reproductive-age women with cystic fibrosis appear to have an • Evaluation of an asymptomatic cyst, found incidentally, is based on the
increased propensity for developing individual follicular cysts. principle that the cyst should be removed if there is any suspicion of
• Follicular cysts are translucent, thin-walled, and are filled with a watery, malignancy.
clear to straw-colored fluid. • Suspicion may develop because of history, including family history,
• If a small opening in the capsule of the cyst suddenly develops-cyst fluid patient age, and other nongynecologic signs and symptoms.
under pressure will squirt out. • The size and physical characteristics of the cyst are as important as are
• These cysts are situated in the ovarian cortex- sometimes they appear other laboratory parameters.
as translucent domes on the surface of the ovary. • CA-125 is helpful in evaluating the adenexal mass in postmenopausal
• Histologically the lining of the cyst is usually composed of a closely women.
packedlayer of round, plump granulosa cells, with the spindle-shaped - In general, complex cyst or persistent simple cysts larger than 10
cells of the cm should be evaluated
• Theca interna deeper in the stroma. • Cyst in a perimenopausal or postmenopausal woman should be
• Temporary disturbance in follicular function that produces the clinical removed if the CA-125 is abnormal (>35), or if the cyst is persistent or
picture of a follicular cyst is poorly understood. large (>10 cm).
• Follicular cysts may result from: • A small simple cyst in a perimenopausal or postmenopausal woman (<5
o either the dominant mature follicle's failing to rupture cm) with a normal CA-125 may be observed with regular reevaluation
(persistent follicle) including ultrasound
o immature follicle's failing to undergo the normal process of • Management of cysts between 5 and 10 cm that are otherwise not
atresia. suggestive should be individualized.
o Incompletely developed follicle fails to reabsorb follicular • premenopausal women, operative management of nonmalignant cysts
fluid is cystectomy, not oophorectomy
• Some follicular cysts lose their ability to produce estrogen, and in • Many clinicians will manage simple cysts with the laparoscope- Since
others the granulosa cells remain productive, with prolonged secretion this procedure has an accompanying risk of spilling malignant cells into
of the peritoneal cavity if the cyst is an early carcinoma, strict
• Estrogens preoperative criteria should be fulfilled before laparoscopy is
• Follicular Hematomas- blood from the vascular theca zone fills the attempted.
cavity of the cyst • Criteria: include the woman's age; size of the mass; and ultrasound
characteristics, such as nonadherent, smooth, and thin-walled cysts,
Diagnosis: without papillae or internal echoes. (simple).
• majority of follicular cysts are asymptomatic and are discovered during
ultrasound imaging of the pelvis or a routine pelvic examination
• Ultrasound cannot distinguish between benign or malignant BENIGN NEOPLASMS OF THE OVARY
• May correlate with malignancy:
o Septations **Benign Cystic Teratoma –Doughy consistency upon palpation;
o Internal papillations Histologically composed of mature cells, usually from all three germ layers;
o Loculations Treatment of a dermoid in pregnancy, as is nonpregnant state, is
o Solid lesions/ cystic lesions with solid components cystectiomy.
o Smaller cyst adjacent to or part of a larger cyst-daughter cyst
• Because of their thin walls, these cysts may rupture during ENDOMETRIOMAS
examination. • 2/3 of women with endometriosis have ovarian involvement
• The patient may experience tenesmus, a transient pelvic tenderness, • One of the most common cause of enlargement of the ovary
deep dyspareunia, or no pain whatsoever • Varies from small, superficial, blue black implants 1-5mm in diameter to
• Rarely- significant intraperitoneal bleeding associated with the rupture large, multiloculated, hemorrhagic cysts 5-10 in diameter
of a follicular cyst. • Surface is often irregular, puckered and scarred
• women who are chronically anticoagulated or • Areas of ovarian endometriosis that become cystic are termed
• those with von Willebrand's disease may bleed endometriomas
• menstrual irregularities and abnormal uterine bleeding -associated with • Rare- large chocolate cyst 15-20 cm
follicular cysts- produce elevated blood estrogen levels. • Common symptoms
• consists of a regular cycle with a prolonged intermenstrual interval, o Asymptomatic-most common
followed by episodes ofmenorrhagia. o pelvic pain
• Some women with larger follicular cysts notice a vague, dull sensation o dyspareunia
or heaviness in the pelvis. o infertility
Diagnosis:
Management: • pelvic exam findings: ovaries are tender and immobile due to adhesions
• initial management of a suspected follicular cyst is conservative to surrounding structures
observation up tp 3-6 cycles- does not regress- ocp’s- still does not
regress- oopherectomy
• Ultrasonography: thick walled cyst with homogenous echogenic pattern • Histologically: connective tissue, stromal cells, and varying amount of
collagen, spindle shaped, mature fibroblast, imperfect pattern, must be
distinguished from stromal hyperplasia fibrosarcomas, and Brenner
tumors
Management:
• Straightforward, any woman with a solid ovarian neoplasm should have
an exploratory operation soon after the tumor is discovered
• surgery (TAH-BSO), oopherectomy
Management:
• operative simple excision being the procedure of choice
• as with ovarian fibromas, the patient's age often is the principal factor
in deciding the extent of the operation.
- heavy, solid, well encapsulated and grayish white
- Cut surface: homogenous white or yellowish solid tissue with
trabeculated or whorled appearance
- 50% grossly edematous
Torsion
• Torsion of the ovary may occur separately from torsion of the fallopian
tube, but most commonly the two adnexal structures are affected
together.
• An important cause of acute lower abdominal and pelvic pain
• most commonly during the reproductive years, with the average
patient being in her mid-20s.
• Adnexal torsion is also a complication of benign ovarian tumors in the
postmenopausal woman.
• Pregnancy appears to predispose women to adnexal torsion
• Most susceptible are ovaries that are enlarged secondary to ovulation
induction during early pregnancy. MATURE FIBROMA TRANSITIONAL ENDOMETRIOMA
• The most common cause of adnexal torsion is ovarian enlargement by CYSTIC CELL TUMORS
an 8- to 12-cm benign mass of the ovary. However, smaller ovaries may TERATOMA
also undergo torsion Dermoid cyst Malignant Brenner tumor Common
• Ovarian tumors are discovered in 50% to 60% of women with adnexal potential low
torsion.
• Torsion of a normal ovary or adnexum is also possible and occurs more All 3 germ cell Variable size Small Variable size
frequently in children. layers
• The right ovary has a greater tendency to twist (3 to 2) than does the Most common Slow growing Rare, unilateral Uni/bilateral
left ovary.
• Patients with adnexal torsion present with acute, severe, unilateral,
lower abdominal and pelvic pain Slow-growing Most common Low malignant Replace a portion of
• Often the patient relates the onset of the severe Uni/bilateral benign solid potential normal ovarian
pain to an abrupt change of position. tumor of ovary tissue
• These associated gastrointestinal symptoms sometimes lead to a Doughy Easily palpable Smooth, solid, Endometrial glands +
preoperative diagnosis of acute appendicitis or small intestinal consistency Pedunculated fibroepithelial stroma,
obstruction Unilocular Solid hemosiderin-laden
• Many patients have noted intermittent previous episodes of similar Sebaceous masses/nest of phagocytes
pain for several days to several weeks fluid, hair, epithelial cells
• Fever is more common in women who have developed necrosis of the teeth, cartilage + stroma
adnexa. Solid + cystic Heavy, solid, “coffee bean” UTZ: thick-walled,
• Most patients with adnexal torsion present with symptoms and signs Tubercle of well- nucleus echogenic,
severe enough to demand operative intervention Rokitansky encapsulate, echolucent
• Abnormal color Doppler flow is highly predictive of torsion of the ovary white
• The most common differential gynecologic conditions are a ruptured Thyrotoxicosis, Basal cell Endometrial Pelvic pain,
corpus luteum or an adnexal abscess. carcinoid nevus hyperplasia dyspareunia,
• Because the majority of cases of adnexal torsion occur in young women, syndrome, syndrome infertility
a conservative operation is ideal autoimmune Meig’s Densely adherent
• Conservative surgery either through the laparoscope or via laparotomy hemolytic syndrome
entails gentle untwisting of the pedicle, possibly cystectomy, and anemia
stabilization of the ovary with sutures Torsion, abdl Pressure, Asymptomatic Malignancy?
• With severe vascular compromise, the appropriate operation is pain enlargement
unilateral salpingo-oophorectomy. The vascular pedicle should be Cystectomy Oophorectomy Oophorectomy Cystectomy/TAHBSO
clamped with care so as not to injure the ureter, which may be tented
up by the torsion.
FROM COMPRE-GYNE:
MENOPAUSE:
THE MENOPAUSE • Permanent cessation of menstruation caused by failure of ovarian
follicular development and estradiol production in the presence of
elevated gonadotropin levels
• Defined by the last menstrual period
• Because cessation of menses is variable and many of the symptoms
thought to be related to menopause may occur prior to cessation of
menses, there is seldom a precise timing of this event
• AGE OF MENOPAUSE
1. General health status: (Western Countries) between 51 and 52
years
2. Socioeconomic status: associated with an earlier age of
menopause Higher parity: associated with a later menopause
3. Smoking: associated with menopause onset taking place 1 to 2
years earlier
4. Body mass: greater body mass index [BMI] with later
menopause
5. Ethnic differences: Black and Hispanic women have been found
to have menopause approximately 2 years earlier than white
women
6. Geographic Location: age of menopause appears to be
somewhat earlier outside the United States
• Malay women: age 45
• Thai women: age 49.5
• Filipina women: ages 47 and 48
• Countries at higher altitude (Himalayas or Andes): menopause 1 to
1.5 years earlier
• Average age of menopause in the United States is 51 to 53 years
CLIMACTERIC
o Refers to the time after the cessation of reproductive function
o Time after the cessation of reproductive function
Aging Ovary
• No more follicles
• No inhibin b or estradiol production
• FSH rises
• Later LH will rise
• Fewer follicles less production of inhibin b
• Pituitary is released from its supression
• FSH rises earlier and follicular development is advanced
PREMATURE OVARIAN FAILURE:
• Measure Day 3 FSH and estradiol will be high compared to
• Defined as hypergonadotropic ovarian failure occurring prior to
younger women
age 40
• Occurred in 5% to 10% of women who are evaluated for
Perimenopause
amenorrhea
• Follows period of declining fertility
• Ongoing rate of atresia of oocytes, this process is accelerated
with various forms of gonadal dysgenesis due to defective X
• Precedes menopause
chromosomes, one possible cause of POF is an increased rate • Characterized by
of atresia that has yet to be explained • Cycle irregularity (shortening then lengthening)
• A decreased germ cell endowment or an increased rate of • Increasing symptoms (*hot flushes)
germ cell destruction can also explain POF • Duration 2 to 8 years (average 4 years)
• Causes: *if the ave age of menopause is 51, the average age of start of
o Genetic perimenopause in 47
o Enzymatic
o Immune Diagnosing Perimenopause
o Gonadotropin defects • Clinical diagnosis based on menstrual cycle pattern.
o Ovarian Insults • Early follicular phase FSH and symptoms may help solidify
o idiopathic diagnosis
Management of Premature Ovarian Failure Symptoms: Highly Variable
• Evaluation of POF in women younger than 30 should include: •
o screening for autoimmune disorders and a karyotype • - physically warm bec you perspire; NOT the brain
o vaginal ultrasound may be useful for assessing the size of telling you that you are warm
the ovaries and the degree of follicular development •
• Treatment: •
o Estrogen replacement •
o If fertility is a concern: the most efficacious treatment is - Fatigue, palpitations, headache, increased migraine, breast pain
oocyte donation. and enlargement.
• Oligo-
• Heavier or irregular cycles.
Oocytes and Follicles *pagwalang corpus luteum, endometrium gets thicker, so by the time you
• menstruate, it’s heavy.
• - 6 - 7 million follicles.
• - 1.5-2 million follicles MENOPAUSE
• - 300,000- 400,000 follicles “The ovaries, after long years of service, have not the ability of retiring in
• graceful old age, but become irritated, transmit their irritation to the
• ted (<1000), menopause abdominal ganglia, which in turn transmit the irritation to the brain,
occurs. producing disturbances in the cerebral tissue exhibiting themselves in
*in a woman’s life, in the utero, that’s the time where in the woman has the extreme nervousness or in an outburst of actual insanity.”
most oocyte ((1.5-2M), paglumbas oonti na lng (hundred thousands na lng). • Marks the end of reproductive life
As the px ages the oocytes decline until the age of 37. Eggs progressive • Cessation of menses for 12 months
decline at 37 until you reach menopause, you don’t have estrogen anymore • Clinical diagnosis (not labs)
(non-functioning eggs) • Result of egg depletion and estrogen production by the ovary due
to Natural aging or surgery
*if you removed the bilateral ovaries, will you remove the uterus? The usual
practice is to remove both ovaries and uterus to avoid development of *a lot of organ system is affected but the most concern is the cardiovascular
cancer disease
*using HRT- some concern will be Breast Cancer. However, some studies
Menopause Facts have shown that women with Breast Ca using HRT had already cancer cells
• Average age at menopause: 51 years before using HRT. Its 5-10 years to develop.
o (1% at age 40, 5% after age 55) *most women think that #1 cause of death in menopausal women with
• Factors impacting age at menopause regards to cancer is Breast Ca but the fact is, its Lung Ca, and the most
o Maternal age at menopause common cause of death is heart-related problem like MI, stroke
o Tobacco use *menopause is a risk factor for MI
o Alcohol use
o Body Mass Index OSTEOPOROSIS (trabecular bone is more affected)
• Decreased bone mass and microarchitectural deterioration of bone tissue
o OCP use leading to enhanced bone fragility and an increase in fractures
o Parity Consequences of Osteoporosis
o Race •
o Height o Back pain
o Loss of height and mobility
Physical Changes o Postural deformities
• Vasomotor instability- *affects primarily the brain •
• Metabolic Changes •
• Coronary Artery Disease •
• Accelerated bone loss- *prone to fractures
• Skin changes- *dry skin *what will you advice women who are approaching menopause? Advice to
take Ca supplements and exercise.
• Urogenital atrophy- *uterine prolapse, cystocele
*50% of women over 65 have spinal compression fractures
• Cognition (?)
The average untreated potmenopausal white women can expect to shrink
• Libido (?) 2.5 inches
*all organ system is affected 25% of patients over the age of 50 with hip fracture die due to the fracture or
Hot Flushes- pathognomonic sign of Menopause
its complications within one year.
• “Sudden onset of reddening of the skin over the head, neck, and Survivors are frequently serrely disaabled
chest accompanied by a feeling of intense body heat and 1.3M osteoperotic fractures in the US annuallly
sometimes concluded by profuse perspiration”
• Number 1 complaint to physicians Premature Menopause
• Few seconds to several minutes Definitions:
• Most severe at night and during times of stress Early: age 40-44
• 25% will last for more than 5 years Premature: <40
Causes
Managing Hot Flushes/Flashes Surgical removal of uterus**
• Set realistic goals! Surgical removal of ovaries
• Lower the ambient temperature Premature ovarian failure
• Estrogen (80-95% reduction)
• Alternative therapies Premature Ovarian Failure
o High dose progestins
o Tibolone
o SERM (selective estrogen receptor modulators)
• Complementary Approaches
• May be effective
o Black Cohosh Evaluation of Premature Ovarian Failure
o Soy/Phytoestrogens
• Vitamin E (1 hot flash per day less) Assessment for Fragile X premutation (number of CGG repeats)
Abnormalities in Insulin
– Insulin resistance Treatment of Premature Menopause
– Insulin elimination
– Insulin secretion
– Hyperinsulinemia
– HT reduces onset of DM and improves insulin resistance From Ice Soria’s notes:
HORMONAL CHANGES WITH ESTABLISHED MENOPAUSE
Other Factors COLLAGEN – nearly 30% of skin collagen is lost within 1st 5yrs after
– Endothelial dysfunction menopause, and collagen decreases approximately 2% per year for the 1st 10
– Visceral fat years after menopause.
– Uric acid
– Blood pressure BONE LOSS
• Role of Estrogen:
o Cortical Bone: With estrogen deficiency, bone density Although cardiovascular disease becomes more prevalent only in
decreases more slowly in cortical bone the later years following a natural menopause, premature
o Cancellous or Trabecullar Bone: With estrogen cessation of ovarian function (before the average age of
deficiency, osteoporosis develops more rapidly in menopause) constitutes a significant risk
trabecular than in cortical bone. o Premature menopause, occurring before
o Loss of trabecular bone (spine) is greater with estrogen age 35, has been shown to increase the risk
deficiency than is loss of cortical bone. of myocardial infarction two- to threefold,
and oophorectomy before age 35 increases
BONE MASS CAN BE DETECTED BY A VARIETY OF WAYS: the risk sevenfold
1. Dual-energy X-ray absorptiometry (DEXA) scans have become the WHY THERES INCREASE RISK?
standard of care for detection of osteopenia and osteoporosis 1. Accelerated rise in total cholesterol in postmenopausal women is the most
T score: reflect the number of standard deviations of bone loss prevalent finding. This increase in total cholesterol is explained by :
from the peak bone mass of a young adult. The T score is increases in levels of low-density lipoprotein cholesterol (LDL-C)
expressed as the difference in standard deviations of the oxidation of LDL-C is also enhanced
measured bone density from the mean value of young adults. decrease levels of very low density lipoproteins and lipoprotein
decrease HDL-C levels
OSTEOPENIA: 2. The changes of weight, blood pressure, and blood glucose with aging,
Decreased quantity of bone mass of lesser amount although important, are not thought to be as important as the rate of rise in
than osteoporosis. An early state of osteoporosis with bone total cholesterol, which is substantially different in women versus
density T score between -1 to -2.5 standard deviations men.
3. Blood flow in all vascular beds decreases after menopause
OSTEOPOROSIS: 4. Prostacyclin production decreases
A systemic skeletal disease characterized by low 5. Endothelin levels increase
bone mass and microarchitectural deterioration of bone tissue 6. Reduced nitric oxide synthetase activity
with a bone mineral density T score less than -2.5 standard
deviations Risk–Benefit Assessment
The WHI was conceived in an attempt to determine the overall
2. Biochemical assays are also available to assess bone resorption and risks and benefits of ET/HT in a prospective randomized trial
formation in both blood and urine Endpoints: ET (CEE 0.625 mg with MPA 2.5 mg)
At present, serum markers appear to be most useful for o reduces cardiovascular disease
assessing changes with antiresorptive therapy o may increase the risk of breast cancer (primary endpoints)
o secondary endpoints were also assessed: venous
Osteoporosis thromboembolism, stroke, osteoporotic fracture, colon
Estrogen deficiency cancer, and mortality
Peak bone mass at 30-35 years old BENEFITS:
Bone loss at a rate of 0.5-1% per year afterward HT ARM: protection of osteoporotic fracture and colon cancer
Bone loss at a rate of 2-3% per year for 10 years after menopause ET ARM: protection of osteoporotic CHD, breast cancer
Osteoporosis is associated with fracture ( femoral neck, vertebral RISK:
body and distal radius) A tally of the various endpoints pointed to overall risks rather
than benefit
Risk factors of osteoporosis “ATTRIBUTABLE” risk:
1. Family history o This is the risk per year for 10,000 women exposed
2. Ethnicity o Thus, an attributable risk of 8/10,000 women/year from
3. Early menopause cancer with HT is a very small risk and according to WHO
4. Hypoestrogenism (excessive exercise, anorexia, bulimia) terminology has been described as “rare.”
5. Hyperthyroidism, excessive thyroxine therapy o This concept has been lost by the media and others who have
6. Cigarette smoking misinterpreted both relative risk and attributable risk.
7. Caffeine Recently there has been a trend to reduce potential risks and adverse effects
8. High alcohol intake by using lower doses of ET/HT, which have been shown to be beneficial.
Pathophysiology
Increase in Prolactin inhibits the GnRH pulsatility
Decrease in FSH
Oligomenorrhea to amenorrhea
>100 ng/ml: hypogonadism MRI
OVARIAN FAILURE
< 30 years old woman: do karyotyping
Fragile X: MC of inherited cause of mental retardation and autism DECREASE GnRH
Increase
Cortisol
due to an unstable trinucleotide (CGG)
FMR1 gene on long arm of chromosome X
Previous ovarian surgery Stress can lead to inhibition of the GnRH axis
Radiation Mechanism: inc secretion of CRH releasing ACTH and cortisol
CRH known to inhibit GnRH
GONADAL DYSGENESIS
Incomplete or defective formation of the gonads resulting from POLYCYSTIC OVARIAN SYNDROME /PCOS
the disturbance in germ cell migration or organization caused by Heterogenous disorder and may present with prolonged periods of
chromosomal abnormlities or mutations amenorrhea; typical menstrual pattern is of irregularity or
Gonads appear streaks oligomenorrhea
o Deletion of the long arm (q) usually do not affect 1935 Stein & Leventhal
height; in place of the ovary a band of fibrous tissue Symptom complex associated with anovulation
called gonadal streak is present 7 obese patients with amenorrhea , hirsutism, enlarged polycystic
o Streaks also present in individuals without gonads ovaries
(pure gonadal dysgenesis) Wedge resection
MC form: Turner’s syndrome Follicles could not escape the thick capsule
Chronic anovulation
Gonadal dysgenesis: Turner’s Syndrome Genetic variant
Karyotype: 45X Environmental factors
Increased daily androgen and estrogen production
Elevated serum testosterone, DHEAS,DHEA, 17-
hydroxyprogesterone
diagnostic criterion
FSH is low
Increased LH:FSH ratio
At least 2 of the 3 major criteria
1. Oligo/anovulation
2. Clinical or biochemical hyperandrogenism
3. PCO on ultrasound
PCOS : Complications
Menstrual dysfunction
Infertility
Increased risk of having endometrial hyperplasia/neoplasia
Increased risk of developing DM type 2
Increased risk of developing CVD
Metabolic syndrome ***
o combination of medical disorders that, when occurring
together, increase the risk of developingcardiovascular
disease and diabetes
END
“The more solid your Batch is, the BETTER you will be.”