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50 Cards in this Set
- Front
- Back
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What is best treatment approach for hirsutism?
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Androgen suppression plus hair removal
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What are common findings in PCOS?
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Elevated LH:FSH (>2:1)
Perimenrchal onset of symptoms polycystic ovaries on US Obesity Insulin resistance in lean or obese pts |
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How do sex steroid levels affect SHGB concentrations?
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Decrease if testosterone is high
Increase in response to estrogens |
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How does PCOS present in teenager?
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Premature adrenarche
Persistent oligomenorrhea Hirsutism Acne Wt gain |
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What are health consequences of PCOS?
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Hyperlipidemia
Adult-onset DM Endometrial hyperplasia Infertility Obesity |
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What is acanthosis nigricans a marker of?
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Insulin resistance
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What percent of PCOS women are obese?
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50-75%
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What are the cysts in PCOS?
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Atretic follicles, usually 3-5mm in diameter
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What percentage of PCOS pts have impaired glucose tolerance?
DM? |
1) 35%
2) 10% |
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What are surgical treatments for PCOS?
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Wedge resection of ovary
Laparoscopic drilling Laparoscopic needle cautery |
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How to prevent endometrial hyperplasia in PCOS?
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Combined OCPs
Cyclic progestin therapy |
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What is a leiomyoma?
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Aka fibroid, fibromyoma, myoma
Growth of uterine muscular wall, +/- fibrous tissue Benign >99% of the time |
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Most common pelvic tumor?
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Leiomyoma
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Incidence of leiomyoma?
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25% caucasians
50% black women Note: 77% of post-hysto uteruses are found to have incidental myomas Account for 25-30% of hysterectomies |
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What is etiology of leiomyomas?
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Thought to be somatic mutation of monoclonal myometrial cell line
Often occur in clusters & recur, so likely is genetic predisposition Have not been documented to occur more frequently in 1st degree relatives of probands, though. |
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What conditions cause leiomyomas to grow?
Under what conditions do leiomyomas stay the same size? Under what conditions do leiomyomas abate? |
1) During menstrual life
2) Pregnancy, OCPs, HRT 3) After menopause (if grow at this time, consider malignancy!) |
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What percent of leiomyomas are malignant?
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0.3-0.7%
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What are most common locations of leiomyomas? (3)
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1) Subserosal (on external surface)
2) Intramural (on uterine wall) 3) Submucosal (protrude into endometrial lining) |
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What symptoms are commonly associated w/ leiomyomas? (4)
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Dysmenorrhea
Abnormal uterine bleeding Pressure Pain (w/ menses or w/ myoma degeneration) |
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What specific symptoms are commonly associated w/ LARGE leiomyomas? (2)
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Urinary frequency
Pelvic pressure |
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What specific symptoms are commonly associated w/ SUBMUCOSAL leiomyomas?
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DUB – usually menorrhagia
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What specific symptoms are commonly associated w/ INTRAMURAL leiomyomas?
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Abnormal uterine bleeding
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What is mechanism behind which myomas lead to DUB (dysfxnal uterine bleeding)? (5)
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1) increased endometrial surface area
2) endometrium ulcerates over myoma 3) endometrial hyperplasia at myomal-endometrial jxn 4) uterine wall can't contract & close spiral arteries during menses 5) abnormal microvascular pattern w/ stasis & change in venous drainage |
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When to remove leiomyomas?
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1) If rapid growth or growing after menopause
2) Persistent abnormal bleeding not responsive to medical tx 3) excessive pain or pressure 4) Consider if >8cm in women who still desires childbearing |
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What are potential treatments for leiomyomas?
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1) Surgery: hysto or myomectomy (laparotomy or -oscopy or w/ hystoscope)
2) Medical: GnRH agonist 3) IR: uterine artery embolization |
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How long does GnRH agonist take to effectively treat leiomyoma?
What is its max reduction in fibroid size? What are major drawbacks of GnRH treatment? |
1) 3-6 mo
2) 30-64% 3) Fibroid will grow back when d/c drug. Drug simulates menopausal state (but can give add-back low-dose HRT to younger pts) |
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What types of degeneration do myomas undergo?
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1) Hyaline (65%)
2) Myxomatous (15%) 3) Calcific (10%) 4) Carneous – the most acute; 5-10% pregnancies have this complication 5) Cystic degeneration 6) Fatty degeneration |
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Relationship btw leiomyomas and infertility?
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Not thought to be a major cause
If do have impact, is likely through uterine cavity distortion or mechanical obstruction @ cervix or tubial ostia If in posterior uterine wall might inhibit implantation |
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If no other cause for infertility is found and leiomyomas are removed, what is resultant pregnancy rate?
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70%
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What is endometriosis?
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Hormonally responsive tissue is found outside the uterus
Can see endometrial glands and stroma; macrophages w/ hemofusin and hemosiderin; & fibrosis on histology Is progressive Can have big impact on pt's quality of life via pelvic pain, dyspareunia + infertility |
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What is adenomyosis?
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Endometrial tissue is found w/in uterine myometrium
Can cause severe menorrhagia & disabling dysmenorrhea |
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What is endometriosis prevalence?
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Controversial
~5-15% of pre-menopausal women 20-50% in infertile women >50% in chronic pelvic pain pts Note: increased incidence amongst 1st degree relatives Affects teens. No racial preponderance |
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What is adenomyosis prevalence?
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15-20%, usually in peri-menopausal women
May be association btw tamoxifen administration and adenomyosis |
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What are endometriosis anatomical sites?
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Posterior cul-de-sac
Uterosacral ligament surface peritoneum Bilateral ovarian fossa + ovarian surfaces Broad ligament Fallopian tubes Anterior cul-de-sac May see peritoneal defects (usu lateral to uterosacral ligs) Has been reported in lung, nasal mucosa, bladder, kidney, incisional sites |
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What is metastatic theory of endometriosis?
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Implantation after retrograde menstruation into peritoneal cavity, lymphatic dissemination, or hematogenous spread of endometrial tissue
Or, iatrogenic dissemination via procedures |
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What factors support the metastatic theory of endometriosis?
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Endometriosis location in dependent parts of body
Endometrial cells can implant Increased incidence of endometriosis in pts w/ outflow obstruction IDing endometriosis in sites distant to abdominal cavity |
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What is embryonic cell rest and coelomic metaplasia theory of endometriosis?
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Is de novo development of endometrial tissue outside uterus
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What factors support the embryonic cell rest and coelomic metaplasia theory of endometriosis?
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NONE
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What is thought to be the true mechanism behind endometriosis?
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Altered macrophage capacity to induce cytolysis of ectopic endometrial cells
Plus increased ability of this tissue to survive, proliferate, invade, and induce angiogenesis Plus impaired endometrial cell apoptosis Are more MPs in endometriosis, along w/ peritoneal MPs making increased synthesis of growth factors, cytokines, angiogenic factors These MPs have impaired cytotoxic ability No one knows why this happens, though. |
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What is clinical presentation of endometriosis? (5)
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1) Pelvic pain
2) Infertility 3) Dypareunia 4) Rectal discomfort and tenesmus 5) Abnormal uterine bleeding |
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What is clinical presentation of adenomyosis?
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Abnormal uterine bleeding (usually prolonged)
Severe dysmenorrhea |
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What are characteristics of pelvic pain associated w/ endometriosis?
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Usually cyclic, occurring prior to or w/ menses
Unilateral or bilateral in lower quadrants Progression: increased pain week before menses |
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What is thought to be the etiology behind the pelvic pain of endometriosis?
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Tissue edema
Blood extravasation These stimulate A-delta and C primary afferent fiber mechanoreceptors |
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What is the relationship between pelvic pain and extent of endometriosis spread?
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NONE!
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What is the mechanism behind infertility caused by endometriosis?
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Scarring and adhesions distort pelvic architecture and affect oocyte transportation from ovary to tube
Peritoneal environment affects oocytes and sperm Peritoneal fluid inhibits sperm function |
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What percent of women w/ endometriosis are affected by infertility?
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30-40%
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What is the mechanism behind dyspareunia in endometriosis?
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An immobile, fixed uterus, usually present w/ severe disease
Note: there's an association btw endometriosis and pain in specific coital positions |
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What is the mechanism behind rectal discomfort and tenesmus in endometriosis?
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Posterior cul-de-sac scarring & immobility
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What are physical findings in endometriosis? (6)
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VARIABLE! Can have:
1) Diffuse lower abdominal tenderness in various locations 2) Nodularity and tenderness along uterosacral ligaments 3) Immobility of pelvic viscera → pain w/ manipulation 4) Fixed, retroverted uterus 5) Narrowing of posterior vaginal fornix 6) Adnexal tenderness and immobility |
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What are physical findings in adenomyosis? (2)
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Mobile uterus, often top-normal size or enlarged
No evidence of leiomyomas |
