Podcast Beta
Questions and Answers
What is the most likely cause of primary ovarian insufficiency?
What is one of the classic scenarios that can lead to Asherman's Syndrome?
Which hormonal test is utilized to detect primary ovarian insufficiency?
What condition is characterized by low energy availability and menstrual dysfunction?
Signup and view all the answers
Which aspect of the HPO axis is most likely affected by significant weight loss or changes in diet?
Signup and view all the answers
What characterizes primary amenorrhea?
Signup and view all the answers
Which condition is characterized by cycles that occur more than 35 days apart?
Signup and view all the answers
Which of the following is NOT a recognized cause of primary amenorrhea?
Signup and view all the answers
What is the main reason for the absence of menses in a patient with Turner syndrome?
Signup and view all the answers
Which option best defines dysfunctional uterine bleeding (DUB)?
Signup and view all the answers
What is a common cause of secondary amenorrhea?
Signup and view all the answers
Which symptom indicates menorrhagia?
Signup and view all the answers
Which part of the HPO axis's dysfunction can result in amenorrhea?
Signup and view all the answers
Which of the following statements accurately describes the primary gonadal issue in Turner syndrome?
Signup and view all the answers
What laboratory test is essential for diagnosing primary ovarian insufficiency in cases of amenorrhea?
Signup and view all the answers
Which condition is associated with the absence of testosterone receptors in an XY fetus?
Signup and view all the answers
Which of the following would NOT typically be seen in a patient with Androgen Insensitivity Syndrome?
Signup and view all the answers
In cases of secondary amenorrhea, what percentage is attributed to ovarian etiologies?
Signup and view all the answers
What is the primary mechanism for menstrual irregularities due to Functional Hypothalamic Amenorrhea?
Signup and view all the answers
What would likely be indicated by a negative Progestin Withdrawal Test following estrogen supplementation?
Signup and view all the answers
Which hormonal contraceptive mechanism contributes to secondary amenorrhea?
Signup and view all the answers
Which imaging study is most helpful in confirming a case of Mullerian Agenesis?
Signup and view all the answers
Which of the following medications is most likely to cause hyperprolactinemia resulting in secondary amenorrhea?
Signup and view all the answers
What feature is likely to be absent in a patient with an imperforate hymen?
Signup and view all the answers
What causes the characteristic signs of Turner syndrome such as short stature and osteoporosis?
Signup and view all the answers
Which of the following statements is true regarding estrogen production in Androgen Insensitivity Syndrome?
Signup and view all the answers
What is the most common cause of secondary amenorrhea?
Signup and view all the answers
What is the most common etiology associated with endometrial cancer?
Signup and view all the answers
Which type of endometrial cancer typically has a good prognosis and is often discovered at an early stage?
Signup and view all the answers
What is the five-year survival rate for patients with stage 1 or 2 endometrioid endometrial cancer?
Signup and view all the answers
Which of the following surgical procedures is preferred for the treatment of endometrial cancer?
Signup and view all the answers
What is the prognosis for early stage grade 3 endometrial cancer?
Signup and view all the answers
What is a distinguishing feature of a hysterosalpingogram (HSG)?
Signup and view all the answers
What is the primary purpose of an endometrial biopsy?
Signup and view all the answers
Which of the following uterine conditions is most likely to cause confusion regarding menstrual patterns?
Signup and view all the answers
What is a key characteristic of saline infusion sonography (SIS)?
Signup and view all the answers
How does adenomyosis differ from endometriosis?
Signup and view all the answers
What is a definitive method for diagnosing adenomyosis?
Signup and view all the answers
Which symptom is most characteristic of endometrial hyperplasia?
Signup and view all the answers
What is the primary risk factor associated with endometrial hyperplasia?
Signup and view all the answers
What is a common presentation of leiomyomata uteri?
Signup and view all the answers
Which of the following is considered a treatment option for adenomyosis?
Signup and view all the answers
Adenomyosis is most commonly diagnosed in which demographic?
Signup and view all the answers
What distinguishes benign endometrial polyps from leiomyomata uteri?
Signup and view all the answers
Which characteristic is atypical of leiomyomata uteri?
Signup and view all the answers
Which method is most effective for managing symptomatic menorrhagia caused by leiomyomata uteri?
Signup and view all the answers
What imaging method is most appropriate for evaluating the size and number of fibroids?
Signup and view all the answers
In what condition is endometrial hyperplasia more likely to progress to endometrial cancer?
Signup and view all the answers
Which of the following treatments is appropriate for endometrial hyperplasia without atypia?
Signup and view all the answers
What condition is characterized by thickened endometrial tissue due to abnormal cell growth?
Signup and view all the answers
Which surgical procedure is typically performed as a definitive treatment for endometriosis?
Signup and view all the answers
What is a common first-line treatment for managing endometriosis pain?
Signup and view all the answers
Which symptom is typically part of the characteristic triad associated with endometriosis?
Signup and view all the answers
What should be done prior to administering GnRH agonists for endometriosis treatment?
Signup and view all the answers
Which factor is NOT considered essential when determining management options for endometriosis?
Signup and view all the answers
What is the typical demographic for a patient presenting with endometriosis?
Signup and view all the answers
Which of the following locations is the most common site for endometriosis to occur?
Signup and view all the answers
What is characterized by the classic triad of symptoms associated with endometriosis?
Signup and view all the answers
What is the definitive method for diagnosing endometriosis?
Signup and view all the answers
Which statement about endometrial cysts, often referred to as 'chocolate cysts,' is correct?
Signup and view all the answers
How prevalent is endometriosis among women experiencing chronic pelvic pain?
Signup and view all the answers
What does the staging system for endometriosis primarily help with?
Signup and view all the answers
What type of pain is typically associated with endometriosis?
Signup and view all the answers
What is the primary reason for shortened luteal phase in Luteal Phase Defect?
Signup and view all the answers
What is a potential complication of using Clomiphene Citrate for ovulation induction?
Signup and view all the answers
What characterizes hydrosalpinx as a common tubal factor in infertility?
Signup and view all the answers
What is the mechanism of action of Metformin when used in women with PCOS who do not ovulate on Clomiphene Citrate?
Signup and view all the answers
Which intervention is commonly recommended for a patient diagnosed with a uterine septum and pregnancy losses?
Signup and view all the answers
What is the primary indicator for evaluating infertility in women older than 35 years?
Signup and view all the answers
Which factor is primarily associated with infertility in men?
Signup and view all the answers
What percentage of infertility cases can be attributed to ovarian/tubal factors?
Signup and view all the answers
Which laboratory test is essential in assessing ovarian reserve in women over 40?
Signup and view all the answers
What is the primary element analyzed in a male infertility workup?
Signup and view all the answers
Infertility is defined as a couple’s failure to achieve pregnancy after how long of regular, unprotected intercourse?
Signup and view all the answers
Which condition is least likely to be recognized as a risk factor for ovarian insufficiency?
Signup and view all the answers
What hormone-related change is typically associated with advancing maternal age affecting fertility?
Signup and view all the answers
Which of the following is characteristic of a benign ovarian cyst on ultrasound?
Signup and view all the answers
What is the primary etiology of a follicular cyst?
Signup and view all the answers
Which symptom might indicate a severe complication of a follicular cyst?
Signup and view all the answers
What complication is commonly associated with corpus luteum cysts?
Signup and view all the answers
Which type of benign ovarian cyst is almost always bilateral?
Signup and view all the answers
What does expectant management of a functional cyst entail?
Signup and view all the answers
Which of the following conditions is characterized by the presence of chocolate cysts?
Signup and view all the answers
What indicates a functional cyst diagnosis rather than a malignant condition?
Signup and view all the answers
What characteristic feature distinguishes mucinous cystadenomas from serous cystadenomas?
Signup and view all the answers
Which symptom is most commonly associated with tubo-ovarian abscesses?
Signup and view all the answers
What is the most common benign neoplasm found in women under 35 years of age?
Signup and view all the answers
In the management of benign ovarian tumors, what is indicated when there are signs suggestive of malignancy?
Signup and view all the answers
Which condition is associated with a high risk of rupturing and requires immediate medical attention?
Signup and view all the answers
What specific type of fluid do endometriomas typically contain?
Signup and view all the answers
In which situation is laparoscopic intervention NOT indicated for tubo-ovarian abscesses?
Signup and view all the answers
What is a common complication associated with tubo-ovarian abscesses that could affect future fertility?
Signup and view all the answers
What percentage of benign epithelial ovarian tumors are bilateral cases?
Signup and view all the answers
What is the most appropriate initial management for a patient diagnosed with an ovarian mature cystic teratoma?
Signup and view all the answers
Which characteristic finding in a transvaginal ultrasound is most concerning for ovarian malignancy?
Signup and view all the answers
In which patient demographic is the CA-125 serum marker most reliable for indicating malignancy risk?
Signup and view all the answers
How does the risk of ovarian cancer change for a 35-year-old woman with a BRCA1 gene mutation compared to the general population risk?
Signup and view all the answers
What is a key limitation of using CA-125 as a screening test in premenopausal women?
Signup and view all the answers
Why are biomarker panels considered less effective as an initial assessment tool for ovarian cancer?
Signup and view all the answers
Which symptom is least indicative of a malignant ovarian mass?
Signup and view all the answers
What ultrasound finding is commonly associated with a malignant adnexal mass?
Signup and view all the answers
Which patient demographic is least likely to require referral to a gynecologic oncologist?
Signup and view all the answers
Which factor is most significantly associated with an increased risk for ovarian cancer?
Signup and view all the answers
Which physical exam finding suggests a malignant ovarian mass?
Signup and view all the answers
What characteristic finding is least likely to be present in benign adnexal masses?
Signup and view all the answers
Which of these conditions is least associated with abdominal swelling or distension?
Signup and view all the answers
Which of the following statements regarding ovarian cancer risk factors is most accurate?
Signup and view all the answers
Which of the following is a necessary criterion for the diagnosis of PCOS?
Signup and view all the answers
What metabolic condition is commonly associated with PCOS due to insulin resistance?
Signup and view all the answers
Which of the following tests is NOT typically included in the evaluation of a patient suspected to have PCOS?
Signup and view all the answers
Which clinical manifestation is directly associated with hyperandrogenism in patients with PCOS?
Signup and view all the answers
What percentage range is suggested to represent the incidence of PCOS in the general population?
Signup and view all the answers
What is the primary goal of using combined hormonal contraceptives in patients with menstrual irregularities who are not attempting conception?
Signup and view all the answers
Which laboratory test is essential for documenting biochemical hyperandrogenemia in patients suspected of having PCOS?
Signup and view all the answers
How does metformin contribute to improving ovulation rates in patients with insulin resistance?
Signup and view all the answers
What is the mechanism of action for clomiphene citrate in the treatment of ovulation induction?
Signup and view all the answers
Which treatment option has been shown to delay the development of diabetes in high-risk populations?
Signup and view all the answers
Which factor is crucial in monitoring the effectiveness of ovulation induction with letrozole?
Signup and view all the answers
What condition is typically characterized by the presence of polycystic ovaries detected via ultrasound?
Signup and view all the answers
Which lifestyle modification is considered integral in reducing the risk of cardiovascular disease and diabetes in patients with PCOS?
Signup and view all the answers
Study Notes
Defining Abnormal Menstruation
- Primary Amenorrhea: No menstruation by age 15
- Secondary Amenorrhea: Absence of menstruation for 3 or more months in a woman who previously menstruated
- Oligomenorrhea: Cycles longer than 35 days apart
- Polymenorrhea: Cycles shorter than 24 days
- Menorrhagia: Blood loss greater than 80 ml (3 ounces)
- Dysfunctional Uterine Bleeding (DUB): Abnormal bleeding without anatomic abnormality, often caused by anovulation
Common Causes of Primary Amenorrhea
-
Ovarian Causes:
- Gonadal Dysgenesis/Turner Syndrome (43%): Absence of normal ovarian tissue
- Polycystic Ovarian Syndrome (7%): Hormonal imbalance leading to cyst formation
-
Uterine/Vaginal Causes:
- Mullerian Dysgenesis/Agenesis (15%): Absence or malformation of the uterus and upper vagina
- Outflow Tract Obstruction (e.g., imperforate hymen): Blockage of the passageway for menstrual blood
-
Hypothalamic Causes:
- Physiologic Delay (14%): Delayed puberty due to normal variations
- Functional Hypothalamic Amenorrhea (2-3%): Caused by stress, low body weight, excessive exercise, or eating disorders
-
Pituitary Causes:
- Hypopituitarism: Deficiency in pituitary hormones
- Hypogonadotropic Hypogonadism (Kallman syndrome): Deficiency in hormones that stimulate the gonads
Turner Syndrome
- Chromosomal Abnormality: 45, XO: Absence of one X chromosome
- Ovarian Function: Ovaries are replaced by fibrous tissue ("streak gonads"), resulting in little or no estrogen production.
- Hormonal Profile: Elevated FSH levels (similar to menopause).
- Management: Hormone replacement therapy starting in adolescence.
- Pregnancy: Possible with donated eggs and IVF.
Androgen Insensitivity Syndrome
- Genetic Basis: XY chromosomes with testes, but no testosterone receptors.
- Presentation: Female-bodied external genitalia, breast development, and lower 1/3 of the vagina.
- Mullerian Structures: Absent due to production of MIS (Mullerian Inhibiting Substance) from testes.
- Testosterone Production: Testes still produce testosterone, which is partially converted to estrogen.
- Breast Development: Estrogen from testosterone conversion binds to estrogen receptors, leading to breast tissue development.
Imperforate Hymen
- Cause: Absence of normal apoptosis of cells in the hymenal membrane.
- Presentation: Complete or partial blockage of the vaginal opening, resulting in accumulation of menstrual blood (hematocolpos).
Mullerian Abnormalities
- Embryological Cause: Malformations during fusion of the paramesonephric ducts, which form the fallopian tubes, uterus, and upper 1/3 of the vagina.
- Diagnosis: Pelvic ultrasound or MRI.
-
Presentation:
- Cyclic pelvic pain
- Possible pelvic mass if functional endometrium is present
- Asymptomatic except for amenorrhea if uterus and/or endometrium are absent.
Functional Hypothalamic Amenorrhea
- Cause: Inadequate stimulation or suppression of the hypothalamic-pituitary-ovarian (HPO) axis, without anatomic pathology.
- Mechanism: Decreased pulsatile GnRH secretion.
- Associated Conditions: Anorexia nervosa, low body weight, excessive exercise, emotional stress, severe illness.
- Risk: Increased risk of osteoporosis due to low estrogen levels.
Primary Amenorrhea Diagnosis Labs
- With Uterus/Vagina Present: B-HCG, FSH (karyotype if FSH is elevated), TSH, Prolactin.
- With Absent Uterus: Karyotype, serum testosterone.
Secondary Amenorrhea: Causes by HPO Axis
-
Uterine (5%):
- Asherman’s Syndrome: Uterine adhesions from scarring.
-
Ovarian (40%):
- PCOS: Hormonal imbalance and cyst formation.
- Primary Ovarian Insufficiency: Premature ovarian failure.
- Iatrogenic: Removal or damage to the ovaries during surgery.
-
Pituitary (15%):
- Prolactinoma: Tumor in the pituitary gland that produces prolactin.
- Other pituitary tumors.
-
Hypothalamic (40%):
- Functional Hypothalamic Amenorrhea
- Infiltrative lesions of the hypothalamus
- Chronic disease.
Medications that Cause Secondary Amenorrhea
- Hormonal Contraceptives: Thin the endometrium and disrupt hormonal cycles.
- Medicated IUD: Same as above for hormonal contraceptives.
- Thyroid Medications and Lithium: Alter thyroid function.
- Metoclopramide (Reglan): Causes hyperprolactinemia.
- Antipsychotic Drugs: Cause hyperprolactinemia.
Secondary Amenorrhea: Workup and Evaluation
- Initial Lab: Serum HCG (pregnancy test).
- Thyroid and Pituitary Assessment: TSH and Prolactin.
- Primary Ovarian Insufficiency Assessment: FSH.
- PCOS Assessment: Testosterone, 17-OHP, serum progesterone.
- Uterine and Ovarian Function Assessment: Progesterone withdrawal test.
Progestin Withdrawal Test
- Purpose: To determine if the endometrium is capable of responding to estrogen and to determine the cause of amenorrhea.
-
Procedure:
- Administer progestin for several days.
- Stop progestin and observe for menstruation.
- Positive Result: Menstruation occurs. Indicates estrogen is present and the uterine lining is functioning.
-
Negative Result: No menstruation:
- Endometrium is scarred (Asherman's Syndrome).
- No estrogen stimulation (POF).
-
If Negative:
- Supplement with estrogen for a few weeks.
- Repeat progestin withdrawal test.
- Positive Result after Estrogen: Endometrium is functional, but not producing enough estrogen (likely ovarian insufficiency).
- Negative Result after Estrogen: Problem with the endometrial lining (Asherman's Syndrome).
Secondary Amenorrhea: Other Conditions
-
Primary Ovarian Insufficiency:
- Age of onset: Before age 40.
- Causes: Genetic, autoimmune, cancer treatment, unknown.
- Diagnosis: Elevated FSH level.
- Complications: Osteoporosis, autoimmune diseases (e.g., thyroid disease).
- Note: Ovaries may sometimes regain function, requiring contraception if pregnancy is not desired.
-
Asherman’s Syndrome:
- Cause: Endometrial scarring, usually after surgery or infection.
- Presentation: D&C after advanced miscarriage or delivery.
- Risk Factors: Rapid drop in estrogen levels.
- PCOS: Creates irregular periods, anovulation, fertility issues, and increased risk for ovarian cancer.
The Female Athlete Triad:
-
Components:
- Low energy availability (with or without disordered eating).
- Menstrual dysfunction.
- Low bone density.
- Mechanism: Energy deficiency affects bone health and can lead to mental dysfunction.
- Prevalence: Common among female athletes.
- Screening: Pre-participation screening for athletes.
Secondary Amenorrhea: History Questions
- Stressors: Hypothalamus involvement (e.g., stress, weight loss, exercise changes)
- Acne, Hirsutism, Voice Changes: Possible ovarian involvement (e.g., PCOS)
- Headaches, Vision Changes: Possible pituitary involvement (e.g., tumor or other pituitary disease)
- Hot Flashes, Vaginal Dryness, Disturbed Sleep: Possible ovarian involvement (e.g., primary ovarian insufficiency).
- Galactorrhea: Possible pituitary involvement (e.g., prolactinoma)
- History of Uterine Surgery or Infection: Possible uterine involvement (e.g., Asherman's Syndrome)
Menorrhagia
- Blood loss greater than 80 ml (~3 ounces)
- Can be estimated using specific criteria
Hysterosalpingogram (HSG)
- Imaging tool frequently used for uterus and tubes
- Injection of radio-opaque dye through the cervix, uterine cavity, and tubes
- Shows the shape of the uterine cavity, tube diameter, and whether the tubes exhibit "fill and spill."
Saline Infusion Sonography (SIS)
- Also called a sonohysterogram
- Performed in the office by injecting sterile saline transcervically while performing vaginal ultrasound
Endometrial Biopsy
- Used to obtain a sample of endometrial tissue
- Catheter is inserted through the vagina into the uterus to remove cells from the uterine lining
Hysteroscopy
- Procedure involving placing a camera through the cervix to visualize the uterine cavity
- A medium, like saline or 4% dextrose, is used to inflate the cavity
Mullerian Variations/Disorders
- Rarely cause menorrhagia but can create a confusing menstrual pattern
Didelphic Uterus and Vagina
- Patients may be aware of one side but not the other, leading to confusion regarding tampon placement
Adenomyosis
- A variation of endometriosis, but it's not called endometriosis
- Endometrial lining grows into the uterine wall
- Often presents as menorrhagia and dysmenorrhea
- Uterine muscle dysfunction
- Muscle must squeeze harder (pain) but still performs suboptimally (bleeding)
Adenomyosis Prevalence
- Usually parous women between 35-50 years old
Adenomyosis Symptoms
- Secondary dysmenorrhea
- Abdominal pressure
- Bloating
- Menorrhagia
- Dyspareunia (Sometimes)
- Chronic pelvic pain(Sometimes)
Adenomyosis Signs on Examination
- Diffusely enlarged, globular, tender uterus
Adenomyosis Diagnosis
- High index of suspicion based on clinical history and exam findings
- Characteristic findings on ultrasound and MRI
- Definitive diagnosis from pathology report
Adenomyosis Management
- Medical: NSAID, Hormonal, Await menopause
- Surgical: Hysterectomy is definitive
Benign Endometrial Polyps
- Focal overgrowths of endometrial tissue
- Soft and fleshy, typically "dangle" into the uterine cavity
- Can prolapse out of the cervix
- Visible with sonohysteroscopy or office hysteroscopy
- Easy to remove with hysteroscopy
- Removed tissue should be sent to pathology for examination
Leiomyomata Uteri (Uterine Fibroids)
- Benign tumors of smooth muscle cells
- Arise in the myometrium
- Most common solid pelvic tumor in women
- Most frequent indication for benign hysterectomy
Leiomyomata Uteri Incidence
- 20-50% of women in the United States
- Incidence increases with age, peaking in the 40s with a sharp decrease postmenopausally
- Genetic component
- Typically estrogen-sensitive
Leiomyomata Uteri Problems
- Can project into the cavity (submucosal) or out to the surface (subserosal)
- Can dangle off the uterine surface (pedunculated)
- Can compress the ureters, causing hydronephrosis
- Can cause abdominal pressure/heaviness and constipation
- Rarely cancerous but commonly contribute to menorrhagia and can cause infertility
- Often asymptomatic
Evaluating Leiomyomata Uteri
- Abdominal exam: At level of pubic symphysis= "12 weeks" (pregnancy sizing)
- Bimanual exam: Uterus is often irregular with nodules
- Transvaginal Ultrasound:
- Determines size and number of fibroids
- Confirms it's not an adnexal mass
- Determines if the fibroid juts into the uterine cavity
- Differentiates polyps vs. submucosal fibroids using SIS
- MRI and/or KUB:
- Determines if kidneys/ureters are affected
Leiomyomata Uteri Management
- Asymptomatic: Leave them alone
- Symptomatic:
- For menorrhagia:
- Medical management: COCs, progesterone (IUD, implant, oral)
- Endometrial ablation
- Removal of submucosal fibroids
- Hysterectomy
- For Pain or pressure symptoms:
- Wait for menopause or remove the uterus
- For Urinary tract symptoms:
- Hysterectomy for obstruction/hydronephrosis
- For Infertility or recurrent pregnancy loss: Myomectomy
- For menorrhagia:
Differential Diagnosis of an Enlarged Uterus
- Pregnancy (Most common cause)
- Adenomyosis
- Uterine fibroids (leiomyomata)
- Hematometra (Cervical stenosis/vaginal septum)
- Malignancy
Endometrial Hyperplasia
- Overgrowth of proliferative endometrium due to prolonged estrogen stimulation in the absence of progesterone ("unopposed estrogen")
Endometrial Hyperplasia Prevalence
- Typically perimenopausal/postmenopausal individuals, but can occur in individuals in their 30s
Endometrial Hyperplasia Risk Factors
- Obesity, especially morbid obesity
- Nulliparity
- Early menarche/late menopause onset
- Anovulation
- Breast cancer/Tamoxifen use
- Family history/Genetic predisposition
- Smoking
Endometrial Hyperplasia Major Symptom
- Abnormal Uterine Bleeding
Types of Endometrial Hyperplasia
- Complex hyperplasia with atypia (most concerning)
- Worry about this type for:
- Peri/postmenopausal individuals with abnormal uterine bleeding
- Individuals with significant estrogen exposure
Endometrial Hyperplasia Diagnosis
- Office endometrial biopsy
- Vaginal ultrasound to assess endometrial stripe thickness
- Gold standard: Hysteroscopy with D&C
Endometrial Hyperplasia Management
- No atypia: Add progesterone
- Repeat biopsy in 3-6 months to confirm resolution
- Atypia: Refer for further evaluation
- Hysteroscopy/D&C to rule in/out cancer
- Hysterectomy (acceptable and definitive treatment)
- High-dose progestin and repeat D&C if surgical candidate is poor
EIN: Endometrial Intraepithelial Lesion
- Same as Endometrial Hyperplasia with Atypia
- Precancerous condition involving thickened endometrial tissue
- 25-40% progression to endometrial cancer if left untreated
EIN Risk Factors and Symptoms
- Same as endometrial hyperplasia
EIN Treatment
- Always biopsy when atypical/heavy bleeding is present
- Sono is helpful but tissue is necessary
- Removal via hysterectomy is preferred
Endometrial Cancer
- Most frequent gynecological cancer in the US
Endometrial Cancer Etiology
- Unopposed estrogen (Most common cause)
- Hereditary factors: Lynch II syndrome
Endometrial Cancer Categories
- Hormone-dependent (majority):
- Endometrioid, low-grade (histo grades 1,2)
- Early stage (1 or 2)
- Good prognosis
- Not hormone-dependent (minority) :
- Endometroid grade III histology, papillary serous adenosquamous, and clear cell histology
- More often discovered at an advanced stage
- Poor prognosis, even when discovered early
- Five-year survival rate:
- Stage 1 and 2 endometrioid endometrial cancer: 95%
- Early grade 3 endometrial cancer: 58% or worse
Endometrial Cancer Treatment
- Hysterectomy
- +/- Removal of tubes and ovaries
- +/- Surgical staging (lymph node removal and assessment)
- Low-grade cancer: Hysterectomy is usually curative
Endometriosis Definition
- Benign condition where endometrial tissue grows outside the uterus
- Can occur in women of reproductive age
- Common in women with chronic pelvic pain
Endometriosis Occurrence
- Found in more than one-third of women with chronic pelvic pain
- Typically presents in women in their 30s who are nulliparous (never given birth) and infertile
Theories of Pathogenesis
- Retrograde menstruation - Endometrial tissue travels through the fallopian tubes during menstruation and implants at other sites
Sites of Occurrence
- Ovaries (most common)
- Cul-de-sac
- Uterosacral ligaments
- Round ligaments
- Broad ligaments
- Fallopian tubes
- Vagina
- Rectosigmoid and bowel, appendix
- Urinary bladder and ureters
Symptoms
- Classic Triad - dysmenorrhea (painful periods), dyspareunia (painful intercourse), dyschezia (painful bowel movements)
- Pain (cyclic and non-cyclic)
- Infertility
- Secondary dysmenorrhea (painful periods that start later in life)
- Premenstrual and postmenstrual spotting (in about 20%)
Physical Exam
- No specific physical findings
- May include findings on recto-vaginal exam
- Cul-de-sac nodularity and tenderness
- Uterosacral nodularity
- Tender, fixed adnexal mass
- Uterus fixed and retroverted
Diagnosis
- Ultrasound: Adnexal mass with internal echoes consistent with blood
- Definitive diagnosis: Direct visualization through surgery (laparotomy or laparoscopy) with histologic confirmation
Pathology
- Chocolate cysts (endometrial cysts) - Filled with old endometrial shedings and blood, can cause chemical peritonitis if ruptured
- Adhesions - Tissue scarring and binding
Staging
- A staging system exists to communicate the location of the disease
- Stage is not directly related to pain frequency or severity
Management
- Factors to consider: Symptom severity, extent of disease, desire for future fertility, age, and threat to GI or urinary tract
Treatment Options
- Surgical: Excision or ablation of endometrial implants, may require laparoscopic surgery (or rarely, laparotomy), removal of endometriomas >3 cm
-
Medical:
- First line treatment (3-6 months trial): Oral contraceptive pills, progestins, aromatase inhibitors
- Second line treatment: Mirena IUD, GnRH agonists (Lupron)
- Important: Always pursue laparoscopy for accurate diagnosis and treatment alongside medical management
Hysterectomy
- Most definitive surgical treatment
- Laparoscopic hysterectomy with ablation or excision of all endometrial implants and adhesions
- Risk of recurrence
Key Concepts
- Typical patient is in their reproductive years and often sub-fertile
- Classic symptom triad is dysmenorrhea, dyspareunia, and dyschezia
- Stage is not related to pain frequency or severity
- Minimizing menstrual flow and suppressing ovarian cycling can reduce risk and symptoms
Infertility Definition
- Infertility is defined as the inability to conceive after one year of regular, unprotected intercourse.
- This definition is adjusted for women over 35 years old, with diagnosis possible after 6 months of trying to conceive.
- It affects 15-20% of couples in the United States.
When to Evaluate for Infertility
- Evaluate couples who meet the definition of infertility.
- Earlier evaluation is recommended for women over 35 years old, as fertility decreases more rapidly after this age, especially after 42.
- Consider earlier evaluation for individuals with:
- History of amenorrhea or oligomenorrhea
- Suspected tubal disease, endometriosis, or Mullerian variations.
- Risk factors for ovarian insufficiency, such as prior chemotherapy/radiation, autoimmune diseases, or significant ovarian surgery.
- Also consider earlier evaluation for men with risk factors including:
- History of testicular torsion/cancer, orchitis/mumps, or unsuccessful conception.
Causes of Infertility
- Male factor contributes to 20% of infertility cases.
- Ovarian and tubal factors are present in over 45% of cases.
- Infertility is often multifactorial, meaning it involves more than one contributor.
Female Infertility Workup - Examination
- Assessment includes weight, BMI, blood pressure, and signs of systemic illness like diabetes, autoimmune disorders, and metabolic syndrome..
- Evaluate the thyroid for enlargement, nodules, and tenderness.
- Assess the breasts for galactorrhea.
- Look for signs of androgen excess, such as acne, hirsutism, or a male-patterned escutcheon.
- Thorough pelvic examination is important to detect any abnormalities.
Female Infertility Workup - Testing
- Along with testing, preconception counseling is crucial.
- Hemoglobin A1C and fasting glucose should be checked for women with a history of diabetes or risk factors.
- Genetic disorder screening should be performed as indicated.
Preconception Care
- Preconception care is essential and should be initiated as soon as possible.
Male Infertility Workup
- Obtain a thorough medical, surgical, and illness history.
- Special attention should be paid to a history of mumps, a known cause of mumps orchitis.
- Semen analysis is the primary test for male infertility.
- Key parameters include total sperm number, total motility, and normal forms.
Ovarian Factor in Infertility
- Can contribute to up to 40% of female infertility.
- Fecundity (ability to reproduce) gradually declines around age 32, and more rapidly after age 37.
- This is associated with increased FSH levels and decreased AMH and Inhibin B.
Ovarian Factor - Assessment
- Consider the patient's age and evidence of disordered ovulation.
- Review menstrual history.
- In women over 40, a day 3 FSH level can provide insight into ovarian reserve, with a value of 13 indicating difficulty with stimulation.
Disordered Ovulation - Labs
- To identify the cause of disordered ovulation, assess TSH and PRL levels.
- Luteal phase progesterone levels should be checked, as high levels indicate ovulation.
- A luteal phase defect refers to a shortened time between ovulation and menstruation, often due to premature involution of the corpus luteum. Treatment involves supplemental progesterone.
Infertility Treatment - Ovarian Factor
- Treatment for ovarian factor infertility usually requires a referral to a specialist.
- Consider quick referrals for patients over 35 years old.
- Clomiphene Citrate (Clomid) is a selective estrogen receptor modulator (SERM) that blocks estrogen receptors in the hypothalamus.
- This leads to increased GnRH release, stimulating FSH production, which in turn, encourages follicle recruitment and increases the likelihood of ovulation.
- Side effects include over-ovulation, menopausal symptoms, and OHSS.
Metformin in Infertility Treatment
- Metformin may be indicated for women with PCOS who do not ovulate with Clomiphene Citrate.
- Can be used as a supplement to Clomiphene Citrate in PCOS patients to promote ovulation.
- For other uses of Metformin, refer to a reproductive specialist.
Ovarian Hyperstimulation Syndrome
- Occurs due to overproduction of large follicles.
- Leads to increased capillary permeability in ovarian tissue, resulting in poor reabsorption and fluid buildup (ascites).
- Severe OHSS can lead to hemoconcentration and a risk of clotting.
Uterine and Tubal Factors in Infertility
- Common uterine issues include Asherman's syndrome, leiomyomata, and congenital Mullerian abnormalities.
- Common tubal issues include prior tubal ligation/surgeries and prior infection/PID.
- HSG (hysterosalpingogram) can be used to assess both uterine and tubal factors.
Mullerian Fusion Disorders
- Uterine septum is the most common Mullerian fusion disorder associated with pregnancy loss.
- Resection of the septum can improve delivery rates.
Hydrosalpinx
- Always (99%) caused by infection.
- Blockage prevents fluid drainage.
- Consider immediate salpingectomy (removal of fallopian tube) and ART (assisted reproductive technology) or tubal reconstruction, requiring a referral to a specialist.
Benign Ovarian Disorders
-
Follicular Cyst:
- Most common type of cyst in reproductive-age women.
- Occurs due to a persistent, unovulated follicle filling with fluid or an immature follicle failing to undergo atresia.
- Often asymptomatic, found during routine examinations.
- Larger cysts can cause pelvic heaviness, vague dull pain, and menstrual irregularities.
- Diagnosis made through pelvic exams and transvaginal ultrasounds (TUS).
- Management includes expectant observation, follow-up ultrasounds, and combination oral contraceptives.
- Surgery is indicated in cases of acute pain, suspected torsion, or suspicion of malignancy.
-
Corpus Luteum Cyst:
- Results from intrafollicular bleeding after ovulation.
- Associated with normal endocrine function or prolonged progesterone secretion.
- Complications include acute pain and rupture with intraperitoneal bleeding.
-
Theca Lutein Cyst:
- Almost always bilateral and significantly enlarge the ovaries.
- Can lead to excessive fluid leakage (ascites) and hemoconcentration, increasing the risk of clotting.
-
Cystadenoma:
- Benign tumor of the ovarian surface epithelium.
- Can be serous (filled with pale yellow fluid) or mucinous (filled with sticky mucin).
- Mucinous tumors are often larger and multiloculated.
- Often asymptomatic, but large mucinous tumors can cause symptoms.
- Management includes surgical removal with frozen section and staging.
-
Tubo-Ovarian Abscess (TOA):
- Infectious disorder of the upper genital tract (PID) involving the fallopian tube and ovary.
- Often bilateral due to ascending infection.
- Symptoms include those of PID, adnexal pain and mass.
- Requires immediate surgery in cases of sepsis, signs of rupture, or when diagnosis is in question.
- Chronic complications include tubal occlusion, infertility, ectopic pregnancy, and chronic pelvic pain.
-
Endometrioma (Chocolate Cyst):
- Ovarian cystic mass arising from growth of ectopic endometrial tissue within the ovary.
- Typically contains thick, brown tar-like fluid.
- Often densely adherent to surrounding structures.
- Management includes surgical intervention for pain relief, exclusion of malignancy, and treatment of infertility.
-
Mature Cystic Teratoma (Dermoid):
- Benign neoplasm arising from a single germ cell that contains tissue from all three germ layers (ectoderm, mesoderm, and endoderm).
- Most common benign neoplasm in women younger than 35 years old.
- Symptoms include pain, commonly due to torsion.
- Management includes surgical removal.
-
Paraovarian Cyst or Fibroid:
- Simple epithelial-lined cyst or benign fibroid located adjacent to the ovary, often within the broad ligament.
-
Ovarian (Adnexal) Torsion:
- Rotation of the ovary or the ovary and fallopian tube, occluding the vascular supply.
- Most susceptible ovaries are enlarged.
- Diagnosis through adnexal mass, TUS with Doppler flow studies.
- Requires surgical emergency intervention.
Ovarian Disorders: Malignant
-
History suggesting a malignant ovarian mass:
- Abdominal pain, dyspepsia, bloating, increase in abdominal girth
- Early satiety, weight loss
- Fatigue
- Dyspnea (due to ascites or pleural effusion)
-
Physical Exam findings suggesting a malignant ovarian mass:
- Weight loss
- Pleural effusion
- Jaundice, ascites
- Abdominal distension
- Nodular or fixed pelvic mass, possibly very large
-
Ultrasound findings suggesting a malignant adnexal mass:
- Thick septations
- Papillary projections into the lumen of a cyst
- Intramural nodule
- Cystic and solid components
- Increased overall volume of the ovary
- Increased Doppler measurement of blood flow
Ovarian Disorders: When to Refer to a Gynecologic Oncologist
- Women with a pelvic mass and at least one of the following clinical characteristics should be referred:
- Elevated CA 125 level
-
35 in postmenopausal women
-
200 in premenopausal women
-
- Ascites
- Nodular or fixed pelvic mass
- Evidence of abdominal or distant metastasis
- Family history of one or more first-degree relatives with ovarian or breast cancer
- Elevated CA 125 level
Cancer of the Ovary
- Most are detected incidentally on physical exam or during pelvic imaging (Ultrasound, CT, MRI)
- Most are benign, so the main goal is to exclude malignancy
-
Risk factors:
- Most important independent risk factor: AGE
- Incidence increases sharply after menopause
- Median age of onset of ovarian cancer: 63 years
- Most important personal risk factor: Strong family history of breast or ovarian cancer.
- Most important independent risk factor: AGE
-
Assessment:
-
Symptoms:
- May help refine differential diagnosis
- Assess for pregnancy – ectopic pregnancy has to be in differential if there is an adnexal mass in early pregnancy
-
Imaging:
- Transvaginal ultrasound - most commonly used
- Size (>10cm = concerning)
- Composition of mass (cystic + solid = concerning)
- Presence or absence of septations, mural nodules, papillary excrescences, or free fluid in the pelvis (worrisome = thick septations, nodules, excrescences)
- Transvaginal ultrasound - most commonly used
-
Serum Marker Testing:
- Used in conjunction with imaging:
- CA-125 - most commonly used
- Protein associated with epithelial ovarian malignancies
- Also expressed at lower levels in non-malignant tissue
- Elevation can occur in: Endometriosis, Pregnancy, PID, Non-gynecologic cancer
- Most useful in postmenopausal women
- Elevated in 80% of patients with epithelial ovarian cancer, but only 50% with stage 1 disease
-
Symptoms:
Cancer of the Ovary: Utility of CA-125
- Not useful as a screening test, even in high-risk women
- Pelvic ultrasound is also not useful as a screening test
- Can be useful in conjunction with other findings
- More likely to represent malignancy in POSTMENOPAUSAL WOMEN
- If there is a mass and elevated CA-125 in a postmenopausal woman, this is a reason for referral to gynecologic oncology.
- There are many reasons a CA-125 may be elevated in a premenopausal woman (Fibroids, endometriosis, PID, ascites of any etiology, inflammatory conditions, like; SLE, IBD)
- Because most of these occur in pre-menopausal women, this makes the CA-125 less useful.
- Biomarker panels are less useful as an initial assessment tool and are a better tool for a patient who is to undergo surgery to determine if Gyn-onc is needed.
- Many of these tests are still under investigation and their clinical utility is being studied.
Ovarian Cancer Risk: with Family History
- For a 35 year-old woman with a single affected family member:
- Risk increases from population risk of 1.6% to 5%, lifetime.
- For a woman with a BRCA1 gene mutation:
- Risk of ovarian cancer, fallopian tube cancer, or peritoneal cancer is 41-46% by age 70 years.
PCOS Overview
- PCOS is a complex endocrine disorder characterized by hyperandrogenism, ovulatory dysfunction, and the presence of polycystic ovaries on ultrasound.
- Though the exact cause is unknown, PCOS can cause metabolic sequelae escalating the risk of type 2 diabetes (T2DM) and cardiovascular disease.
Diagnostic Criteria and Incidence
- There's no single, universally accepted definition for PCOS.
- The Androgen Excess Society mandates hyperandrogenism as a necessary component for diagnosis.
- Diagnosing PCOS involves excluding secondary causes like adult-onset congenital adrenal hyperplasia (CAH), hyperprolactinemia, and androgen-secreting neoplasms.
- The estimated incidence of PCOS is approximately 10-13%.
Etiology and Pathophysiology
- Hyperinsulinemia and high androgen levels in PCOS patients can lead to decreased sex hormone-binding globulin (SHBG) levels, resulting in increased bioavailability of circulating androgens.
- Increased androgen levels can further stimulate androgen production in both the adrenal gland and the ovary.
Clinical Manifestations
-
Menstrual Dysfunction:
- Amenorrhea or oligomenorrhea (varying with age)
- Menorrhagia
-
Infertility:
- Reduced fertility due to ovulatory dysfunction.
-
Skin Disorders (Androgen Excess Related):
- Hirsutism: Excessive hair growth due to high androgens.
- Acne: Inflammation of the hair follicles, often triggered by increased androgens.
- Acanthosis Nigricans: Darkening and thickening of skin, particularly in skin folds.
-
Increased Risk of Insulin Resistance and Associated Disorders:
- Metabolic Syndrome: A cluster of factors including abdominal obesity, high blood pressure, high blood sugar, and abnormal cholesterol levels.
- Nonalcoholic Fatty Liver Disease: Fat accumulation in the liver unrelated to alcohol consumption.
-
Long-Term Metabolic Sequelae:
- T2DM: Increased risk due to insulin resistance.
- Cardiovascular Disease: Increased risk due to multiple risk factors.
-
Endometrial Cancer:
- Increased risk due to chronic anovulation and unopposed estrogen exposure.
-
Other:
- Chronic anovulation
- Centripetal obesity (fat accumulation around the waist)
- Increased risk of diabetes (but the strength of this association remains debated).
Suggested Evaluation for PCOS
-
Hormonal Assessment:
- Thyroid-stimulating hormone (TSH)
- Prolactin (PRL)
- Follicle-stimulating hormone (FSH)
- 17-hydroxyprogesterone (17-OHP)
- Testosterone
- Cholesterol
-
Imaging:
- Vaginal ultrasound to assess the endometrium and ovaries.
-
Other Assessments:
- Body Mass Index (BMI) and waist circumference to assess body fat distribution.
- Evaluate for signs of hyperandrogenism and insulin resistance.
- Document biochemical hyperandrogenemia.
- Perform a 2-hour oral glucose tolerance test (including fasting glucose).
- Assess fasting lipid and lipoprotein levels.
- Confirm presence of polycystic ovaries on ultrasound.
- Identify any endometrial abnormalities.
Treatment: Menstrual Irregularities (Not Attempting Conception)
-
Combined Hormonal Contraceptives (COCs):
- Prevent unopposed estrogen exposure.
- Increase SHBG levels, reducing the effects of androgens.
-
Progestins:
- Aim to avoid unopposed estrogen stimulation.
- COCs often provide more benefit due to their impact on binding globulins.
-
Insulin-Sensitizing Agents: Metformin
- Increase insulin sensitivity, reducing insulin levels.
- Lower circulating androgens and increase SHBG levels.
- Enhance glucose tolerance.
Treatment: Reducing CVD and Diabetes Risk (Not Attempting Conception)
-
Lifestyle Modifications:
- Weight management
- Healthy diet
- Regular exercise
-
Insulin-Sensitizing Agents:
- Metformin
-
Diabetes Prevention Program:
- Metformin can delay the development of DM in high-risk individuals with impaired glucose tolerance.
Treatment of Hirsutism
- Hirsutism is a common concern for PCOS patients, but there's no established primary treatment.
- Medical methods can often improve hirsutism symptoms.
Ovulation Induction
-
Letrozole (Preferred First Line):
- Aromatase inhibitor, converting androgens to estrogens.
- Increases FSH and LH levels, stimulating the development of a single follicle in the ovary.
- Typically prescribed for 5 days during the follicular phase.
- Ovulation is confirmed by elevated progesterone levels in the luteal phase.
-
Clomiphene Citrate (CC):
- Selective estrogen receptor modulator (SERM).
- Blocks estrogen receptors in the hypothalamus and pituitary, preventing negative feedback.
- Sustained FSH and LH stimulation of the ovaries, increasing the likelihood of a dominant follicle.
-
Combination Therapies:
- Metformin + CC may also be employed.
Referral
- For complex cases or fertility concerns, referral to a Reproductive Endocrinology and Infertility (REI) specialist is recommended.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz explores the definitions and classifications of abnormal menstruation, including conditions such as amenorrhea and dysmenorrhea. It also examines the common causes of primary amenorrhea, detailing ovarian, uterine, and hypothalamic factors. Test your understanding of these important medical concepts.
