Gynecology: Dysfunctional Uterine Bleeding Quiz
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Questions and Answers

Which of the following is a common cause of dysfunctional uterine bleeding?

  • Hormonal imbalances in the thyroid
  • Endometritis
  • Anovulatory cycles (correct)
  • Structural abnormalities of the uterus

    • What is a key risk factor for developing pregnancy-related endometritis?

  • Miscarriage
  • Vaginal delivery
  • Cesarean section delivery (correct)
  • Premature rupture of membranes

    • What is the characteristic symptom of dysfunctional uterine bleeding?

  • Painful periods
  • Heavy bleeding
  • Irregular bleeding (correct)
  • Bleeding between periods

    • Which of the following is not a characteristic of anovulatory cycles?

    <p>Formation of a corpus luteum (A)</p> Signup and view all the answers

    Which type of endometritis is often associated with a fever and abdominal pain?

    <p>Pregnancy-related endometritis (A), Acute endometritis (B)</p> Signup and view all the answers

    What type of cell does the squamous metaplasia of lactiferous ducts involve?

    <p>Cuboidal (C)</p> Signup and view all the answers

    Which of the following risk factors for breast cancer is protective?

    <p>Breastfeeding (B)</p> Signup and view all the answers

    What is the most common type of invasive breast carcinoma?

    <p>Invasive ductal carcinoma (C)</p> Signup and view all the answers

    Which type of breast cancer is associated with a higher risk of carcinoma in both breasts?

    <p>LCIS (A)</p> Signup and view all the answers

    The majority of breast carcinomas are a disease of:

    <p>Older post-menopausal women (D)</p> Signup and view all the answers

    Which of the following is NOT a type of breast cancer?

    <p>Periductal mastitis (A)</p> Signup and view all the answers

    What is the most important prognostic factor for invasive breast cancer?

    <p>Axillary lymph node metastases (A)</p> Signup and view all the answers

    What does the acronym TDLU stand for?

    <p>Terminal Ductal Lobular Unit (A), Terminal Ductal Lobular Unit (D)</p> Signup and view all the answers

    What is the common drug used for chemoprevention of LCIS?

    <p>Tamoxifen (C)</p> Signup and view all the answers

    What is the term for the dimpling of skin often associated with inflammatory carcinoma?

    <p>Peau d'orange (B)</p> Signup and view all the answers

    Which of the following is a predictive marker for breast cancer?

    <p>Estrogen receptor positivity (C)</p> Signup and view all the answers

    What is the most common location for invasive ductal carcinoma?

    <p>Upper outer quadrant (A)</p> Signup and view all the answers

    Which of the following is TRUE regarding Paget disease of the breast?

    <p>It is always associated with an underlying DCIS (B)</p> Signup and view all the answers

    What is the most common type of breast cancer that occurs in men?

    <p>Invasive ductal carcinoma (A)</p> Signup and view all the answers

    What is the name of the gene that contributes to about 85% of single gene familial breast cancer cases?

    <p>BRCA2 (A), BRCA1 (B)</p> Signup and view all the answers

    What is the classic regimen for treating pelvic inflammatory disease?

    <p>Doxycycline and ceftriaxone (A)</p> Signup and view all the answers

    Which of the following is a common cause of chronic endometritis?

    <p>Intrauterine devices (IUDs) (B)</p> Signup and view all the answers

    What is the hallmark finding on biopsy that indicates chronic endometritis?

    <p>Plasma cells (C)</p> Signup and view all the answers

    What is the most common type of endometrial polyp?

    <p>Benign (D)</p> Signup and view all the answers

    Which of the following is a potential risk factor for endometrial polyps?

    <p>Estrogen excess (B)</p> Signup and view all the answers

    What is the mechanism by which tamoxifen can cause endometrial polyps?

    <p>Tamoxifen acts as an estrogen agonist in the endometrium, causing proliferation and polyp formation. (D)</p> Signup and view all the answers

    Which of the following is NOT a common location for endometriosis?

    <p>Cervix (B)</p> Signup and view all the answers

    Which of the following theories about the pathogenesis of endometriosis is NOT widely accepted?

    <p>Infection (D)</p> Signup and view all the answers

    What is the classic symptom of endometriosis?

    <p>Pelvic pain (C)</p> Signup and view all the answers

    What is the definitive diagnosis of endometriosis?

    <p>Biopsy of lesion (A)</p> Signup and view all the answers

    Which of the following is NOT a feature of endometriosis?

    <p>It is associated with an increased risk of colon cancer. (D)</p> Signup and view all the answers

    Which of the following is the first-line therapy for endometriosis?

    <p>Oral contraceptive pills (OCPs) (A)</p> Signup and view all the answers

    Which of the following medications is a weak androgen and progesterone agonist that can be used to treat endometriosis?

    <p>Danazol (C)</p> Signup and view all the answers

    Which of the following is NOT a potential side effect of Danazol?

    <p>Increased risk of breast cancer (D)</p> Signup and view all the answers

    What is the classic finding on pelvic exam in a patient with adenomyosis?

    <p>Diffusely enlarged uterus (A)</p> Signup and view all the answers

    Which of the following is NOT a potential cause of endometrial hyperplasia?

    <p>Progesterone deficiency (D)</p> Signup and view all the answers

    What is the most common gynecologic cancer?

    <p>Endometrial cancer (C)</p> Signup and view all the answers

    Which of the following is NOT a risk factor for cervical cancer?

    <p>Heavy alcohol consumption (A)</p> Signup and view all the answers

    Which of the following is TRUE about the HPV vaccine?

    <p>It is effective in preventing cervical cancer caused by HPV. (B)</p> Signup and view all the answers

    What is the function of the p53 protein in the cell cycle?

    <p>It inhibits cell growth by blocking the G1 to S phase transition. (B)</p> Signup and view all the answers

    Which of the following is a characteristic of koilocytes, the epithelial cells infected by HPV?

    <p>Large, darkened nuclei (A)</p> Signup and view all the answers

    Which of the following statements is TRUE about vaginal adenosis?

    <p>It is a benign condition that can lead to clear cell carcinoma of the vagina. (D)</p> Signup and view all the answers

    Which of these is TRUE about the lymphatic drainage of the vagina?

    <p>The lower vagina drains to inguinal nodes. (B)</p> Signup and view all the answers

    What is the most common type of cervical cancer?

    <p>Squamous cell carcinoma (C)</p> Signup and view all the answers

    Which of these is NOT associated with maternal DES exposure?

    <p>Infertility in male offspring (D)</p> Signup and view all the answers

    What is the primary function of the E7 gene product of HPV?

    <p>Inhibits the function of the RB suppressor gene. (A)</p> Signup and view all the answers

    Which of the following is NOT a characteristic of DES?

    <p>An effective treatment for cervical cancer. (B)</p> Signup and view all the answers

    Which of the following statements is TRUE about cervical intraepithelial neoplasia (CIN)?

    <p>CIN2 and CIN3 are high-grade lesions with a high risk of progression to cancer. (D)</p> Signup and view all the answers

    Which of the following is a marker of rhabdomyosarcoma?

    <p>Desmin (B)</p> Signup and view all the answers

    Which of the following is a characteristic of clear cell carcinoma?

    <p>It is a rare malignancy associated with maternal DES exposure. (D)</p> Signup and view all the answers

    Which of the following is a TRUE statement about the transformation zone in the cervix?

    <p>All of the above. (D)</p> Signup and view all the answers

    Which of the following is a potential complication of untreated embryonal rhabdomyosarcoma?

    <p>Bladder obstruction (A)</p> Signup and view all the answers

    Flashcards

    Dysfunctional Uterine Bleeding

    Abnormal menstrual bleeding not due to structural causes; common gynecologic issue.

    Anovulatory Cycle

    Menstrual cycle without ovulation; lacks corpus luteum and progesterone, leading to irregular bleeding.

    Key cause of Anovulatory Cycle

    Most commonly due to failure of ovulation, leading to excess estrogen and endometrial growth.

    Acute Endometritis

    Inflammation of the endometrium, often due to bacterial infection postpartum, especially after C-section.

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    Polymicrobial Infections

    Infections involving multiple types of bacteria, often seen in acute endometritis postpartum.

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    Vaginal Carcinoma

    Very rare cancer, usually squamous cell, often related to HPV.

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    Clear Cell Carcinoma

    Rare vaginal or cervical malignancy linked to DES exposure, causing reproductive issues.

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    Diethylstilbestrol (DES)

    Nonsteroidal estrogen linked to reproductive tract abnormalities when used in pregnancy.

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    Vaginal Adenosis

    Presence of Mullerian tissue in the vagina, linked to in utero DES exposure.

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    Embryonal Rhabdomyosarcoma

    Rare tumor in children, resembles a grape-like mass in the vagina.

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    Desmin

    Muscle filament marker used in diagnosing rhabdomyosarcoma.

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    Cervical Cancer

    3rd most common gynecologic cancer; strongly associated with HPV.

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    Squamocolumnar Junction

    Area where squamous and columnar epithelium meet; site of 95% of cervical cancers.

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    Cervical Intraepithelial Neoplasia (CIN)

    Classification of cervical neoplasia; CIN1 is low grade, CIN2 and CIN3 are high grade.

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    Human Papillomavirus (HPV)

    Common sexually transmitted infection; implicated in cervical cancer.

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    HPV Oncogenes

    E6 and E7 genes promote cancer by inhibiting tumor suppressor proteins p53 and Rb.

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    Pap Smear

    Screening test for cervical dysplasia and cancer, detects koilocytes.

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    Endometrium

    Inner lining of the uterus; undergoes cyclical growth and shedding.

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    Proliferative Phase

    Phase of the menstrual cycle driven by estrogen, increases endometrial tissue.

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    Secretory Phase

    Phase of the menstrual cycle driven by progesterone, promotes gland activity.

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    Aureus Treatment

    Usual treatment includes dicloxacillin or cephalexin.

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    Periductal Mastitis Causes

    Inflammation of ducts mainly in female smokers due to smoking toxins.

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    Paget Disease Symptoms

    Erythema at the nipple indicating underlying malignancy and may cause discharge.

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    Ductal Carcinoma In Situ (DCIS)

    Malignant growth limited by intact basement membrane, fills ductal lumen.

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    Carcinoma Risk Factors

    Female gender, age, race, family history, and estrogen exposure increase risk.

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    Lobular Carcinoma In Situ (LCIS)

    Proliferation of cells limited by basement membrane, risk factor for invasive carcinoma.

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    Invasive Ductal Carcinoma

    Most common invasive breast cancer type (~80%), often found in outer breast quadrants.

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    Inflammatory Carcinoma Symptoms

    Erythema and swelling resembling orange peel, poor prognosis.

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    Prognostic Factors

    Axillary lymph node metastases are the most important predictor of invasive cancer prognosis.

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    Predictive Markers in Breast Cancer

    ER+, PR+, HER2 are crucial for treatment response and prognosis.

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    BRCA Gene Mutations

    Gene mutations associated with breast cancer and DNA repair, ~85% cases familial.

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    Male Breast Cancer

    Rare, usually occurs in older men, often presents as a subareolar mass.

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    Risk from Estrogen Exposure

    Increased exposure from early menarche, late menopause, and obesity raises risk.

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    Breast Cancer Detection

    Mammography detects micro-calcifications occurring in malignant lesions.

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    Breast Disorder Types

    Includes fibrocystic changes, proliferative disorders, and stromal tumors, mostly benign.

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    Broad-Spectrum Antibiotics

    Antibiotics effective against a wide range of bacteria.

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    Clindamycin Plus Gentamycin

    A classic antibiotic regimen with a cure rate over 90%.

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    Retained Products of Conception (RPOC)

    Placental or fetal tissue remaining in the uterus post-delivery. Symptoms include bleeding and pain.

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    Chronic Endometritis

    Chronic inflammation of the endometrium associated with infertility and plasma cells on biopsy.

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    Endometrial Polyps

    Benign growths in the endometrium, often asymptomatic, but may cause bleeding.

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    Tamoxifen

    A SERM used to treat ER+ breast cancer, acting as an agonist and antagonist in different tissues.

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    Endometriosis

    Presence of endometrial tissue outside the uterus, causing pain and infertility.

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    Cyclic Pelvic Pain

    Classic symptom of endometriosis leading to painful menstruation and potential infertility.

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    Dysmenorrhea

    Painful periods often associated with endometriosis due to ectopic tissue bleeding.

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    Ovarian Cysts

    Fluid-filled sacs on the ovary, can be functional or pathological.

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    Polycystic Ovarian Syndrome (PCOS)

    A condition marked by multiple cysts, irregular periods, and excess androgens.

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    Granulosa Cell Tumor

    Most common type of ovarian stromal tumor, may secrete estrogen and indicate malignancy risk.

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    Serous Cystadenocarcinoma

    Most common malignant ovarian tumor with complex cysts similar to fallopian tube cells.

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    BRCA1/BRCA2 Genes

    Genes associated with DNA repair and increased risk of breast and ovarian cancer when mutated.

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    CA-125

    A biomarker used to monitor ovarian cancer response and evaluate adnexal masses.

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    Study Notes

    Vaginal Cancer

    • Vaginal malignancies include vaginal carcinoma, clear cell carcinoma, and embryonal rhabdomyosarcoma (infants).
    • Vaginal carcinoma is rare, usually squamous cell carcinoma, and almost always involves HPV.
    • Risk factors are similar to cervical cancer.
    • Rarely a primary vaginal tumor; most commonly an extension of cervical carcinoma.
    • Upper vagina drains to iliac nodes; lower vagina drains to inguinal nodes.

    Clear Cell Carcinoma

    • Rare malignancy of the cervix or vagina.
    • Associated with maternal diethylstilbestrol (DES) exposure.
    • Nonsteroidal estrogen.
    • Used to prevent miscarriage and premature birth, removed from the US market in 1971.
    • Reproductive tract abnormalities in female babies.

    Diethylstilbestrol (DES)

    • Abnormal uterus and cervix.
    • Vaginal adenosis.
    • Vaginal clear cell adenocarcinoma.
    • High rate of infertility.

    Vaginal Adenosis

    • Upper vagina: Mullerian duct.
    • Lower vagina: Urogenital sinus.
    • Mullerian tissue in outer cervix/vagina.
    • Columnar epithelium in vagina.
    • Lack of normal squamous epithelium.
    • Associated with in utero DES exposure.
    • May lead to clear cell carcinoma.

    Sarcoma Botryoides

    • Also known as embryonal rhabdomyosarcoma.
    • Rare vaginal tumor in young children, may also occur in boys ("paratesticular tumors").
    • Scrotal or inguinal enlargement.
    • Derived from embryonal rhabdomyoblasts.
    • Immature muscle cells.
    • Clear, grape-like mass growing from the vagina.
    • May invade peritoneum, obstructing the bladder.
    • Treatment: surgery and chemotherapy.

    Desmin

    • Muscle filament.
    • Part of Z-disks in sarcomeres.
    • Marker of rhabdomyosarcoma.
    • 99% of rhabdomyosarcomas are positive for desmin.

    Cervical Cancer

    • Third most common gynecologic cancer in the US.
    • Human papillomavirus (HPV) detected in 99.7% of cases.
    • Identifiable in precursor stage via a Pap smear.
    • Occurs in the squamocolumnar junction.

    Cervical Neoplasia

    • Epithelial neoplasia occurring in the squamocolumnar junction (junction of squamous and columnar epithelium).
    • Endocervix: columnar epithelium.
    • Ectocervix: squamous epithelium.
    • Transformation zone where 95% of cancers arise.
    • Extends outward.

    HPV Cancer Risk

    • Persistent HPV infection can lead to cancer.
    • Malignancies associated with HPV infection include cervical, anal, penile, and oropharyngeal squamous cell cancers (mouth and throat).
    • Usually types 16 and 18 are associated with this.
    • High-risk subtypes are associated with cancer.

    HPV Virology

    • Non-enveloped, double-stranded circular DNA virus.
    • Multiple subtypes (1, 2, 6, 11, 16, 18).
    • Most common sexually transmitted infection.
    • Clinical disease depends on subtype (cutaneous warts, genital warts, cancer).
    • Two key oncogenes: E6 and E7.

    Cervical Carcinoma

    • Most common form is squamous cell carcinoma.
    • Second most common form is adenocarcinoma (endocervix origin).
    • Almost always in women with HPV infection.
    • Usually occurs in the 40s or 50s.
    • Usually affects women who don't get screened.

    Cervical Carcinoma Diagnosis

    • Colposcopy (use of a colposcope to provide illuminated, magnified view of the cervix).
    • Biopsy often taken after an abnormal Pap smear.

    Pap Smear

    • Secondary prevention of cervical neoplasia.
    • Screening test for cervical dysplasia and carcinoma.
    • Used to detect Koilocytes (epithelial cells infected with HPV).
    • Large, darkened nuclei are often visible on a smear.
    • Best at detecting squamous cell carcinoma.

    Endometrial Disorders

    • Myometrium = Smooth muscle
    • Endometrium = Mucosal surface
    • Glands and stroma are within the endometrium
    • Growth and shedding during menstrual cycle.
    • Estrogen stimulates growth; progesterone stimulates secretory activity; progesterone withdrawal leads to menstruation.
    • Proliferative phase—estrogen driven, glands and stroma increase; Secretory phase—progesterone driven, proliferation decreases, secretory vacuoles appear, prominent spiral arterioles.

    Dysfunctional Uterine Bleeding (DUB)

    • Abnormal bleeding not due to a structural cause.
    • Uterus and endometrium have normal structures.
    • Very common gynecologic problem.
    • Most common cause is anovulatory cycles.

    Anovulatory Cycle

    • No ovulation; no corpus luteum formation.
    • Absence of luteal phase secretions.
    • Excessive endometrial growth from estrogen ("unopposed growth").
    • Irregular bleeding.

    Endometritis

    • Inflammation of the endometrium.
    • Acute or pregnancy-related.
    • Chronic/non-pregnancy related.

    Acute Endometritis

    • Occurs after delivery or miscarriage (post-partum).
    • Bacterial infection.
    • Key risk factor: cesarean section delivery.
    • Prophylactic antibiotics often used before C-section.
    • Often involves myometrium ("metritis").
    • Fever, abdominal pain, and uterine tenderness are common symptoms.
    • Usually diagnosed clinically.
    • Polymicrobial infections involve gram positive, gram negative, anaerobes (ex. Staph, strep, E. coli, and Bacteroides).
    • Treatment with broad-spectrum antibiotics (ex., clindamycin + gentamycin or ampicillin-sulbactam).

    RPOC

    • Retained products of conception: placental/fetal tissue remaining in the uterus after delivery or miscarriage.
    • Prone to infection, leading to endometritis.
    • Diagnosed by history and imaging.
    • Treated with antibiotics sometimes with surgery.

    Chronic Endometritis

    • Intrauterine devices (IUD) may cause an ascending infection.
    • This can lead to infection of the uterus, fallopian tubes and/or ovaries, known as pelvic inflammatory disease (PID).
    • Caused by chlamydia or gonorrhea.
    • Treatment: antibiotics.
    • Tuberculosis spread hematogenously from lungs; biopsy: acid-fast bacilli; indicated for infertility diagnosis.
    • Associated with infertility; biopsy hallmark: plasma cells.

    Endometrial Polyps

    • Hyperplastic growth of glands and stroma.
    • Most (95%) benign.
    • Project from endometrium (exophytic mass).
    • Often asymptomatic.
    • May cause painless uterine bleeding.
    • Removed surgically to stop bleeding and prevent infection.
    • Small chance of malignancy.

    Endometriosis

    • Endometrial tissue outside the uterus (glands and stroma).
    • May occur anywhere.
    • Common locations: ovaries, fallopian tubes, uterosacral ligaments, and pelvic peritoneum.
    • Exact etiology unknown; several theories exist (retrograde menstruation, metastasis, metaplasia, stem cells).
    • Symptoms include cyclic pelvic pain, dysmenorrhea/menorrhagia.
    • Infertility may result from ovarian or fallopian tube damage.
    • May cause issues with pain during intercourse, defecation, urination.
    • Diagnosis is often done through physical exam, image tests (such as ultrasound or MRI) or surgical exploration (including biopsy).

    Tamoxifen

    • SERM (selective estrogen receptor modulator).
    • Breast cancer drug that is an estrogen receptor antagonist in breast tissue and an estrogen agonist in other tissues (bone/uterus).
    • Can cause endometrial problems in some cases.

    Leiomyoma (Fibroid)

    • Benign tumor of the myometrium (smooth muscle).
    • Typically multiple tumors.
    • Occur in premenopausal women.
    • Growth stimulated by estrogen, resolves at menopause.
    • Usually asymptomatic, can cause irregular bleeding or pelvic pain.

    Leiomyosarcoma

    • Malignant smooth muscle tumor of the uterus.
    • Arise de novo (not from fibroids).
    • Occurs in postmenopausal women.
    • Usually a single large mass.

    Endometrial Hyperplasia

    • Endometrium stimulation by unopposed estrogen.
    • Absence of progesterone stimulation and/or withdrawal.
    • Usually occurs in peri/postmenopausal women.
    • Menstruation slowed or stopped.
    • Anovulation leads to lack of progesterone from ovary.
    • Any estrogen source results in hyperplasia.
    • Sources of estrogen: obesity, PCOS (polycystic ovarian syndrome) and tamoxifen and supplemental estrogen.

    Endometrial Carcinoma

    • Most common gynecologic cancer in postmenopausal women.
    • Average age of diagnosis: ~60 years old.
    • Often associated with anovulation/unopposed estrogen exposure.
    • Classic presentation: abnormal uterine bleeding.
    • Diagnosed via endometrial biopsy, often preceded by hyperplasia.
    • Classifies histologically into types endometriod (estrogen-dependent hyperplasia) and serous (estrogen-independent).
    • HNPCC (hereditary nonpolyposis colorectal cancer) has some association.

    Ovarian Cysts

    • Frequently detected by ultrasound.
    • Often functional/originate from normal ovarian structures.
    • Common functional cysts: follicle, corpus luteum, and theca-lutein.

    Ovarian Follicle

    • Egg surrounded by cells; theca and granulosa cells.
    • Antrum (filled with fluid).
    • Oocyte (immature egg).

    Hormone Synthesis (Estrogens)

    • Theca cells convert cholesterol to androstenedione (androgen); stimulated by LH.
    • Granulosa cells convert androstenedione to estradiol (estrogen); stimulated by FSH.

    Follicular Cysts

    • Common in young women.
    • Derive from an ovarian follicle in the first half of the menstrual cycle.
    • Failure of the follicle to rupture, or rupture and resealing.
    • Lined by granulosa cells; filled with estrogen; may stimulate endometrial growth.
    • Classic symptoms: pain and irregular bleeding.

    PCOS (Polycystic Ovarian Syndrome)

    • Multiple follicular cysts.
    • Amenorrhea.
    • Excess androgens.
    • Insulin resistance/diabetes.

    Corpus Luteal Cysts

    • Large, functional structure in second half of the menstrual cycle.
    • Failure to involute leads to cyst formation.
    • Produces progesterone.
    • May delay menstruation.
    • Presents clinically as pain and adnexal (ovarian/fallopian tube) mass.

    Theca-Lutein Cysts

    • Usually bilateral, multiple cysts.
    • Luteinized theca cells with edema (theca cell hyperplasia).
    • Benign.
    • Associated with elevated β-hCG levels (ex., twins, molar pregnancy).
    • Usually regress.

    Ovarian Epithelial Tumors

    • Most common type of ovarian tumor.
    • Germ cell tumor (oocytes, supporting cells/theca and granulosa).
    • Sex cord stromal tumor (fibroblasts).
    • Surface epithelium—adenomas/carcinomas.

    Ovarian Surface Epithelium

    • Simple cuboidal epithelium derived from coelomic epithelium.
    • Forms the outer layer of female gonads.
    • Also lines other organs (body wall, liver, lungs, GI tract).

    Epithelial Cell Tumors (Clinical Features)

    • Often a "silent" disease, presenting as an adnexal mass.
    • Detected on physical exam or imaging.
    • Vague abdominal symptoms, including bloating, early satiety, and pelvic/abdominal pain.
    • Rarely presents acutely.
    • May spread through peritoneum, causing ascites or pleural effusion.

    Epithelial Cell Tumors (Histologic Subtypes)

    • Most common subtypes: serous, mucinous, and endometrioid.
    • Serous: most common type, cysts filled with water.
    • Mucinous: cysts filled with mucous; often larger and multiloculated.
    • Endometrioid: similar to endometrium.

    Serous Cystadenoma

    • Often bilateral.
    • Cyst filled with watery fluid.
    • Thin cyst wall with single cell lining.

    Serous Cystadenocarcinoma

    • Most common malignant ovarian tumor.
    • Complex cysts with watery fluid.
    • Growth of epithelial layer (similar to fallopian tube cells).

    Psammoma Bodies

    • Microscopic finding.

    Mucinous Tumors

    • Mucinous cystadenoma (thin walled cyst filled with mucous, often larger).
    • Mucinous cystadenocarcinoma (malignant variant of cystadenoma).
    • Can spread and cause pseudomyxoma peritonei (diffuse gelatinous material in abdomen/pelvis).

    Pseudomyxoma Peritonei

    • Mucinous spread to abdomen.
    • "Mucinous ascites" (diffuse gelatinous material in abdomen/pelvis).
    • Bowel obstruction may occur.
    • Seen in appendiceal cancer.

    Endometrioid Tumors

    • Contain tubular glands similar to endometrium.
    • Often occur in patients with endometriosis.
    • Good prognosis.
    • Often identified at early stage.
    • Sensitive to chemotherapy.

    Brenner Tumor

    • Rare subtype of epithelial ovarian tumor.
    • Contains bladder epithelial (transitional) cells.
    • Usually benign.
    • Often found incidentally.
    • "Coffee bean" nuclei seen on biopsy.

    Epithelial Cell Tumors (Risk Factors)

    • More ovulation associated with higher risk.
    • Possible risk factors include advanced age, early menarche, late menopause, nulliparity (lack of childbirth).

    BRCA1 and BRCA2

    • Gene mutations associated with breast and ovarian cancer.
    • More common among Ashkenazi Jews (1 in 40): BRCA1 and BRCA2 genes → DNA repair proteins.
    • Autosomal dominant inheritance.

    HNPCC

    • Hereditary non-polyposis colorectal cancer/Lynch Syndrome.
    • Germline mutation in DNA mismatch repair genes.
    • Commonly associated with colon cancer and an increased risk of endometrial cancer.

    Male Breast Cancer

    • Incidence: 1% compared to women; typically occurs in older men (60-70).
    • Often presents as a subareolar mass with/without discharge.
    • Associated with Klinefelter syndrome and BRCA2 gene mutations.

    CA-125

    • Biomarker for epithelial ovarian cancer (poor performance for screening).
    • Useful for evaluating adnexal mass and monitoring treatment response.
    • Serial measurement for follow-up.

    Ovarian Stromal Tumors

    • Including granulosa cell tumors, sertoli-leydig cell tumor, fibromas and thecomas

    Granulosa Cell Tumors

    • Most common ovarian stromal tumor.
    • Derived from granulosa-type cells (may contain theca cells).
    • Secrete estrogens.
    • Usually unilateral.
    • May become malignant ("malignant potential").

    Adult Subtype (Granulosa Cell Tumors)

    • Median age: 50-54 years old.
    • Symptoms from excess estrogen production.

    Juvenile Subtype (Granulosa Cell Tumors)

    • Develop before puberty.
    • "Sexual precocity" from excess estrogen production.
    • Puberty at a very early age (<8 years old).

    Granulosa Cell Tumors (Clinical Features)

    • Often present as a large adnexal mass.
    • Possible symptoms related to estrogen include endometrial hyperplasia and uterine bleeding, bleeding in postmenopausal women, and breast tenderness.
    • Often associated with endometrial carcinoma; endometrial biopsy often performed for diagnosis.

    Granulosa Cell Tumors (Histology)

    • Pathognomonic finding: Call-Exner bodies.
    • Cells surrounding a space filled with pink material.

    Fibroma

    • Benign tumors of fibroblasts.
    • Solid, white, usually unilateral.
    • No hormone activity.
    • Often occurs in postmenopausal women.
    • Usually presents as a pelvic/adnexal mass.
    • Associated with ascites (Meigs syndrome).

    Ascites and Meigs Syndrome

    • Ascites: occurs in 40% of ovarian fibroma cases.
    • Fibroma (Meigs syndrome).
    • Ascites (effusion).
    • Unclear etiology, possibly related to capillary leak from tumor factors.
    • Removal of tumor usually resolves ascites and effusion.

    Thecoma

    • Usually co-exists with fibromas ("fibrothecoma").
    • Pure thecoma: rare.
    • May produce estrogens.
    • May lead to endometrial hyperplasia.

    Sertoli-Leydig Cell Tumor

    • Tumor of Sertoli and Leydig cells.
    • Often occurs in males as testicular tumors.
    • May occur in the ovary.
    • Tumor produces androgens.
    • Symptoms include breast atrophy, amenorrhea, and sterility (anovulation).

    Ovarian Germ Cell Tumors

    • Occur in young women (usually 10-30 years old).
    • Many tumors secrete AFP or β-hCG.
    • Tumor of germ cell derivatives.

    Teratoma

    • Most common overall germ cell tumor.
    • Cells from all three germ layers (ectoderm, endoderm, mesoderm).
    • Benign form = dermoid cyst.
    • Malignant form = immature teratoma.

    Dermoid Cyst (Mature Cystic Teratoma)

    • Similar structure to the skin, contains hair, squamous cells, sebaceous material, calcifications, and tooth-like material.
    • Usually asymptomatic and unilateral (10-20% bilateral).
    • Distinguished on ultrasound: characteristic features on ultrasound; usually removed surgically.

    Struma Ovarii

    • Specialized subtype of teratoma made up mostly of thyroid tissue.
    • May cause hyperthyroidism; symptoms include hyperthyroid symptoms and ovarian mass.

    Immature Teratoma

    • Malignant teratoma; solid mass; immature fetal tissue; neural tissue most commonly present, elements from all three germ layers.

    Dysgerminoma

    • Most common malignant germ cell tumor.
    • Similar to seminoma in males (though much less common in males).
    • Usually unilateral (in 90% of cases).
    • May produce LDH, β-hCG, or placental alkaline phosphatase (tumor markers).
    • Highly responsive to treatment.

    Dysgerminoma (Histology)

    • Undifferentiated germ cells, nests of large cells with clear cytoplasm, central nuclei, "fried egg" appearance.

    Yolk Sac Tumor (Endodermal Sinus Tumor)

    • Rare malignant germ cell tumor.
    • Derives from extraembryonic yolk sac cells.
    • Similar to endodermal sinuses of yolk sac in rats.
    • Secretes alpha-fetoprotein (AFP).
    • Large, solid mass; necrosis and hemorrhage; abdominal pain; also occurs in males in testes.

    Yolk Sac Tumor (Histology)

    • Hallmark: Schiller-Duval bodies, glomerular-like structures ("glomeruloid").

    Choriocarcinoma

    • Rare malignant gestational neoplasm.
    • Often follows normal or molar pregnancy.
    • Rarely may occur in ovary as a germ cell tumor.
    • Syncytiotrophoblast and cytotrophoblast cells; no villi formation.
    • Secretes human chorionic gonadotropin (hCG).
    • Aggressive hematogenous spread (often to lungs, liver, and bone at diagnosis); more difficult to treat/cure than placental tumors; mimics LH, may cause precocious puberty in girls and irregular vaginal bleeding.

    Breast Tissue

    • Produces milk for babies; made up of ~15-20 lobes, with lobules attached to ducts draining to nipple. Lobes are surrounded by fat and stroma.

    Breast Epithelium

    • Lines ducts and lobules; contains two layers over basement membrane—luminal epithelial cells secrete milk, myoepithelial cells are contractile and respond to oxytocin.

    Milk Lines

    • Two thickenings of ectoderm (axilla to groin) that form breasts and nipples; mammary ridges disappear later, but extra nipples can develop.

    Hormones (Breast Tissue)

    • Breast tissue is hormone-sensitive.
    • Estrogens—major effect on ducts, increase breast size during puberty and menstrual cycle.
    • Progesterone—primarily affects lobules, growth of lobules during pregnancy and preparation for delivery.
    • Prolactin—increased levels in pregnancy lead to increased breast size; important for lactation.

    Pregnancy (Breast Development)

    • Estrogens, progesterone, and prolactin drive breast growth during pregnancy; no significant milk production during pregnancy; progesterone and estrogen inhibit milk formation.
    • Delivery leads to fall in hormones, and milk production begins.

    Lactation Maintenance

    • Removal of milk and nipple stimulation triggers prolactin from anterior pituitary and oxytocin from posterior pituitary; absence of removal leads to involution.
    • Lactation inhibits ovulation.

    Breast Milk Contents

    • Lactose, antibodies, macrophages, lymphocytes, lactoferrin, and lysozymes.

    Breastfeeding Benefits (Child)

    • Lower risk of infant infections (GI, pulmonary); possible long-term benefits include reduced allergies, diabetes, and obesity.

    Breastfeeding Benefits (Mother)

    • Decreased risk of breast and ovarian cancer, cardiovascular disease.
    • Faster childbirth recovery, reduced stress, maternal-infant bonding, and enhanced weight loss.

    Galactorrhea

    • Milk production outside of lactation.
    • Common complaint is nipple discharge.
    • Typically caused by prolactin (milk production); prolactin release inhibited by dopamine in hypothalamus.

    Galactorrhea Causes

    • Chronic nipple stimulation (neurogenic).
    • Prolactinoma (pituitary tumor).
    • Drugs (typical antipsychotics, such as Haldol).

    Gynecomastia

    • Breast development in males.
    • May be physiological (newborn, puberty, or older age).
    • May occur with galactorrhea.
    • Associated with physiological causes like cirrhosis, Klinefelter syndrome, or drug interactions.

    Fibrocystic Breast Changes

    • Group of breast changes/lesions; all are benign—not associated with cancer risk.
    • In premenopausal women; presents as lumpy, bumpy breasts.
    • Simple cysts, fibrosis, and apocrine metaplasia.

    Proliferative Breast Disorders

    • Proliferation of epithelial cells; small increase in cancer risk.
    • Epithelial hyperplasia (normal cells), sclerosing adenosis, intraductal papilloma.

    Epithelial Hyperplasia

    • Normal ducts/lobules: double-layer epithelium.
    • Hyperplasia: increased luminal and myoepithelial cells; distended ducts and lobules; lumen filled with cell clusters.

    Sclerosing Adenosis

    • Increased number of compressed acini.
    • Dense stroma.
    • May result in calcifications.

    Intraductal Papilloma

    • Growth of ductal epithelial cells within ducts or lactiferous sinuses.
    • Proliferation of normal epithelial cells.
    • Finger-like projections ("papillae").
    • Often presents with bloody or serous nipple discharge.

    Stromal Tumors

    • Most breast cancers are carcinomas arising from epithelial cells.
    • Stromal tumors include fibroadenoma and phyllodes tumor.
    • Both arise from intralobular stroma; sometimes stromal growth triggers epithelial proliferation.

    Fibroadenoma

    • Most common benign breast tumor in women 15-35.
    • Made of fibrous and glandular tissue; well-defined, solid, mobile mass.
    • Hormone-sensitive, increasing in size during menstrual cycle/pregnancy, decreasing after menopause.

    Phyllodes Tumor

    • Stromal fibroepithelial tumor.
    • Usually benign, low-grade tumors are similar to fibroadenomas, while high-grade tumors can metastasize.
    • Most often occurs in older women (>60).
    • Leaf-like stroma cover by epithelial cells; may present as large mass.

    Mammary Duct Ectasia

    • Benign inflammatory condition; older women (~50); classically occurs in multiparous women; distension (ectasia) of subareolar ducts (nipple), due to chronic inflammation and fibrosis.
    • Presents as breast mass with thick, white discharge. Usually no pain or erythema.
    • Differentiate from breast cancer.

    Fat Necrosis

    • Result of trauma (sports injury, seatbelt injury); benign, inflammatory process often mimicking breast cancer.
    • May present as painless mass in the breast; often asymptomatic.
    • Calcifications may be visible on mammogram.
    • Biopsy shows fat necrosis with inflammatory cells.

    Lactational Mastitis

    • Occurs in women during breastfeeding; trauma to skin around nipple; often fever and malaise; commonly caused by S. Aureus.
    • Usual treatment = dicloxacillin.

    Periductal Mastitis

    • Inflammation of subareolar ducts; more than 90% cases in female smokers.
    • Smoking is harmful to ducts, potentially causing relative vitamin A deficiency.
    • Inflammation → squamous metaplasia; duct cells change from cuboidal → squamous.
    • Periareolar mass with redness, tenderness, and warmth. Often 2º infection requiring antibiotics, and sometimes incision/drainage.

    Breast Disorders Summary

    • Fibrocystic changes—benign (cysts, fibrosis, apocrine metaplasia).
    • Proliferative breast disorders—increased cancer risk (epithelial hyperplasia, sclerosing adenosis, intraductal papilloma).
    • Stromal tumors—benign (fibroadenoma, phyllodes tumor).
    • Summary of Breast Disorders: mammmary duct ectasia (white discharge), fat necrosis (trauma), mastitis (erythema and tenderness).

    Breast Carcinoma

    • Most common non-skin cancer in women.
    • Second most deadly cancer.
    • Mostly a disease of older postmenopausal women; incidence increases after age 30.
    • Rare before age 25; can occur in men.

    Breast Carcinoma (Risk Factors)

    • Female gender (99% of cases).
    • Age (peak incidence 70–80 years).
    • Race (Non-Hispanic white women—greatest risk).
    • 1st-degree relative with breast cancer—mother, sister, or daughter.
    • Increased estrogen exposure (early menarche/late menopause, obesity).
    • Breastfeeding protective.

    Breast Carcinoma (Detection)

    • Palpable breast mass or microcalcifications (detected via mammography).
    • Can occur in malignant lesions; also seen in fat necrosis and sclerosing adenosis.

    Breast Carcinoma (Major Types)

    • Almost all (95%) are adenocarcinomas, arising from epithelial cells of ducts/lobules.
    • Ductal versus lobular (ductal resembles duct cells, lobular resembles lobules).
    • In situ versus invasive (in situ = limited by the basement membrane).
    • Ductal carcinoma in situ (DCIS): malignant growth of epithelial cells filling ductal lumen, often microscopic; limited by the basement membrane.
    • Important subtypes: comedo and cribriform.
    • Lobular carcinoma insitu (LCIS): noninvasive lesion, can be bilateral, does not lead to microcalcifications and often discovered incidentally, may become invasive.
    • Invasive ductal carcinoma: most common; invasive; outer quadrant of the breast often affected.
    • Invasive lobular carcinoma: cells grow in single file, often bilateral.
    • Important to note that inflammatory carcinoma also exists (erythema, swelling; often mimics infection).

    Breast Carcinoma (Prognosis)

    • Axillary lymph node metastases—most important prognostic factor.
    • Sentinel node biopsy often performed.

    Breast Carcinoma (Predictive Markers)

    • Important for prognosis and therapy.
    • Estrogen receptor positivity (ER+), progesterone receptor positivity (PR+), human epidermal growth factor receptor 2 (HER2).
    • ER+/PR+ tumors can respond to Tamoxifen (SERM); HER2+ tumors may respond to Trastuzumab.
    • "Triple negative" tumors are highly aggressive.

    Familial Breast Cancer

    • Cause about 10% of breast cancers
    • BRCA1 and BRCA2 gene mutations—associated with increased breast cancer risk
    • Genes code for DNA repair proteins; also associated with ovarian cancer (BRCA1), male breast cancer and pancreatic cancer (BRCA2).

    Additional Information for Further Study

    • Look up specific clinical presentations and treatments for each category.

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