origin of most abnormal vaginal bleeding
> 90% endometrial
what causes dysfunctional uterine bleeding*?
disorders of ovulatory cycle (anovulation)
MCC of dysfuncitonal uterine bleeding
idiopathic*
PCOS
abnormal vaginal bleeding in POST menopausal women
endometrial atrophy*
endometrial ATOROPHY/ HYPERPLASIA/CARCINOMA*
OR
*structural disorders of the endometrium/myometrium:
endometrial POLYPS, leiomyomas, adenomyosis, endometriosis
all CAUSE:
abnormal vaginal bleeding
abnormal vaginal bleeding during gestation
abnormal gestation*
early trimester miscarriage
ectopic gestation
mid/late trimester bleeding
post menopausal vaginal bleeding is considered…
cancer until proven otherwise
adnexal mass
lump in adnexa of uterus (usually FT or ovary)
causes of NON-neoplastic ovarian/tubal disease
PID*
ectopic gestation
cysts: paratubal, ovarian follicle, corpus luteal
endometriosis
Most neoplastic adnexal diseases occur here
ovary
Primary ovarian neoplasms
- epithelial
- sex cord/stromal tumors
- germ cell> dermoid cyst
tumors that are metastatic to the ovary*
appendix
colon
breast
stomach
Common gestational disorders
early trimester miscarriage**
ectopic gestation
abnormal placental implantation
previa, abruption, accreta
what can occur peripartum/postpartum
hemorrhage*
infection
DIC
category?
hydatidiform mole
choriocarcinoma
placental site trophoblastic tumor
trophoblastic neoplasias
HSV transmission
can occur during ASYMPTOMATIC/SUBCLINICAL viral shedding (w/out lesions)
extragenital infections caused by HSV
aseptic MENINGITIS
distant SKIN LESIONS
urinary BLADDER RETENTION (d/t sacral ANS dysfunction)
dx HSV
swabs from UNROOFED vesicles or active ulcers
PCR* for HSV DNA vs. viral culture (50% sensitivity)
most useful for rapid dx of HSV
Tzank smear (can be used w/ pts w/ active genital ulcers in the vesical phase)
used in evaluating HSV to assess risk status for future infection or if pregnant pt is at risk to infect baby
serology
PAP smear test screening ideally samples form what zone
TRANSFORMATION ZONE
spatula/brush device rotates around cervical os than smeared on slide
*1941
what does PAP smear testing take advantage of
CIN disease exfoliates abnormal dysplastic cells for YEARS prior to onset of invasive carcinoma**
allows you to catch it early!
main considerations for abnormal vaginal bleeding in REPRODUCTIVE age women
dysfunctional uterine bleeding**
pregnancy disorders
anatomic lesions (fibroids, polyps, endometriosis)
inherited/acquired hemostasis disorders
chief causes of vaginal bleeding in POST menopausal women
endometrial ATROPHY**
endometrial POLYPS**
endometrial hyperplasia
endometrial carcinoma
percent of women w/ endometrial carcinoma that present w/ abnormal uterine bleeding
75-90%
enendometrial histoloogy grades 1-2
type I carcinoma
accounts for 80% of endometrial Ca and is usually limited to the UTERUS
type I carcinoma
chronic estrogen excess and precursor endometrial hyperplasia can lead to…
type I carcinoma
*also associated w/ mutations in PTEN TSG
grade 3 endometriod w/ numerous rare subtypes: mucinous, squamous, undifferentiated
serous/clear cell carcinoma**
associated with ENDOMETRIAL ATROPHY and NO prior estrogen excess
seen more in ELDERLY pts than type I
type 2 endometrial Ca
associated w/ mut in p53 TSG tends to be a tumor w/ a higher stage and poor prognosis
type 2 endometrial CA (5 yr survival is only 35%)
“endometrial intraepithelial carcinoma” and phenomena of extra uterine disease WITHOUT mymetrial invasion require…
FULL STAGING SURGERY
Pelvic pain dysmenorrhea deep dyspareunia (pain w/ intercourse) cyclical bowel/bladder sx infertility
endometriosis
how do you dx endometriosis
LAPAROSCOPY w/ finding of PUNCTUATE SURFACE LESIONS: usually BLACK/BLUE/BROWN
“chocolate cyst”
markedly enlarged and cystic ovaries seen w/ endometriosis
MC myometrial pathology
Leiomyomas**
adenomyosis*
leiomyosarcoma
an “internal endometriosis” when endometrial GLANDS and STROMA are present in the MYOmetrium in up to 20% of the uterus
adenomyosis
leads to poorly circumscribed focal/nodular myometrial wall thickening
non-neoplastic source that when large (up to 2 cm) can simulate early cystic neoplasm
prominent follicle or corpus luteal cysts
oophoritis
secondary to PID
major non-neoplastic considerations when thinking about ovarian pathology
PCOS**
oophoritis secondary to PID
endometriosis/endometriotic cysts
Mentrual irregularity associated w/ oligo/anovulation and infertility
+
hyperandrogenism (hirsutism, acne, male pattern balding)
PCOS
in 6-8% of women
PCOS is associated w/
enlarged ovaries w/ polycystic fxs (seen by transvaginal US)
obesity
insulin resistance/diabetes
bilateral epithelial ovarian tumor
serous
unilateral epithelial ovarian tumor
mucinous
benign
adenoma
malignant
carcinoma
“borderline” epithelial ovarian tumor
usually serous
accounts for 70% of ovarian neoplasias in F 10-30
ovarian germ cell tumors (GCT)
accounts for MAJORITY of germ cell tumors
consists of SKIN/HAIR*, fat, brain, retina, bronchus, teeth, bone, cartilage, tissue
Mature cystic teratoma (dermoid cyst)**
*rarely see monodermal differentiation
what percent of teratomas are benign
99%
how do teratomas usually present
ASYMPTOMATIC/INCIDENTAL FINDING
ACUTE (torsion/infarction, cyst rupture, chemical peritonitis)
what percent of malignancies involving the ovary are from ADJACENT GYN CANCERS
5-10%
from FT, endometrium, peritoneum
what are non-gyn primary cancers that may spread to the ovaries (often BILATERALLY)?
COLORECTUM*
APPENDIX*
stomach
breast
signet ring cell adenocarcinoma from the stomach
Krukenberg tumor
mucinous peritoneal carcinomatosis (from appendiceal tumor)
pseudomyxoma peritonei
MC placental/maternal infection
Ascending** type
ascending infections of the placenta usually come from….and can occur with intact or ruptured membranes
vagina/cervix
ascending infection that is limited to fetal membranes
chorioamnionitis**
can also involve amniotic fluid, fetus, placental parenchyma
complication of placental infection
can cause PREMATURE membrane rupture (PROM)
preterm delivery
fetal sepsis
endomyometritis
source of most ascending placental infections
Bacterial
Often polymicrobial: streptococcus e. coli ureaplasma fusobacterium anaerobes
transmission of hematogenous infections from mom to fetus occur
transplacentally
infections that spread transplacentally to fetus
Toxoplasmosis TB o Rubella hCv CMV Syphillis
also malaria, listeriosis, HBV
infection usually transmitted perinatally
HIV
MC congenital viral infection
CMV
fetal infection via birth canal passage if active ulceration is present
HSV
MC cause of life-threatening newborn ifnection
group B strep**
what percent of 3rd trimester women are carriers of group B strep
20%
Fetal infections that can occur via birth canal
HSV
group B strep
chlamydia
gonococcus (newborn conjunctivitis)