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Slide 1-

Clinical Aspects of Gynecologic Diseases M2 - Reproduction Sequence Caren M. Stalburg, M.D. M.A. Clinical Assistant Professor Obstetrics and Gynecology Medical Education Winter, 2009
Slide 2-

Learning Objectives For diseases of the vulva, vagina, cervix, uterus, and ovaries understand and describe: 1. The presentation of disease 2. The evaluation of disease 3. The basic treatment of disease
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Overlying Themes Age of patient ? Pregnant History and symptoms Physical exam and pertinent findings Diagnostic testing Medical versus Surgical management Future fertility concerns
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Patient Scenarios Young woman with vaginal itching and discharge Middle aged woman with pelvic pain and heavy periods Post-menopausal woman with vague history of bloating and vaginal spotting Peri-menopausal woman with chronic yeast infection College-aged student with painful periods and pain with intercourse Young woman with pelvic pain and irregular periods
Slide 5-

Diseases of the Vulva Presentation: Irritation/pruritis/burning, lesions Evaluation: History, inspection, palpation, culture, biopsy Differential Diagnoses: Infection Dermatologic condition Neoplasia
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Vulvar Infections Candida Condyloma acuminatum Herpes simplex Bartholin’s gland abscess Molluscum contagiosum Pthirus pubis (crab louse) Sarcoptes scabiei (itch mite) SkinSight Operational Medicine 2001
Slide 7-

Genital Herpes Simplex Virus Double-stranded DNA virus Primary outbreak fever, malaise, lesions, urinary symptoms Recurrent outbreak less severe, prodrome, lesions Acyclovir: inhibit viral thymidine kinase HSV and pregnancy
Slide 8-

Ulcerative lesions Erythematous base Bilateral Source Undetermined
Slide 9-

Dermatologic Conditions of Vulva Chemical irritation/contact dermatitis Squamous cell hyperplasia Lichen sclerosis Psoriasis Nevi Seborrheic dermatitis Fibroma/Lipoma
Slide 10-

Lichen sclerosis Vulva appears thin “Tissue paper” On biopsy: Loss of rete pegs Inflammatory cells Source Undetermined
Slide 11-

VIN/Vulvar carcinoma Women aged 60-70, now more bimodal Pruritis, mass, pain, ulceration Increased RR: coffee, occupation, h/o vulvitis, HPV Melanoma Local invasion via lymphatics Treatment involves wide local excision Good prognosis
Slide 12-

Biopsy lesions for diagnosis! Source Undetermined Source Undetermined
Slide 13-

Diseases of the Vagina Abnormal vaginal discharge What’s normal? Acidic lactobacilli Variations with menstrual cycle/hormones DIFFERENTIAL Infections Vaginal Carcinoma DIAGNOSIS Wet prep Culture Biopsy
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Bacterial Vaginosis Grey, homogenous, non-inflammatory discharge pH of 5.0-5.5 Clue cells Amine odor with addition of 10% KOH Polymicrobial Lack of lactobacilli Role in pre-term labor Treatment with metronidazole or clindamycin Source Undetermined
Slide 15-

Candida Vulvovaginal yeast DM, Pregnancy, Antibiotics, Obesity Itching, irritation, dyspareunia Thickened white d/c adherent to side walls Pseudohyphae on KOH wet prep, pH <4 Antifungal treatment Source Undetermined
Slide 16-

Trichomoniasis Protozoan T. vaginalis, sexually transmitted Diffuse, malodorous, yellow-green d/c, itch Flagellated, mobile protozoa on wet prep +WBC’s on wet prep Metronidazole 2 grams orally 500 mg po BID for 7 days
Slide 17-

T. vaginalis Source Undetermined Source Undetermined
Slide 18-

Atrophic vaginitis Due to low estrogen levels Menopause Breast feeding Itching, irritation, burning Immature squamous epithelial cells on wet prep, rounded basal cells Systemic or intravaginal estrogen Source Undetermined
Slide 19-

Vaginal Carcinoma Rare, mean age 60-65 Presents with vaginal bleeding, foul discharge SCCA as metastatic spread Clear cell carcinoma and DiEthylStilbesterol (DES) Sarcoma botryoides: < 5 yo, red-tan grape clusters BIOPSY Treatment—radiation, surgical excision
Slide 20-

Diseases of the Cervix Variety of presentations: discharge, pain, post- coital bleeding, incidental Differential Cervicitis: GC/chlam/HSV/trich Cervical polyps Cervical dysplasia: HPV Cervical cancer: SCCA, adenoCA
Slide 21-

Chlamydia trachomatis Most common, often present with GC Obligatory intracellular bacterium Cervicitis, salpingitis, urethritis Infertility Ectopic pregnancy Neonatal conjunctivitis, blindness, pneumonitis Azithromycin, EES, Doxycycline, Ofloxacin
Slide 22-

Neisseria gonorrhea Humans as only host Urogenital tract Disseminated gonoccal infection bacteremia vesicular, centrally necrotic skin lesions arthritis Ceftriaxone 125 mg IM etc. + Doxy
Slide 23-

Cervical polyps Common Benign Irregular spotting Post-coital bleeding Polypectomy Geneva Foundation for Medical Education and Research Also see: http://health.allrefer.com/health/cervical-polyps-cervical-polyps.html
Slide 24-

Cervical dysplasia Risk factors Early coitarche Multiple/Serial partners Tobacco use HPV 16,18,31,33,35,39 Immunosuppression/HIV Other STDs
Slide 25-

Cervical Cytology Papanicolau smear, ThinPrep Exfoliative cytology HPV typing Screening tool Must biopsy for diagnosis Image of Pap smear procedure removed Source Undetermined Original image can be viewed here
Slide 26-

Colposcopy Visualization of cervix under magnification Must see entire transformation zone Acetic acid Assess for vascular changes Biopsy Endocervical currettage S. Kellam Source Undetermined
Slide 27-

Management of abnormal pap www.asccp.org Majority of CIN I regresses in one year Ok to follow with serial pap smears q 3-4 months Smoking cessation High grade abnormalities likely to progress therefore treat AGUS Cone biopsy, Loop electrosurgical excision procedure (LEEP)
Slide 28-

Cone biopsy, LEEP Source Undetermined
Slide 29-

Female Cancer Deaths, 2007 estimates from www.cancer.org C. Stalburg
Slide 30-

Cervical Cancer Majority is squamous cell HPV related Present with AUB, PCB, often painless Late symptoms: back pain, wt. loss, foul d/c Invasion via local spread/extension Early stages treated with radical hysterectomy Later stages treated with radiation
Slide 31-

Endometriosis 1-2% of general population 30-50% women with infertility 20% patients with chronic pelvic pain Pathogenesis Retrograde menstruation, vascular/lymphatic dissemination, coelomic metaplasia, iatrogenic, hereditary? Location of lesions Dependent portions of pelvis Distant sites
Slide 32-

How do patients with endometriosis present? Pelvic pain Infertility Dysmenorrhea Dyspareunia GI symptoms/dyschezia Some with AUB Severity of disease does NOT correlate with symptoms Source Undetermined
Slide 33-

Management of endometriosis On exam: fixed retroverted uterus, uterosacral nodularity, tender ovaries Diagnostic tests?? laparoscopy Treatment based on: Symptoms Severity Location of disease Future fertility
Slide 34-

Source Undetermined (All Images)
Slide 35-

Management of endometriosis Surgical Medical Goal is amenorrhea, decrease pain OCPs Progestins Danazol Lupron/GnRH agonist
Slide 36-

Adenomyosis Endometrial glands/stroma in the myometrium Incidental finding on hysterectomy specimen Dysmenorrhea, menorrhagia Enlarged, soft uterus, globular, tender ?pathogenesis Temporize with NSAIDs, hormonal suppression Hysterectomy
Slide 37-

Diseases of the Uterus Presentation: AUB, dysmenorrhea, menorrhagia, pain, pressure, infertility Differential Endometrial polyps Leiomyomata Endometrial hyperplasia Endometrial carcinoma
Slide 38-

Endometrial polyps Overgrowth of endometrial glands/stroma Peak incidence age 40-49 ?etiology Irregular/abnormal bleeding Ultrasound with hysterosonogram +/- endometrial biopsy Hysteroscopy, D&C
Slide 39-

Endometrial polyps Source Undetermined
Slide 40-

Leiomyomata Monoclonal smooth muscle cell tumor Most frequent pelvic tumor Location within uterus affects presentation, symptoms Intramural Subserosal Submucosal Cervical
Slide 41-

Source Undetermined (All Images)
Slide 42-

Fibroids What types of symptoms???? Dependent on location AUB Dysmenorrhea Menorrhagia Pain Pressure Infertility Urinary symptoms
Slide 43-

Diagnosis of Leiomyomata Pelvic exam How big is the uterus? Ultrasound CT/MRI CBC to assess for anemia
Slide 44-

University of Michigan Health System
Slide 45-

University of Michigan Health System (Both Images)
Slide 46-

Treatment of Fibroids Hormonal Surgical Myomectomy Hysterectomy Uterine artery embolization
Slide 47-

University of Michigan Health System
Slide 48-

University of Michigan Health System
Slide 49-

University of Michigan Health System
Slide 50-

Endometrial hyperplasia/carcinoma Most common gyn malignancy AUB, post-menopausal bleeding Must sample the endometrium Adenocarcinoma Peri/post-menopausal women Unopposed estrogen Obesity, HTN, DM, anovulation, nulligravid, Tamoxifen Peripheral conversion of androgens to estrone Progesterone is protective
Slide 51-

Endometrial carcinoma Progression from hyperplasia to carcinoma Presents as post-menopausal bleeding, AUB Surgical staging Prognostic factors Tumor grade, depth of invasion, spread Lymphatic spread Role of radiation, progesterone
Slide 52-

Diseases of Ovaries/Fallopian Tubes Variable presentation Asymptomatic Pain Irregular menses Mass on exam Bloating Constipation Vague abdominal discomfort
Slide 53-

Evaluation of adnexal masses Ovaries palpable about 50% of the time Except in adolescents and post-menopausal women Evaluate size, shape, consistency, mobility Imaging modalities USN is preferred for adnexal structures Ca-125, tumor markers
Slide 54-

Other actors Urinary tract infections Renal calculus Appendicitis Pregnancy complications Inflammatory bowel disease Exophytic myoma Ovarian mass/torsion
Slide 55-

Functional ovarian cysts Anatomic variations due to normal function May be as large as 5-8cm, most regress Follicular cysts Corpus luteum Hemorrhagic corpus luteum
Slide 56-

Follicular cyst Ovulation does not occur Symptoms: Unilateral pain, irreg. menses Exam: unilateral mass, tenderness USN: simple cyst Treatment: reassurance, pain management, OCPs, re-eval in 6-8 weeks Rupture can cause acute pain, peritoneal signs Source Undetermined
Slide 57-

Corpus luteum cyst Prolonged luteal phase Symptoms: Delayed menses, dull LQ pain, adnexal mass Evaluation: Exam, pregnancy test, USN with echogenic material within cyst Treatment: reassurance, pain management Source Undetermined
Slide 58-

Hemorrhagic corpus luteum Rapidly enlarging CL cyst with hemorrhage Ruptures late in luteal phase Acute onset of pain, hemoperitoneum ? reminds you of…. Check CBC, pregnancy test, serial exams, analgesics, possible laparoscopy
Slide 59-

Ovarian torsion Twisting of ovary, obstructing blood flow Acute onset of pain, nausea, vomiting, peritoneal signs Mass on exam USN reveals mass, compromised blood flow on doppler eval Laparoscopy, can sometimes save ovary by untwisting
Slide 60-

Ovarian torsion Brown Medical School Division of Pediatric Surgery Source Undetermined
Slide 61-

Ovarian neoplasms Ovarian mass which does not regress Benign neoplasms are more common Risk of malignancy increases with age Appearance, size on USN often helpful in decision process Tumor frequencies Surgical management
Slide 62-

Ovarian tumor types Epithelial Serous cystadenoma Mucinous cystadenoma Endometrioma Germ Cell Benign cystic teratoma (dermoid) Stromal Cell Dr. Lieberman’s Lecture……….
Slide 63-

Ovarian carcinoma 1 in 70 lifetime risk Late diagnosis leads to poor prognosis Risk factors Family hx, personal hx of breast CA, nulliparity, talc, obesity Incessant ovulation Oral contraception use reduces RR by 50% ? Role of ovulation induction medications
Slide 64-

Genetics and ovarian cancer 5-10% of all epithelial ovarian CA Lower age of onset Autosomal dominant with variable penetrance 1 first degree relative: 5% risk, 2 first degree relatives: 50% risk Breast/Ovarian CA syndrome BRCA 1, Chrm 17q HNPCC (Lynch II),autosomal dominant Colon, endometrial, breast, ovary
Slide 65-

Management of Ovarian Cancer Tumor spreads by direct extension to peritoneal surfaces Surgical staging: tumor debulking/cytoreduction Adjuvant chemotherapy Combination chemotherapy Intraperitoneal chemotherapy
Slide 66-

Fallopian Tubes Ectopic pregnancy Salpingitis Hydrosalpinx Tubo-ovarian abscess Paratubal cysts/paraovarian cysts Fallopian tube CA is rare Watery vaginal discharge, pain, pelvic mass
Slide 67-

Tubo-ovarian abscess Severe complication of pelvic inflamm. disease Tender inflammatory adnexal mass Mixed bacterial infection Consequences of rupture? Short v. Long-term Broad spectrum IV antibiotics Consider laparoscopy to differentiate b/w other source of pelvic abscess such as ?????
Slide 68-

Patient Scenarios Young woman with vaginal itching and discharge Middle aged woman with pelvic pain and heavy periods Post-menopausal woman with vague history of bloating and vaginal spotting Peri-menopausal woman with chronic yeast infection College-aged student with painful periods and pain with intercourse Young woman with pelvic pain and irregular periods
Slide 69-

Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 8: Operational Medicine 2001, http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Manuals/enhanced/vulva/Bartholin.htm; SkinSight, http://www.skinsight.com/adult/molluscumContagiosum.htm Slide 10: Source Undetermined Slide 12: Source Undetermined Slide 14: Source Undetermined Slide 16: Source Undetermined Slide 17: Source Undetermined Slide 19: Source Undetermined; Source Undetermined Slide 20: Source Undetermined Slide 25: Geneva Foundation for Medical Education and Research, http://www.gfmer.ch/Books/Cervical_cancer_modules/Images/MII5.jpg Slide 27: Source Undetermined Slide 28: Original image: http://1.bp.blogspot.com/_a23uhKQsbfc/TEPH_ZPSgeI/AAAAAAAAAJA/yQLclWV8PAA/s1600/paps+pic1.jpg Slide 28: S. Kellam; Source Undetermined Slide 30: Source Undetermined Slide 32: Caren Stalburg Slide 34: Source Undetermined Slide 36: Source Undetermined (All Images) Slide 41: Source Undetermined Slide 43: Source Undetermined (All Images) Slide 46: University of Michigan Health System Slide 47: University of Michigan Health System (Both Images) Slide 49: University of Michigan Health System Slide 50: University of Michigan Health System Slide 51: University of Michigan Health System Slide 58: Source Undetermined Slide 59: Source Undetermined Slide 62: Brown Medical School Division of Pediatric Surgery; Source Undetermined