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Duke PA CM - GYN

A&P, CA, Breast,

pelvic cavity is bounded superiorly by abdominal cavity
pelvic cavity is inferiorly bounded by pelvic floor
pelvic cavity develops as these three bones Ilium, Pubis, Ischium
Pelvic girdle also includes sacrum
The False pelvis (=inferior abdomen)and true pelvis are separated by the pelvic inlet (“linea terminalis”)
Anterior margin of pelvic girdle pubic symphysis
Posterior margin of pelvic girdle sacral promontory
Inferior margin of pelvic girdle; Partly bony/ partly ligamentous pelvic outlet
Parietal peritoneum drapes over pelvic viscera
Sacrotuberous ligament & Sacrospinous ligament Form greater/ lesser sciatic foramina
Hormones released during pregnancy (e.g., relaxin) contribute to loosening of ligaments and increase mobility of joints
Female pelvis Ilium more flared; Pelvic inlet circular; Wider sub-pubic angle
Male pelvis Ilium more upright; Heart shaped pelvic inlet; Acute sub-pubic angle
Roots of external genitalia & the openings for urogenital system form the Urogenital triangle
AKA vaginal corona Hymen
Thickest in infants and may be redundant and protruding (although perforated); Appearance is highly variable Hymen
Crura attach along pubic arch Corpora cavernosa
Anchored to perineal membrane Bulbs of the vestibule
Female Erectile Tissues Corpora cavernosa, Bulbs of the vestibule, Glans clitoris
AKA paraurethral glands; 10 and 2 o’clock in vestibule Skene’s glands
AKA greater vestibular glands; 4 and 8 o’clock – prone to abscess Bartholin’s glands
Attached to pubic arch, Inferior to pelvic diaphragm, Attachment for external genitalia, Openings for urethra and vagina Perineal membrane
Connective tissue structure to whichpelvic floor muscles and perinealmembrane attach The Perineal Body
Often injured during childbirth The Perineal Body
1st degree- injury of Perineal Body vaginal epithelium/perineal skin
2nd degree- injury of Perineal Body perineal body (fascia+ muscle)
3rd degree- injury of Perineal Body vaginal epithelium/perineal skin; perineal body (fascia+ muscle); + ext. anal sphincter
4th degree injury of Perineal Body vaginal epithelium/perineal skin; perineal body (fascia+ muscle); + ext. anal sphincter; + rectal mucosa
Collectively referred to as the uterine adnexa (may also include ligaments) Uterine tubes & Ovaries
Fetus undifferentiated before 6 weeks
male ducts Wolffian (aka mesonephric)
female ducts Müllerian (paramesonephric) ducts
s female
Secretion of ____ causes development of male ducts, and regression of female ducts testosterone
Muscular and membranous tube; Anterior wall contacts bladder; Posterior wall contacts rectum; Recto-uterine pouch; Upper portion separated into fornices; Corrugated inner surface (rugae) Vagina
Innervation of vagina Upper 2/3 visceral sensory, Lower 1/3 somatic sensory
Blood Supply: Vaginal a./v. to vagina
Incomplete fusion of urogenital sinus (lower 1/3) and Mullerian ducts (upper 2/3s)can result in transverse vaginal septum
Gartner’s duct- remnant of Wolffian duct system; May give rise to Gartner’s duct cysts
Separated into: External os; Cervical canal; Internal os, Non-muscular, collagenous tissue The Cervix
Cervical glands may form these which are Mucus filled & usually disappear on their own Nabothian cysts
Blood Supply: Uterine a./v. The Uterus
3 layers of tissue: Perimetrium (aka Serosa), Myometrium, Endometrium The Uterus
Position is variable: Normally lays superior to bladder, with slight anteflexion (1) May be severely anteflexed, retroverted (2) or retroflexed (3) The Uterus
Three stages of development of uterus 1. Appearance of ducts 2. Fusion of ducts 3. Resorption of septa
Approximately 7 classes of anomalies of uterus 1. Hypoplasia/ agenesis 2. Unicornuate uterus 3. Didelphys uterus 4 Bicornuate uterus 5. Septate uterus 6. Arcuate uterus 7. Diethylstilbestrol-related anomaly
prescribed to prevent miscarriage from 1945-1971 Diethylstilbestrol (DES)
T-shaped uterine cavity Diethylstilbestrol-related anomaly
aka fallopian tubes, oviduct Uterine tubes
4 structures of the Uterine tubes Isthmus, Ampulla, Infundibulum, Fimbrae
Ovaries are suspended by broad ligament
Remnant of gubernaculum, Attaches ovary to uterus Ovarian ligament
~3cm long, On lateral wall of true pelvis, Blood supply: ovarian a./v. The Ovaries
Where germ cells develop in ovaries, Follicles Outer cortex
Arteries and veins are found in ovary Inner medulla
Peritoneum draped over uterus, uterine tube, and ovary broad ligament
ligament of the ovary (infundibulopelvic ligament), Contains ovarian a./v. Suspensory ligament
Aka tranvserse cervical ligament, Contains uterine a./v. Cardinal ligaments
Ligaments of the Uterus Cardinal ligaments, Uterosacral ligament, Pubocervical ligament
Off of aorta below renal artery Ovarian arteries
From anterior trunk of internal iliac a. Uterine/ vaginal arteries
Drain directly to lateral aortic nodes Ovaries
Internal/ external iliac nodes to lateral aortic nodes Pelvic cavity
L4 - S4 spinal levels L4 - S4 spinal levels
Weakness or damage to pelvic floor muscles (and urethral and anal sphincters) can result in urinary or fecal incontinence
prolapse of bladder thru anterior wall of vagina Cystocele
prolapse of rectum thru posterior wall of vagina Rectocele
prolapse of intertine into vagina Enterocele
prolapse of uterus thru vaginal cavity Uterine prolapse
Complex series of biologic transitions during adolescence. development of secondary sexual characteristics is one aspect Puberty
Maturational increase in adrenal androgen production, which begins at about 6 years of age in both girls and boys. Causes hair growth, body odor, skin oiliness, acne Adrenarche
Seems to be unrelated to the pubertal maturation of the neuroendocrine-gonadotropin-gonadal axis Adrenarche
Beginning of breast development usually age 8 or beyond Thelarche
First menstruation; Averages 2.5 years after onset of puberty Menarche
Cyclical changes in hormones from hypothalamus, anterior pituitary and ovaries Menstrual cycle
If no fertilization menses occur
Menstrual cycle Produces one ______ which is ovulated mid cycle fully mature oocyte
Day 1: Bleeding starts Menses
ovarian follicles develop leading to mature graafian follicle; estrogen levels rise Follicular/proliferative phase
Follicular phase= estrogen
After ovulation; Mature follicle transforms into corpus luteum secreting progesterone and estrogen Luteal Phase
Luteal Phase = progesterone
Mature follicle transforms into corpus luteum secreting progesterone and estrogen
released by the hypothalamus in pulses Gonadotropin releasing hormone (GnRH)
Initiates release of both LH and FSH by the anterior pituitary Gonadotropin releasing hormone (GnRH)
High tonic levels GnRH supress the cycle used medically Lupron can induce a “medical menopause”
Released by the anterior pituitary; Essential for early ovarian follicle growth, Negative feedback on GnRH secretion Follicle stimulating hormone (FSH)
Induces proliferation of granulosa cells in the follicle that secrete estrogen Follicle stimulating hormone (FSH)
Induces granulosa cells to become sensitive to LH leading to ovulation Follicle stimulating hormone (FSH)
Secreted by the anterior pituitary; this “Surge” induces ovulation of the dominant follicle. Surge triggered by increasing estrogen from dominant follicle Lutenizing hormone (LH)
Induces androgen synthesis by the follicular theca cells
LH surge needed, around day 14; Midcycle, estrogen induces further release of LH rather than being suppressive Ovulation
Cause proteolysis of dominant follicle now a Graffian follicle with layers of granulosa and theca cells and release of egg Ovulation
Ovulation kits detect LH surge
Steroid hormone, made predominantly by ovarian granulosa cells Estrogen
help by producing androgens Theca cells
convert androgens to estrogen Granulosa cells
Negative feedback to pituitary for FSH secretion. Causes proliferation of the endometrial glands Estrogen
Steroid hormone made by the corpus luteum = hormone factory left in ovary after ovulation Progesterone
Slows endometrial proliferation induces secretion of glands in endometrium in preparation for implantation and early pregnancy maintenance Progesterone
Progesterone level over 4 at day 21 of cycle is indicative that ovulation occurred
Proliferation, straight glands, no glycogen Endometrium- follicular phase
Secrete glycogen, mucous, Glands become tortuous, Length constant at 14 days Endometrium luteal phase
Spiral arteries rupture, functional endometrium is shed, Averages 2-8 days , 25-60 cc Menstrual endometrium
Cervical mucous- Thinner proliferative phase
Cervical mucous- Thicker luteal phase
Symptoms: acne, breast swelling, fatigue, GI disturbance, insomnia, bloating headache, food cravings, depression/anxiety/irritability. Onset 2 weeks before menses and resolve with menses Premenstrual syndrome
Severe form of PMS. 5 or more of sxs: sadness/despair/suicidal, tension/anxiety, panic attacks , irritability that affects others, mood swings /crying, disinterest in daily activities, binge eating/craving , physical sxs PMDD
Treatment for PMS & PMDD Exercise, regular sleep habits, stress mgt, eat properly avoid caffeine, sugar, salt , OCPs? PMDD- antidepressant, counseling
Average age 47.5; Average 4 years prior to menopause Perimenopause
Irregularity of cycles, Heavy bleeding and clots, Anovulatory cycles, Variable cycle length Perimenopause
Definition is no menses for > 1 year Menopause
FSH >35 is widely used ( no negative estrogen feedback to pituitary), State of estrogen deficiency; Average age 51, pathologic <40 Menopause
First symptoms are often menstrual irregularities, Cycles shorten or lengthen. Hot flashes and vasomotor instability -sudden sensation of warmth, skin of face Menopause
Sleep/mood disruption in Menopause The time it takes to fall asleep is longer. Total length of time asleep is shorter. Depression/crying spells may develop.
is lost at a rate of 1-2% per year after menopause Bone density
after menopuse, Risk of hip and vertebral fracture increases
after menopuse Total cholesterol increases
after menopuse HDL cholesterol decreases
after menopuse LDL increases
after menopuse the risk of heart attack and stroke increases
Loss of collagen & adiposity in vulva; Clitoris loses protective covering; Vaginal surface thinner, less elastic; more friable; Vaginal dryness/genital tract atrophy; Vaginal mucosa and endometrium become thin and dry Vulvovaginal changes after menapause
Symptoms of Vulvovaginal changes Itching, Burning, Dyspareunia
Pale, smooth, or shiny vaginal epithelium. Loss of elasticity or turgor of skin. Sparsity of pubic hair. Dryness of labia. Fusion of labia minora. Introital stenosis. Friable, unrugated epithelium. Signs of Vulvovaginal changes
Pelvic organ prolapse. Vulvar dermatoses/ lesions. Petechiae of epithelium Signs of Vulvovaginal changes
Preceded by VIN Vulvar cancer
VIN--presenting complaints Vulvar pruritus, Chronic irritation, Raised lesions, often white or grey. Most frequent on posterior vulva and perineum.
Treatment early VIN local cauterization (cryo, electro, laser)
Treatment in higher grade VIN wide local excision with or without laser or simple vulvectomy
Fiery red lesions with white hyperkeratotic areas Paget Disease
Higher incidence of underlying carcinoma, esp colon and breast. Age group over 65 Paget Disease
Paget Disease Treatment wide local excision or vulvectomy (wide margins)
Raised, irritated, pruritic, pigmented lesion Melanoma/Vulva
Only 5% of all vulvar malignancies. Wide local excision. Excisional biopsy mandated with this type of lesion. Melanoma/Vulva
Another reason to avoid an overall tanning booth tan! Melanoma/vulva
4% of all gynecologic malignancies Vulvar cancer
most common Vulvar cancer Epidermoid
Typically postmenopausal woman, but can occur in 30 to 40 year olds Vulvar cancer
Vulvar pruritus. Red or white ulcerative or exophytic lesion, but not necessarily. Posterior 2/3 of labium majus. Vulvar cancer
Remains localized for long periods of time then spreads lymphatically. Inguinal lymphadenopathy Vulvar cancer
s deep lymphatics in pelvis
Vulvar cancer diagnosis Biopsy positive. Work up CXR, IVP, cysto, procto. Adjunctive postoperative radiation
Vulvar cancer 5-year surivival 75%
Presents: abnormal bleeding, pain, mass, dyspareunia Vaginal cancer
Rare. Risk factors HPV: squamous cell. DES: clear cell. Colposcopy, biopsy to excision. Vaginal cancer
Most common gyn cancer Endometrial carcinoma
Presents as abnormal bleeding Endometrial carcinoma
Begins as endometrial hyperplasia, then atypia, then carcinoma. Younger perimenopausal women. History of unopposed estrogen. More favorable prognosis Estrogen-Dependent Endometrial carcinoma
Progestin withdrawal or OCs as treatment. Why “naturally not having a period” is not OK Estrogen-Dependent Endometrial carcinoma
Occurs spontaneously. Thin, older postmenopausal women without unopposed estrogen. Atrophic endometrium. Cancers less well-differentiated. Poorer prognosis Estrogen-independent Endometrial carcinoma
to assess endometrial stripe, doppler flow Transvaginal ultrasound
Greater than 5 mm stripe, mass, fluid warrants biopsy
<5 mm stripe reassuring on Transvaginal ultrasound, but does not exclude non estrogen-dependent carcinoma
Treatment of Endometrial carcinoma Primary surgical treatment is cornerstoneTAH/BSO. Node dissection dependent on invasion depth. Adjunctive postoperative radiation. Medroxyprogesterone for recurrence
2nd most common gynecologic malignancy Ovarian cancer
Most common cause of death due to gyn cancer Ovarian cancer
5th leading cause of cancer deaths in women in US & is Associated with repeated ovulation Ovarian cancer
90% of Ovarian cancers are epithelial tumors
Ovarian Cancer: Risk Factors Family history. History of breast cancer. Nulliparity or poor reproductive history. Infertility. Early menarche, late menopause, PCOS, Genetic (BRCA, others),Endometriosis, Obesity
Ovarian cancers: protective factors Oral contraceptives. Multiparity. Tubal ligation, breastfeeding
Ovarian malignancy: Symptoms Symptoms are vague. Pelvic pain, bloating, urinary tract symptoms. “Clothing too tight,” “Abdomen enlarging”
Postmenopausal gyn exam Palpable adnexal mass. Rectovaginal exam important. Ultrasound with doppler blood flow. CA 125 (not good marker), CT/MRI
Probably Benign Mobile. Cystic. Unilateral. Smooth
Possibly Malignant Fixed. Solid. Bilateral. Nodular
<10 cm. Minimal septations. Unilateral Probably Benign
>10 cm. Solid. Multiple septations > 3 mm. Bilateral. Ascites. Doppler blood flow? Possibly malignant
Definition: any abnormal growth of tissue Neoplasm
Synonym: tumor Neoplasm
Key to neoplasms is determining if benign or malignant
Pruritus, burning, irritation or abnormal growth Vulvar disease
Common in women of all ages. Maintain high index of suspicion in peri- and postmenopausal women due to higher risk of malignancy Vulvar disease
Common Vulvar Dermatoses Lichen sclerosus; Lichen simplex chronicus; Lichen planus; Psoriasis
“An itch that rashes” Lichen chronicus
Vicious cycle of itch, scratch, itch. Original trigger often unknown. Progressive vulvar pruritus and burning. Thickened, white, unilateral/localized. Biopsy! Topical steroids (medium potency), hydroxyzine, SSRIs Lichen chronicus
Thin, white “onion skin” or “cigarette paper” Lichen sclerosus
Chronic, intense vulvar pruritus. Disfigurement, stenosis of vaginal introitus. Biopsy! Refer! Treatment potent topical steroids. Possibly topical testosterone, progesterone (not EBM) Lichen sclerosus
In Lichen sclerosus there is a 4-6% risk of squamous cell cancer
Violaceous, flat topped papules (erosive type) Lichen planus
White patches, ulcerations. May have oral, vaginal lesions. Chronic burning and itching-autoimmune. Biopsy, refer Lichen planus
Lichen planus treatment Topical steroids, douches, suppositories. Vaginal estrogen cream if atrophic. Beware adhesions, introital stenosis.
Benign uterine neoplasm Leiomyomas (fibroids)
Bleeding the most common presenting symptom Fibroids
Acute pain associated with “red degeneration” or torsion of pedunculated myoma Fibroids
Very often asymptomatic. Progressive increase in pelvic pressure, fullness. Pelvic pain Fibroids
Irregular, enlarged uterus. If large enough, palpable abdominally. Size referred to in gestational weeks pregnancy size Fibroids
Fibroids Diagnose by ultrasound
If calcified fibroid may show up on X-ray
Most frequently associated with pregnancy. Rapidly outgrow blood supply and die off. Fibroids—red degeneration
Must be differentiated from malignancy. Usually spontaneously regress. Very common. Also called “physiologic ovarian cysts” Functional Ovarian Cysts
Failure of ovulation, follicle continues to grow. May rupture and cause acute pelvic pain. Surgery not indicated. always do pregnancy test. Follicular cysts
May be felt on exam, refer to ultrasound, ultrasound no cyst but “free fluid in cul de sac” due to rupture of cysts,
Missed onset of menses. Corpus luteum fails to involute and continues to enlarge after ovulation. Secretes progesterone. Adnexal enlargement. One-sided pain Persistent corpus luteum cyst
Treatment: functional ovarian cysts (recurrent) Symptomatic. No EBM for oral contraceptives to resolve or prevent (maybe it worked in the 1970s). Warnings: risk of torsion if large
Asymptomatic, unilateral cystic adnexal mass. Mobile, nontender, often high in pelvis. Dermoid (teratoma)
Dermoid derivatives in cyst cartilage, bone, teeth
Hirsutism, acanthosis nigricans, acne. Oligo- or amenorrhea. Obesity (not always!). Infertility. Insulin resistance. Polycystic ovary syndrome (PCOS)
Complex genetic trait, related to type 2 DM. Hyperandrogenism. Insulin resistance, increased LH. Polycystic ovary syndrome (PCOS)
PCOS--treatment Oral contraceptives. Medroxyprogesterone for W/D bleed if contraception not needed. Spironolactone for hirsutism, Yasmin. Weight loss. Metformin
PCOS--complications Type 2 DM. Hypertension. Hyperlipidemia. CV disease. Infertility, recurrent SABDepression.
Modified sweat/ mammary gland; Function: Lactation Female Breast
10-20 surround the nipple. Glandular tissue Lobes
20-40 in each lobe. Contain milk producing cells Lobules
Thousands in each lobe. Lined with epithelial milk producing cells (acini) Alveoli
Color varies from pale pink to black. Muscular contractions cause erection Pigmented erectile tissue of nipple
Pigmented area, surrounds the nipple. Size varies between women Areola
Sebaceous (oil producing) glands. Protect and lubricate nipple (lactation) Montgomery glands
ACS Recommendation: Women at average risk should begin annual mammography at age 40
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
survival benefit is "strongest for women aged 50 to 69
CBE should be part of regular health maintenance, performed at least every three years for women age 20-39 yrs
Asymptomatic women __ should continue to receive CBE, preferable annually. greater than 40 yrs
about every 3 years for women in their 20s and 30s and every year for women 40 and over Clinical breast exam (CBE)
RCT data show combined mammograpghy and CBE= lower breast cancer mortalilty
there is moderate certainty that the harms outweigh the benefits. For the teaching of BSE
On breast exam be alert for Dimpling, Color changes, Retraction, Skin thickening, Pronounced/ recent asymmetry, Spontaneous nipple discharge
The USPSTF recommends against teaching breast self-examination (BSE).Grade: D recommendation
Supernumerary breasts. May be seen as normally shaped female breast. Usually in axilla or directly beneath normal breast. Polymastia
Supernumerary nipples. Often miniature compared to normally placed nipples and located in the milk line. Polythelia
trauma, breaks in skin integrity, insect bites, cosmetic surgery can lead to cellulitis of the breast
may be associated with diabetes, RA, steroid tx, trauma Abscess
Widening of breast ducts. Occurs in women near or past menopause. May have thick, sticky discharge and/or frequent itching around the nipple. Treat with warm compresses and antibiotics. Duct Ectasia
Firm, round lump which forms in an area of fatty tissue damage. Fat Necrosis
Benign breast pain. Most common breast complaint. Associated with hormonal changes. More intense in teens and 40’s. Usually ends with menopause. Mastalgia
Chest wall pain. Increases with deep inspiration. May be arthritic. Can occur at any age. Can result from cervical nerve compression. Rx: NSAIDS Costochondritis
bilateral pain with heaviness/ diffuse tenderness and occurs during luteal phase cyclical breast pain
uni or bilateral, sharp, burning pain, smoking hx, no relation to menses non- cyclical breast pain
unilateral and medical, sharp with deep inspirations and variable occurence chest wall breast pain
is a catch-all term for benign conditions of the breast. Grainy, palpable, small lumps. May fluctuate with menstrual cycle (progesterone changes?) Fibrocystic disease
Most frequent benign breast condition. Ages 30-50 most frequent incidence Fibrocystic disease
most frequent location for Fibrocystic disease UOQ of breast
Mobile, well-defined cystic masses. Bilateral single or multiple masses. Pain/ tenderness last half of cycle. Fibrocystic disease
differentiate cystic mass from solid mass Aspiration and U/S
If find mass on CBE Order a diagnostic mammogram, unless age <30, then order U/S.
The second most common benign breast condition. Fibroadenoma
More common in African American women. Occurs late teens, early adulthood Fibroadenoma
Hormone influenced abnormal growth of fibrous and ductal tissue. May grow rapidly during pregnancy. No significant correlation with breast cancer. Fibroadenoma
Well circumscribed lump. Usually firm, rubbery, round, mobile, non-tender, solitary. Usually UOQ. Generally 1-5 cm in diameter. Fibroadenoma
Fibroadenoma diagnosis FNA (fine needle aspiration). Cytology study of bloody fluid or solid tumor aspirate. U/S to differentiate solid from cystic mass
Fibroadenoma definitive diagnosis excisional biopsy and tissue examination
is a simple procedure that involves passing a thin needle through the skin to sample fluid or tissue from a cyst or solid mass Fine Needle Aspiration (FNA) Biopsy
obscure 10% of breast tissue on mammogram Submuscular implants
Cancer cells block lymph vessels in breast skin. Breast becomes red, swollen and warm. No palpable mass present. Usually grows rapidly with metastasis. uncommon. Inflammatory breast cancer
Nipple retraction & Peau d'orange are seen in Inflammatory Breast Cancer
Begins in breast duct and spreads to nipple and areola. Usually occurs with infiltrating ductal breast cancer. Gradual onset, rare Paget’s Disease of the Nipple
Scaly, crusty, eczema-like lesions on nipple area. Tingling, itching or burning in nipple area. Nipple discharge. Lump in nipple area Paget’s Disease of the Nipple
Diagnosis of Paget’s Disease of the Nipple Biospy with tissue exam
Treatment of Paget’s Disease of the Nipple Lumpectomy. Mastectomy
Advocate a threefold approach, with education: Monthly BSE. CBE at recommended intervals. Annual mammography.
Age <30yo, Palpable lump, still there after menses, order unilateral breast ultrasound
Age > 30yo, palpable lump, order unilateral diagnostic mammogram & u/s
If 40 or more, and due for screening mammo., get mammo. on unaffected side at same time
Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year
Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram.
Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.
Created by: ac202