Table II-4-4. Endometrial Carcinoma Management
Stage I
Stage II
Stage III
Stage IV
| Unopposed estrogen |
TAH-BSO: Basic Treatment for All Stages
| TAH | ||
| Radiation | ||
| BSO | ||
| Lymph node | Radiation, chemotherapy | |
| dissection | ||
| Natural History |
| Treatment | ||||||
|
|
| |||||||
| Simple hyperplasia, | Progestin | |||||||
| no atypia | ||||||||
|
|
| |||||||
| Complex hyperplasia, | Progestin | |||||||
| no atypia | ||||||||
|
|
| |||||||
| Complex hyperplasia | Hysterectomy or | |||||||
| with atypia | progestin | |||||||
|
| ||||||||
| Endometrial carcinoma | TAH, BSO | |||||||
Figure II-4-14. Management of Endometrial Hyperplasia
185
S2 OB-GYN.indb 185 
7/8/13 6:36 PM
GI
USMLE Step 2 l Gynecology
Prevention
|
|
|
Postmenopausal patients taking estrogen replacement therapy must be also treated with pro-gestins to prevent unopposed estrogen stimulation, which may lead to endometrial cancer.
Reproductive age women who have chronic anovulation, such as PCO syndrome, should alsobe treated with progestins to avoid endometrial hyperplasia from unopposed estrogen.
186
| S2 OB-GYN.indb 186 | 7/8/13 6:36 PM | |||
GI
| Disorders of | 5 | ||
| the Ovaries and Oviducts | |||
PHYSIOLOGIC ENLARGEMENT
Functional Cysts
A 22-year-old woman comes for annual examination and requests oral contraceptives pills. On pelvic examination, a 6-cm mobile, smooth, soft, left adnexal mass is palpable. An endovaginal pelvic ultrasound shows a 6-cm, round, fluid-filled, simple ovarian cyst without septations or calcifications. She has no other significant personal or family history.
Definition. The most common cause of a simple cystic mass in the reproductive age years is aphysiologic cyst (luteal or follicular cyst). During the reproductive years the ovaries are func-tionally active, producing a dominant follicle in the first half of the cycle and a corpus luteum after ovulation in the second half of the menstrual cycle. Either of these structures, the follicle or the corpus luteum, can become fluid-filled and enlarged, producing a functional cyst.
Differential Diagnosis
• Pregnancy. The most common cause of a pelvic mass in the reproductive years ispregnancy.
• Complex mass. The most common complex adnexal mass in young women is a der-moid cyst or benign cystic teratoma. Other diagnoses include endometrioma, tubo-ovarian abscess, and ovarian cancer.
Diagnosis
• Qualitative b-human chorionic gonadotropin (b-hCG) test. If negative, this will ruleout pregnancy.
|
|
|
• Sonogram. A complex mass on ultrasound appearance will rule out a functional cyst.
S2 OB-GYN.indb 187
GYN Triad
Functional Ovarian Cyst
• Pelvic mass in reproductive years
• b-hCG (–)
• Sonogram: fluid-filled ovarian simple cyst
187
7/8/13 6:36 PM
GI
USMLE Step 2 l Gynecology
With permission, Brookside Associates, brooksidepress.org
Figure II-5-1. Ultrasonographic Appearance of a Functional Cyst
Management. Most functional cysts can be managed expectantly, but surgery is indicated ifcertain characteristics are present.
• Observation. If the sonogram shows a simple cyst it is probably benign but carefulfollow-up is needed. Follow-up examination should be in 6–8 weeks, at which time the functional cyst should have spontaneously resolved. During this period of observation the patient should be alerted to the possibility of acute onset of pain, which may be indicative of torsion of the adnexal cyst. Oral contraceptive medication can be used to help prevent further functional cysts from forming.
• Laparoscopy. Even if the cyst is simple in appearance, surgical evaluation should beperformed if the cyst is >7 cm or if patient had been on prior steroid contraception. Physiologic cysts do not usually get larger than 7 cm in diameter. Functional cysts should not form if the patient has been on oral contraception for at least 2 months because gonadotropins should have been suppressed.
Polycystic Ovarian Syndrome
The ovaries are bilaterally enlarged with multiple peripheral cysts (20-100 in each ovary). This is due to high circulating androgens and high circulating insulin levels causing arrest of fol-liclular development in various stages. This along with stromal hyperplasia and a thickened ovarian capsule results in enlarged ovaries bilaterally. PCOS is associated with valproic acid use. Management is conservative regarding ovaries. For further discussion of PCOS pathophysiol-ogy and treatment, refer to chapter 12, Hormonal Disorders.
|
|
|
188
| S2 OB-GYN.indb 188 | 7/8/13 6:36 PM | |||
GI
Chapter 5 l Disorders of the Ovaries and Oviducts
Ovarian Hyperthecosis
Definition. Ovarian hyperthecosis refers to the presence of nests of luteinized theca cells inthe ovarian stroma that may be steroidogenically active. These nests, or islands, of luteinized theca cells are scattered throughout the stroma of the ovary, rather than being confined to areas around cystic follicles, as in polycystic ovary syndrome (PCOS). The result is greater production of androgens.
• Why hyperthecosis occurs is not known.
• The ovarian secretion of large amounts of androgen in women with hyperthecosis means that peripheral estrogen production is increased. As a result, the risks of endo-metrial hyperplasia and endometrial carcinoma are increased, especially in postmeno-pausal women.
Findings. The clinical features of hyperthecosis are similar to PCOS, and most patients are obese.However, women with ovarian hyperthecosis have more severe hirsutism, with shaving being common. Virilization is frequent, with clitoral enlargement, temporal balding, deepening of the voice, and a male habitus.
• Most patients have amenorrhea, and the remainder have irregular and anovulatory cycles. Some have acanthosis nigricans, suggestive of severe insulin resistance.
• Unlike PCOS, which occurs only during the reproductive years, hyperthecosis of the ovaries can occur in postmenopausal women. Severe hirsutism and virilization in postmenopausal women are more often due to ovarian hyperthecosis than to virilizing ovarian tumors.
Management. Treatment is similar to that for hirsutism, using oral contraceptive pills both tosuppress androgen production (by reducing LH stimulation of the theca cells) and to decrease free androgens (by stimulating sex hormone binding globulin).
|
|
|
Luteoma of Pregnancy
Luteoma of pregnancy is a rare, non-neoplastic tumor-like mass of the ovary that emerges during pregnancy and regresses spontaneously after delivery. It is usually asymptomatic and is found incidentally during a cesarean section or postpartum tubal ligation. It can be hormonally active and produce androgens resulting in maternal and fetal hirsutism and virilization.
Theca Lutein Cysts
These are benign neoplasms stimulated by high levels of FSH and b-hCG. They are associated with twins and molar pregnancies but they are only rarely associated with a normal singletonpregnancy. The natural course of these tumors is postpartum spontaneous regression and require only conservative managment.
189
| S2 OB-GYN.indb 189 | 7/8/13 6:36 PM | |||
GI
USMLE Step 2 l Gynecology
PREPUBERTAL PELVIC MASS
An 8-year-old girl is evaluated in the emergency department for sudden onset of severe lower abdominal pain. A general surgery consult was obtained, and appendicitis is ruled out. Pelvic ultrasound reveals a 7-cm solid and irregular right adnexal mass. Pelvic examination is consistent with a 7-cm right adnexal mass, and there is lower abdominal tenderness but no rebound present.
Etiology. An adnexal mass in the prepubertal age group is abnormal. During the prepubertaland the postmenopausal years, functional ovarian cysts are not possible because ovarian fol-licles are not functioning. Therefore any ovarian enlargement is suspicious for neoplasm.
Differential Diagnosis. If sonography shows a complex adnexal mass in a girl or teenager, thepossibility of germ cell tumors of the ovary has to be considered. The following serum tumor markers should be obtained: lactate dehydrogenase (LDH) for dysgerminoma,b-hCG for cho-riocarcinoma, and a-fetoprotein for endodermal sinus tumor.
Presentation. Sudden onset of acute abdominal pain is a typical presentation of germ celltumors of the ovary. These tumors characteristically grow rapidly and give early symptomatol-ogy as opposed to the epithelial cancers of the ovary that are diagnosed in advanced stages. Germ cell tumors of the ovary are most common in young women and present in early stage disease.
Diagnosis. Surgical exploration. In a prepubertal patient who is symptomatic and has ultra-sound evidence of an adnexal mass, a surgical evaluation is recommended.
• Simple mass. If the ultrasound shows the consistency of the mass to be simple (noseptations or solid components), this mass can be evaluated through a laparoscopic approach.
• Complex mass. If the mass has septations or solid components, a laparoscopy or lapa-rotomy should be performed, depending on the experience of the surgeon.
Дата добавления: 2018-11-24; просмотров: 269; Мы поможем в написании вашей работы! |
Мы поможем в написании ваших работ!