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Androgen-producing ovarian tumors are rare
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- Peri-genital
- HSV-1, HSV-2 (vulvovaginal)
- Chlamydia trachomatis
Androgen-producing ovarian tumors are rareArrhenoblastoma is most common type (see ovarian tumors) Hyperthecosis (of the ovary) probably represents severe form PCOS / try meds, but oophorectomy may be necessary Adrenal tumorsadenomas or carcinomas may produce excess androgens (+ or – cortisol) Diagnosis: high levels of adrenal androgens (urinary 17-ketosteroids, serum DHEA) that cannot be suppressed by dexamethasone suggest Labs: 24-hr urinary 17-ketosteroid level > 50-100 mg strongly suggestive Congenital adrenal hyperplasia (see other) Idiopathic hirsutism poorly understood but common / mild hirsutism and sometimes acne, menstrual irregularities Labs: T high-normal or slightly elevated, or elevated T (with decreased SHBG) and adrenal androgens Ovaries are otherwise normal Treatment: E-P combinations, steroids, spironolactone (1st choice), ?metformin sometimes decrease the androgen levels and symptoms psammoma bodies epithelial inclusion cysts serous ovarian tumor papillary carcinoma of thyroid meningioma
unclassified poxvirus Insects: scabies, crab lice Vulva Yeast infections (vulvovaginal) common / not an STD / white patches Risk Factors: antibiotic use, DM, obesity, oral contraceptives, pregnancy
abscess associated with gonorrhea Condyloma acuminatum [pic][dermis] STD / koilocytosis / HPV 6, 11 / no atypical mitoses Extramammary Paget’s Disease 20% have underlying adenocarcinoma / velvety-red lesions / local excision if no mets / high recurrence Vulvar intraepithelial neoplasia (VIN) peaks in 50s – 60s / HPV-16 predominates (80-90%), lesions in younger women usually more aggressive Presentation: pruritis, vulvodynia Diagnosis: multiple punch biopsies Treatment: wide local excision or laser vaporization Follow-up: colposcopy ever 3 months (then every 6 months after 2 years) precursor to squamous carcinoma (10%)
5% of gynecological malignancies / epidermoid (85-90%), malignant melanoma (5-10%), basal cell carcinoma (2-3%), sarcomas (<1%), fibrous histiocytomas associated with diabetes, hypertension, obesity, vulvar dystrophies, granulomatous PID
most common carcinoma of vulva / usually > 60 yrs / HPV 16 / 5 yr survival 75% Vagina Vaginal Infections Bacterial Vaginitis Organisms: Gardnerella vaginalis, Ureaplasma hominis > Chlamydia, N. gonorrhea Diagnosis: 3 of 4 criteria: increased vaginal discharge (fishy odor when mixed with 10% KOH), pH > 4.5, clue cells on wet mount [pic] Ddx: bacterial (40%) > candida (30%) > T. vaginalis / chemical irritants, HSV Treatment: oral or vaginal metronidazole or clindamycin N. Gonorrhea (see micro) Chlamydia trachomatismost common STD in W. hemisphere / 20% asymptomatic / infects glandular epithelia / may cause PID and infertility / treat partner / Treatment: azythromycin, doxycycline Trichomonas vaginalis (see micro)25% asymptomatic / variable pruritis / strawberry mucosa, frothy, purulent discharge / pear-shaped “wobbling” flagellated organisms + epithelial cells / fishy odor (w/ or w/out addition of 10% KOH) Treatment: 500 mg metronidazole PO bid x 7 days / must treat partner, no intercourse during Rx Candida vaginitis Lower pH, more itching, fungal elements on KOH Vaginal Neoplasia Vaginal intraepithelial neoplasia (VIN) Peaks in 40s / diagnosed with colposcopy and acetic acid/biopsy Treatment: CO2 laser or topical 5-FU if not-invasive
Peak in 50s (mean age 55) / most common carcinoma of vagina Presentation: discharge, bleeding, pruritis Spread by direct extension into bladder, rectum and lymphatics (upper 1/3 iliac nodes, lower 2/3 inguinal nodes) Stage I and II upper 1/3 surgical resection Stage III and IV and lower 2/3 radiation alone (palliative surgery) Adenocarcinoma clear cell carcinoma / fetal DES exposure causes adenosis / subset become CA / young women / Treatment: surgery and radiation Cervix Cervical Infection PID (pelvic inflammatory disease) Criteria: all 3 present: (1) lower abdominal tenderness (2) CMT (cervical motion tenderness) (3) adnexal tenderness at least 1 of these: temperature > 38 C / WBC > 10.5 / positive culdocentesis / mass on exam or ultrasound / evidence of GC or chlamydia in endocervix
Clotted from vessel? or recently ruptured ectopic? Differential: ovarian torsion, ovarian cysts, fibroids, endometriosis, appendicitis, bowel disease, ectopic pregnancy Organisms: C. trachomatis (25-45%) / N. gonorrhea (10-40%) / anaerobes (Bacteroides, C. perfringens) (30-60%) / aerobes (Staph, Strep, E. Coli) (30-65%) / Mycoplasma sp. (2-10%) Treatment: different opinions from OB/GYN vs. ID people Ceftriaxone 250 mg IM x 1 and doxycycline 100 mg bid x 14d (follow-up 48 hrs) / treat partner, consider in-patient treatment – cefotetan 2 g IV q 12 hrs or cefoxitin plus doxycycline / alternative: Unasyn + doxy, cipro + doxy, ofloxacin, metronidazole with abscess (TOA) (more likely anaerobic; bacteroides): Unasyn, clindamycin, gentamicin Complications: peritonitis, GI obstruction, bacteremia, infertility (ectopic pregnancy later on) Cervical Neoplasia Endocervical polyp most common cervical growth / inflammatory cause / may bleed Cervical Intraepithelial Neoplasia (CIN) – vaccine available! Incidence: 6th leading COD in women / 5000 deaths/yr Risk factors: early start, many partners, history of STD, smoking / also an AIDS-defining illness caused HPV 16,18,31,33 (integration, replication vs. episomal (HPV 6, 11) more common in anterior / Schiller test (dysplastic EC’s do not stain for glycogen)
Atypical squamous cells of undetermined significance (ASCUS) 10-15% will have significant lesions on colposcopy (80% of them will resolve with repeat PAP in 4-6 months Squamous intraepithelial lesions (SIL) low grade: CIN I (30% or progress in 7 yrs) and HPV changes high grade: CIN II (4 yrs to progress) and CIN III Squamous cell carcinoma 20% of CIN III progress to invasive carcinoma by 10yrs Treatment: cryotherapy, laser therapy / loop electrosurgical excision procedure (LEEP) for endocervical lesions Prevention: anti HPV vaccine (effective if given prior to sexual activity) Invasive squamous cell carcinoma (cervical cancer) cervical cancers are 90% large cell (keratinizing or non-keratinizing) and 10% small cell / remainder are adenocarcinoma and rarely (sarcoma/lymphoma) Presentation: post-coital bleeding, abnormal vaginal bleeding, watery discharge, pelvic pain/pressure, rectal or urinary problems microinvasive SCC refers to <3 mm invasion, no blood vessels, no mets invasive SCC is the most common cervical cancer / may be fungating, ulcerating, infiltrative
abortion, PID, IUD, pregnancy / plasma cells / may be asymptomatic / culture for chlamydia and gonococci chronic endometritis specific mycoplasm subacute focal inflammation (SFI) / lymphocytes, NO germinal centers, NO plasma cells tuberculosis infertility / systemic infection / superficial endometrial granulomas Functional Disorders of Endometrium estrogen withdrawal bleeding and anovulation 1st cause of dysfunctional uterine bleeding / asynchronous / proliferative pattern / fibrin thrombi inadequate luteal phase luteal phase defect / premature menses / infertility / >2 day lag in endometrium endometrial polyp (benign) abnormal uterine bleeding / associated with tamoxifen use hyperplastic polyp: originate in basalis, may have squamous metaplasia functional polyp: least common / glandular and respond to hormones atrophic polyp: post-menopausal / regressive polyp
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