Gyn Adnexal Mass The Medical Education



let's start talking about at necks amasses and for most of the diseases we cover we need to stratify them into age group based on puberty and menopause that is preman Arkell reproductive and postmenopausal because for at next amasses mass is in the ED miksa in the preman oracle age group it is cancer until proven otherwise generally going to be germ cell cancers in the post menopausal age group and an ad NEX ulm s amass in the end exa is cancer until proven otherwise generally epithelial cell if you remember from your ovarian cancer lecture epithelial cell is a very poor prognosis generally form found in stage 3b and has to be treated with total abdominal hysterectomy bilateral South bingo for ectomy and chemotherapy whereas germ cell cancers are generally benign and need only unilateral cell Pingo who for ectomy in an exome ass's the only time where they are allowed that is that they can be normal is in the reproductive age group they can be physiologic or if they're not physiologic and is they are complex they have a fairly large differential diagnosis which is going to be the subject of this lecture today regardless if you find and adnexa mass in any age group what you're going to do is exactly the same you're going to get a transvaginal ultrasound to better qualify that mass and either you're going to see a simple cyst which is physiologic or you're going to see a complex cyst get to the definition of each one in just a second that simple cysts are generally physiologic and will resolve with time on their own whereas complex this is our differential that is the teratoma endometrium the tubo-ovarian abscess PID torsion of the ovary ectopic pregnancy and cancer but how do you tell something that's simple or a complex cyst a simple cyst is simply going to be a fluid-filled follicle that is responsive to FSH and LH the patient will present with an asymptomatic adnexal mass you find it by doing an exam she wouldn't even know she has it the diagnosis is made by the ultrasound that shows a simple cyst and you're going to treat it with oral contraceptives for two months and you're going to track it and so the things that transfer a simple cyst to a complex cyst is if there's failure to resolve if it was too big greater than seven centimeters on the initial finding or if she was already on OCPs these necessitate a CT scan and consideration for the complex cyst let me show you what they look like a simple cyst is generally like a balloon it's smooth it's homogeneous there aren't any septation Zoar lock you lations it's generally small homogeneous and smooth whereas a complex cyst is large it's got multiple different lock you lations and lobule agents it's updated you can see multiple different color echoes on the ultrasound it is not smooth and contiguous like a balloon it is large loculated or lobulated and it is heterogeneous so anytime you see any of these categorizations or a failure to treat that simple cyst it is now a complex cyst and now we begin our discussion of the different causes of complex cysts beginning with teratoma the dermoid cyst this is a benign tumor of the ovary it occurs in young women generally in their teenage years presenting only as an abdominal or an excellent game the diagnosis is made on the ultrasound that shows a complex cyst and is generally obvious by its size because these can get quite large the treatment is very conservative it is simply cystectomy you remove the cyst only because it is benign and they are likely to recur on the opposite side if you were to take out the ovary and it recurred and a teenager you may force a teenager to go through menopause so you need to be very conservative with the teratomas because they are benign you simply remove the cyst itself these can be quite visually impressive if this is the uterus tubes and an ovary tubes and ovary the tumor itself may be bigger than the entire all the GYN organs together and it is generally a very large complex cyst this is the tumor that might have teeth hair or eyes in it the next center differential is endometrium a product of endometriosis we're not really sure what causes this and is a theory that we've got retrograde flow retrograde menses not sure but what we are sure of is that there is estrogen responsive tissue is endometrium outside of the uterus that is in other organs and so with each cycle that tissue builds up and Slough Soph only instead of sloughing off into the vagina and out the way normal menses does it bleeds into whatever organ it happens to have attached itself to this is uncomfortable it is going to hurt there's painful menses dysmenorrhea sometimes it causes pain during sex dyspareunia and will often be a cause of infertility the diagnosis is made first with an ultrasound that shows you the complex cysts and then with an OCP trial you actually treat it before you do the next step the best test is a diagnostic scope with laser ablation I'm actually put a camera in the belly and go find the chocolate cyst you find the blue lesions and actually burn them away in the treatment not surprisingly is to control the axis because it is an estrogen responsive and Dmitry 'm control the axis either Weatherall contraceptives or continuous loop relied and then ultimately you will go in and do it the diagnostic scope with laser ablation here's a set up for endometrium o what we think happens is that since these occurs in interrogate fashion but it's possible because the ovaries are not attached to the fallopian tubes during ovulation the fallopian tubes actually have to grab on to the egg as it pops out so there's space for retrograde flow and retrograde flow allows endometrium –is to develop on different organs now this theory does not explain everything and so probably is not correct but at least you'll see that there can be endometrium –is outside of the URIs even far distant from the uterus itself and that every cycle bees are going to proliferate and eventually slough off either into the peritoneum or into the organ they affect which is going to hurt the way the treatment works is by inhibiting the axis the hypothalamic anterior pituitary axis normally the hypothalamus secretes GnRH in a pulsatile fashion that stimulates the anterior pituitary to release FSH and LH which stimulates the ovary to make estrogen which proliferates the endometrium and then eventually ovulation causes progesterone just be secreted which causes the endometrium just level off what we do with our therapies is inhibit the axis OCPs turn off the axis here continuous OCP is essentially allowed the endometrium to build up she hurts and suffers when she bleeds so you do a trial of OCPs to see if you can turn off for pain if you can you're almost certain of the diagnosis if you use loop relied which is a GnRH agonist in a continuous fashion you override the pulsatilla T of the endogenous GnRH system continuous loop relied will shut off the entire axis so what you're doing is you are trying to turn off the liberation of the endometrium so that it doesn't slough and the ultimately you go into the abdomen find the chocolate cysts and burn them away the next cause of an X amass is an ectopic pregnancy you can see we're increasing the acuity of disease as we go the pathogenesis is simply that salpingitis that is PID cause the stricture of the tubes and early fertilization allows for early implantation that is the sperm can get through the stricture but the egg cannot or earlier fertilization too soon in the tubes allows that embryo to begin to develop and becomes too large and gets implanted in the tube or even somewhere in the peritoneum this most commonly occurs in the ampulla the patient is going to be pregnant so she's going to have a menorah and navy will present with some spotting she's going to have some lower abdominal pain and other signs that she is pregnant the diagnosis begins with the beta HCG which will be positive and then in ultrasound what you're doing with the ultrasound is attempting to confirm interviewed and preg intrauterine pregnancy but there's not what you'll see instead is an egg nestled mass and probably some free fluid this is your time to intervene you have to treat treatment of an ectopic pregnancy involves either cell pinged ostomy that is drainage helping jek t'me removal of the fallopian tube or methotrexate helping gosta me is used if there is no rupture southing ejected me is used if there is rupture and methotrexate has a very discreet use it is someone who has an ectopic pregnancy who has not ruptured it's very early on so there are no fetal heart tones and the patient was not on folate multivitamin the beta HCG quant has to be less than 8000 again very early on in the pregnancy and if the mass itself is less than 3.5 centimeters essentially you're going to choose between cell being ostomy and South being ejected me and here's why it doesn't matter which ones you choose the overall risk of ectopic pregnancy is approximately 1% the chance of repeat ectopic pregnancy after you've had one 15% the chance of having an ectopic pregnancy after selfing gosta me 15% chance of ectopic pregnancy after self injecting me 15% it doesn't matter what you do her risk of recurrent ectopic pregnancy is the same so your decision is whether or not there is high acuity that is she has already ruptured and is bleeding out or she has not ruptured and you have time just to do an open tube and of course they were going for 270 memorize the indications for methotrexate two more to go hang with me one cause of an annex amass could be the tubo-ovarian abscess this is pelvic inflammatory disease what happens is that repeated trauma of the cervical barrier allows access of those STDs in the normal flora to get into what is normally the sterile uterus and tubes so you're going to see normal vaginal flora causing an abscess and it's an abscess so it's going to present like one the patient is going to have lower abdominal pain probably a fever and a leukocytosis and a physical exam will receipt reveal that Nixle mass because you've got an annex alas you're gonna get an ultrasound it's gonna show you a complex mass complex cyst which cuz she's got a known history of pelvic inflammatory disease lower abdominal pain fever and leukocytosis you pretty much know what this is is his pelvic inflammatory disease so you're going to treat her with antibiotics you can use amp and gen plus metronidazole and now whenever you see amp and gen during this lecture series know that you can substitute a fluoroquinolone for amp and gen gen not being used that often because of its nephrotoxic side-effects and of course if they do not improve on antibiotics you may need to go in and drain it last one before we're done net axial mass can be torsion generally this is not a hey I felt a mass I wonder what it could be torsion of the ovary is a high acute disease same thing as ectopic pregnancy the pathogenesis is that the ovary actually twists around itself usually in the presence of a complex cyst so the weight of the cyst causes the ovary to twist about its own blood supply causing ischemia this is going to present as the patient who's just sitting at her computer desk not moving not doing anything and all of a sudden has a sudden onset lower abdominal pain its fever and leukocytosis spontaneous and comes out of the blue the diagnosis is made with an ultrasound showing a complex cyst and if you see excruciatingly sudden onset of domina pain and sizeof in signs of inflammation of the complex cyst without an inciting event you take this girl to surgery immediately and you untwist the ovary then you decide can I leave that ovary in if the ovary Pink's up that is you returned its vascular supply and it comes back to normal you can leave it if instead you've untwisted the ovary and it's still dead and necrotic you take it out that is your do an ex-lap and see if you can revascularize the ovary before it dies it comes back to life you'll leave it if it's dead you take it out the most important thing that you're able to do when you see a nate nixel mass is determine whether or not it is simple or complex if it's simple you can leave it alone and treat it with OCPs if it's complex especially on the USMLE look for associated symptoms that tell you which one it's going to be is it a sudden onset abdominal pain with no inciting event that's a torsion is it a massive cyst it's been slowly growing over time that's a teratoma has she had repeated bouts of pelvic inflammatory disease that's probably an abscess is she pregnant without an intrauterine pregnancy that's probably an ectopic so what you're gonna do on the test is first decide could this potentially be a physiologic cyst worse of cancer and then if it is complex use the history and diagnostic clues they give you ticking up with the most likely diagnosis knowing that some treatments are going to be surgical in others medical that is adnexal 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