1. Epidermal Inclusion Cyst (Sebaceous Cyst)
    • -Most common cystic lesion of vulva
    • -Located below epidermis
    • -Caused by occlusion of sebacious gland in labia majora or minora
    • -Usually no Sx
    • -Usually don't need to Tx, but can incise and drain or excise if troublesome
  2. Bartholin's Cyst
    • -Caused by chronic inflammation or trauma resulting in occlusion of Bartholin's duct
    • -Sx: Usually asymptomatic
    • -Tx: If Sx, marsupialization and insert Word catheter
    • -Excision if malignant, esp. important in menopausal women
  3. Lichen Sclerosis
    • -White, flaky, onion-like skin on labia; usually in older women
    • -Sx: pruritus, burning, introital stenosis, dyspurenia in menopausal women; labia min. gets lost, labia maj. flattens, clitoris inverted
    • -Complications: has 4-6% chance of developing SCC
    • -Tx: Topical steroids (clobetasol), Intralesional steroid injection in refractory cases, Oral antihistamine for pruritis
  4. Location of leiomyomas
    • -Subserosal: under serosa (outermost layer); palpable on pelvic exam
    • -Intramural: within wall of uterus (middle layer); palpable
    • -Submucosal: under endometrium (innermost layer); causes abnormal uterine bleeding
    • -Pedunculated: attached to stalk; torsion and necrosis can occur, can parasitically use blood supply of omentum
  5. Changes in leiomyomas
    • 1. Fatty degeneration
    • 2. Cystic, calcified
    • 3. Red or carneous degeneration during pregnancy from bleeding into tumor
    • 4. Sarcomas - rare and after menopause
  6. Leiomyomas
    • -Sx: mostly asymptomatic; 35-50% have Sx (uterine bleeding, long heavy menses, pelvic mass, pelvic pressure, pedunculated one going through cervix/vagina, infertility & spontaneous abortion)
    •        *leads to anemia, pain w/ torsion, frequent urination, pressure, bloating, GI symptoms

    -Tx: menorrhagia managed w/ hormones, GnRH (effects only last as long as it's taken; only used 6 months or less), myomectomy after GnRH, hysterectomy, embolization
  7. Follicle Cyst of Ovary
    • -Most common cyst of ovary; seen in reproductive years
    • -Sx: none or pain w/ rupture, mentrual changes, dyspareunia
    • -PE: unilateral tenderness, mobile, cystic adnexal mass
    • -Dx: bimanual exam, US
    • -Tx: Observation cus most disappear in 60 days; OC to suppress gonadotropin; cystectomy if needed
  8. Corpus Luteum Cysts
    • -Sx: pelvic pain, menstrual irregularities; hemmorrage and torsion may ocur
    • -PE: lage, tender cystic or solid adnexal mass
    • -Dx: bimanual exam, pelvic US, 
    • -Tx: OC for 2-3 cycles to speed up resolution of cysts; surgery if medical therapy not successful
  9. Thuca Letein Cysts
    • -Occurs during pregnancy or with gonadotropic stim. (hydatidoform mole or choriocarcinoma)
    • -Usually bilaterally filled with straw colored fluid
    • -Can become large
    • -regaress following treatment of causative condition'
    • -Sx: pelvic heaviness, aching; regresses when gonadotropic levels fall
    • -Tx: Observation. Surgery if complications (torsion, hemorrhage)
  10. Hydatidiform Mole
    • -Sx: bleeding in 1st half of preganancy; vomiting; passage of vesicles; preeclampsia before 24 weeks
    • -Dx: US, high hCG
    • -Tx: Evacuation
  11. Choriocarcinoma
    • -Malignant transformation of trophoblastic tissue; may follow molar, normal, or ectopic pregnancy
    • -Sx: enlarged uterus and ovaries, vaginal bleeding, high hCG
    • -Dx: CT scan
    • -Tx: methotrexate
  12. Benign Cystic Teratoma (Dermoid Cyst)
    • -Most common ovarian neoplasm
    • -Contains a bunch of weird shit inside
    • -Dx: transvaginal US or Ct
    • -TX: cystectomy with pervation of ovarian tissue
    • -Cx: torsion due to weight of tumor, chemical peritonitis if ruptured
  13. Polycystic Ovarian Syndrome (PCOS)
    • -Persistent anovulation
    • -Sx: hirsutism (female hairyness), menstrual irregularities, acne, inferitility, obesity, ovaries have multiple small follical cysts
    •       *high LH, androgen, and estrogen levels, you get fucked up
    • -Dx: US of ovaries, eval of hyperinsulinism, lipid studies, HDL, LDL, androgen levels, LH, FSH
    • -Tx: suppress LH w/ OC, hair removal, weight loss
  14. Endometriosis
    • -Benign condition where endometrial tissue is present outside uterine cavity; typical case is woman in 30's who is nulliparous and infertile
    • -Theories:
    • 1. Retrograde Menstruation Theory of Sampson - endometrial fragments travel through fallopian during during menturation and implant and grow in weird places; does not explain lesions in distant areas (lung, axilla)
    • 2. Coelomic Metaplasia Theory of Meyer - endometriosis is from metaplastic transformation of peritoneal mesothelium into endometrium cus of some stimulus
    • 3. Lymphatic Spread Theory of Halban - endometrial tissue is taken up by lymphatics with drain uterus and go to various pelvic sites where tissue continues to grow

    It is most likely from the 3 theories, immunologic factors, and genetics
  15. Endometrius - Sx
    • -Sx: triad = dysmenorrhea (painful menstruation), dyspareunia (hard to sex), and dyschesia (hard to shit)
    • *pelvic pain
    • *infertility more frequent
    • *may be asymptomatic
    • No clear correlation between extent of disease and severity of pain
    • *tender nodularity in culdesac; pelvic pain; firm fixed tender adnexal mass
    • *gotta use laparotomy or laparoscopy
  16. Endometriosis - Tx
    -Expectant Mgmt = no med or surgical therapy in patients with mild disease

    • -Surgical mgmt = when bowel or bladder involved, adhesions, endometrioma > 3 cm, distortion of pelvin organs
    • *Conservative surgical mgmt = excision, cauterization, laser, or electrocoagulation ablation
    • *Definitive surgical mgmt = hysterectomy, salpingo-oophorectomy, destruction of all implants and adhesions

    • -Medical mgmt =
    • 1. Danazol (inhibits LH and FSH which lowers estrogen, induces pseudomenopause)
    • 2. GnRH agonists
  17. Adenomyosis
    -Extension of uterine glands and stroma into uterine musculature. Uterus is diffusely enlarged with thickened myometrium. 

    • Sx: dysmenorrhea, menorrhagia
    • Tx: NSAIDS, OC's, hormone patches, hysterectomy
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