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GINECOLOGA

A la mujer hay que amarla, no comprenderla. Eso


es lo primero que hay que comprender"

Dr. Christiam Ochoa


UNMSM
GINECOLOGA TENDENCIAS RESIDENTADO 2000-
2015
GINECOLOGA ONCOLOGICA 56

TTNO DEL CICLO MENSTRUAL 48

INFECCIONES EN GINECOLOGIA 29

ALTERACION DEL SUELO PELVICO 16

CCBB 13

INFERTILIDA Y ESTERILIDAD 13

EXTRAS 13

PLANIFICACION FAMILIAR 12

MENOPAUSIA 9

0 10 20 30 40 50 60

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FLEXION = Eje cuerpo / cuello
VERSION = Eje cuello / vagina

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PAT. BENIGNA MAMA
ASPECTOS GENERALES

FUNCIONALES:
Mastodinea,
Galactorrea.
Ginecomastia.

INFLAMATORIOS: agudo, cronico y Mondor (tromboflebitis).

MASTOPATIA FIBROQUISTICA
TIPOS: no proliferativos 68%, proliferativos sin atipia 26%, hiperplasia
atipica 4%. DX: mastodinea premenstrual bilatral, areas induradas,
nodulos, telorrea. Patron fibroso denso, nodulos diseminados. ECO! Tto:
solo control. Otros hormonas, vitE

Pseudotumorales: Ectasia ductal, necrosis grasa.

Tumoraciones: Mixtos(fibroadenoma 75%,


Phyllodes), epiteliales (adenoma, papiloma), otros.
FIBROADENOMA:
NO DOLOR.
TTO: >30, >2-3cm,
rapido crecimiento.

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CNCER DE MAMA
ASPECTOS GENERALES
EPIDEMIOLOGA: 1ra muerte mujer. 2da PATOLOGA: EPITELIALES
general. Riesgo en vida: 12%. 70% METASTSICOS MESENQUIMATOSOS.
espordicos, 15% familiares, 5-10% DUCTAL: 85% Palpable, postmeno.
hereditarios. Alt. Mamografia(masa necrotica central,
Low risk High risk Relative risk microcalcificaciones agrupadas).
RISK FACTORS
Deleterious BRCA1/BRCA2 Negative Positive 3.0 to 7.0
LOBULILLAR: Casual en Bx. Premeno.
Mom or sis with breast cancer No Yes 2.6 Marcador de riesgo. DISEMINACIN:
Age 30 to 34 70 to 74 18.0
ESPECIALES: INTRAMAMARIA: Duplica 2-9m. 5-8 para
Age at menarche >14 <12 1.5
Age at first birth <20 >30 1.9 to 3.5 ENF PAGET: 2%: Eccematosa, 99% palpar. Invasin trae retraccin fibrosa Cooper.
Age at menopause <45 >55 2.0 epidermico del galactoforo.
LOCAL: Fascias, musculo, hueso, piel: edema,
Use of contraceptive pills Never Yes 1.07 to 1.2 CA INFLAMATORIO 2%: Malaso! ulcera, ca en coraza, ca erisipeloide.
HRT (estrogen + progestin) Never Current 1.2
T4. 1/3 mama inflamada.
Alcohol None 2 to 5 d/day 1.4
Carcinomatosis linfatica de la dermis.
LINFTICA: 40% al dx. Micrometastasis si
density on mammography % 0 75% 1.8 to 6.0
<2mm. GANGLIOS AXILARES (directo al tamao,
Bone density Q1 Q3 2.7 to 3.5 CA MAM VARON 1%: 0.2%
History of a benign breast bx No Yes 1.7 pronostico + importante, niveles de BERG)
maligno del hombre, tumor indoloro
History of atypical hyperplasia No Yes 3.7 linfadenectomia? CADENA MAMARIA INTERNA.
retroaleolar. Tipo ductal infiltrante.
PROTECTIVE FACTORS INTERCOSTALES INTERNOS.
Breast feeding (months) 16 0 0.73 Mastectomia Madden. En XXY o
Parity 5 0 0.71 BRCA2 DISTANCIA: Embolos, directo al tamao y
Recreational exercise Yes No 0.70
CA OCULTO DE MAMA: 1%: tiempo. No importa en sangre. PULMON, HIGADO
Postmenopause IMC <22.9 >30.7 0.63
metastasis axilares. Tto cirugia (ductal), peritoneal (lobulillar), OSEA, SNC
Oophorectomy < 35 years Yes No 0.3
radical de mama y axilas. (leptomeninges lobulillar), OJOS.
Aspirin 1/sX6 m Nonusers 0.79

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CNCER DE MAMA
DIAGNSTICO

CLNICA TUMOR PALPABLE 75%, superoexterno,


autoexamen no eficaz.
TELORREA: 10%hem. ECCEMA O
ULCERA PIEL: 2.7% retraccion.
RX ADENOPATIA AXILAR MASTODINEA

ECO: Diferenciar quistes. Mamas jovenes (<30) y embarazadas.


Guia PAAF y BAG. Adenopatias.
MAMOGRAFIA:
PRIMARIOS: nodulo
denso, irregular,
espiculado (40%
calcificaciones
malignas), imagen
estelar, espiculada,
microcalcificaciones
agrupadas 70%
minimos y 90%
insitu.
SECUNDARIOS:
retraccion cutanea,
edema, adenopatias.

RMN: S 100%, especificidad 22-97%. Ver extension, adenopatias,


valorar respuesta tto, protesis mama, BRCA jovenes.
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Primary tumor (T)*
CNCER DE MAMA TX Primary tumor cannot be assessed
BX: Definitivo. A cielo T0 No evidence of primary tumor
DIAGNSTICO abierto, BAG para Tis Carcinoma in situ
BIRADS 3,4,5, Tis (DCIS)Ductal carcinoma in situ
Likelihood of Tis (LCIS) Lobular carcinoma in situ
Assessment Management palpables o axilar.
cancer Paget's disease (Paget disease) of the nipple NOT associated
0: Incomplete Need METASTASIS with invasive carcinoma and/or carcinoma in situ (DCIS
additional imaging Recall for additional imaging N/A 1. Pulmn (63%) and/or LCIS) in the underlying breast parenchyma.
Tis
evaluation 2. Hgado Carcinomas in the breast parenchyma associated with
(Paget's)
Routine mammography 3. Peritoneal Paget's disease are categorized based on the size and
1: Negative Essentially 0% characteristics of the parenchymal disease, although the
screening
4. Huesos presence of Paget's disease should still be noted.
Routine mammography
2: Benign Essentially 0% 5. SNC (cerebro) T1 Tumor 20 mm in greatest dimension
screening
T1mi Tumor 1 mm in greatest dimension
Short-interval (6-month)
T1a Tumor >1 mm but 5 mm in greatest dimension
3: Probably benign follow-up or continued >0% but 2%
surveillance mammography T1b Tumor >5 mm but 10 mm in greatest dimension
T1c Tumor >10 mm but 20 mm in greatest dimension
4: Suspicious >2% but <95% T2 Tumor >20 mm but 50 mm in greatest dimension
4A: Low suspicion for T3 Tumor >50 mm in greatest dimension
>2 to 10%
malignancy Tumor of any size with direct extension to the chest wall
T4
4B: Moderate Tissue diagnosis and/or to the skin (ulceration or skin nodules)
>10 to 50% Extension to the chest wall, not including only pectoralis
suspicion for malignancy T4a
4C: High suspicion for
muscle adherence/invasion
>50 to <95% Ulceration and/or ipsilateral satellite nodules and/or edema
malignancy
T4b (including peau d'orange) of the skin, which do not meet the
5: Highly suggestive of
Tissue diagnosis 95% criteria for inflammatory carcinoma
malignancy
T4c Both T4a and T4b
6: Known biopsy-proven Surgical excision when
N/A T4d Inflammatory carcinoma
malignancy clinically appropriate

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HER2+ HER2-
CNCER DE MAMA Node-positive: HT and
chemotherapy
TRATAMIENTO Node-positive or node-
Node-negative or pN1mi,
negative, tumor >1 cm:
tumor >0.5 cm: 21-gene
HT, QT, and trastuzumab
recurrence score assay or
Node-negative, tumor
if not done: HT
ER/PR+ 0.6 cm to 1.0 cm: HT,
chemotherapy
QT, + trastuzumab
pN1mi, tumor 0.5 cm or
Node-negative or pN1mi,
microinvasive: + HT
tumor 0.5 cm or
Node-negative, and tumor
microinvasive: HT
0.5 cm or microinvasive:
HT
Node-positive or node-
negative, tumor >1 cm:
chemotherapy and
Node-positive, node-
trastuzumab
negative or pN1mi, tumor
Node-negative or pN1mi,
>1 cm: chemotherapy
tumor 0.6 cm to 1.0 cm:
Node-negative or pN1mi,
"consider"
tumor 0.6 cm-1.0 cm:
chemotherapy, +
"consider" chemotherapy
ER/PR- trastuzumab
pN1mi, and tumor 0.5 cm
pN1mi, tumor 0.5 cm or
or microinvasive:
SERM: TAMOXIFENO: Ca ductal o lobulillar, in situ tratado. Hiperplasia atipica en >40. Historia microinvasive: "consider"
"consider" chemotherapy
familiar en >35. Parientes de 1er grado y <40. Tambien hay el RALOXIFENO. chemotherapy, +
Node-negative, and tumor
INHIBIDORES DE LA AROMATASA postmenopausica con R+, Her neu+ resistentes al tamoxifeno. trastuzumab
0.5 cm or microinvasive:
MASTECTOMA SUBCUTNEA. Casual en Bx. Premeno. Marcador de riesgo. Node-negative, and
no adjuvant therapy
tumor 0.5 cm or
OOFORECTOMIA PROFILCTICA:Reduce 50% en mama y 99% ovario microinvasive: no
PX: Ca contrlateral 0.5-1% ao y en BRCA 5%. Evitar embarazo 2 aos. NUNCA THR O ACO adjuvant therapy
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CNCER DE CRVIX
ASPECTOS GENERALES
High-risk (oncogenic or cancer-
associated) types. Common
types: 16, 18, 31, 33, 35, 39, 45,
51, 52, 56, 58, 59, 68, 69, 82
Low-risk (non-oncogenic) types
Common types: 6, 11, 40, 42, 43,
44, 54, 61, 72, 81

CLULAS ESCAMOSAS
CLULAS ESCAMOSAS ATPICAS (ASC)
De significado incierto: ASC-US
No se puede excluir lesin NIC de alto grado: ASC-H
LESIN ESCAMOSA INTRAEPITELIAL DE BAJO GRADO
(LSIL):
incluye VPH+, NIC1, displasia leve.
LESIN ESCAMOSA INTRAEPITELIAL DE ALTO GRADO
(HSIL):
incluye NIC 2-3, displasia moderada, severa y Ca insitu.
CARCINOMA ESCAMOSO

CLULAS GLANDULARES:
CEL. GLANDULARES ATPICAS (AGC)
CEL. GLAN. ATPICAS, POSIBLE NEOPLASIA
ADENOCARCINOMA IN SITU ENDOCERVICAL : AIS
ADENOCARCINOMA

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2011 IFCPC cervical colposcopy nomenclature: IFCPC:
CNCER DE CRVIX International Federation for Cervical Pathology and Colposcopy.

GENERAL ASSESSMENT
DIAGNSTICO Adequate/inadequate for the reason (ie, cervix obscured by inflammation, bleeding, scar)
Squamocolumnar junction visibility: completely visible, partially visible, not visible
Screening en: QxUtero Transformation zone types 1, 2, 3
Inicio Fin HPV vac
Age 21 to 29 Age 30 benigno
Co-testing (pap test and NORMAL COLPOSCOPIC FINDINGS
Pap test ever Original squamous epitheliumMature Atrophic - Columnar epitheliumEctopy - Metaplastic squamous
HPV testing) every five
y three years Same epitheliumNabothian cysts - Crypt (gland) openings - Deciduosis in pregnancy
years (preferred)
recomm
Can consider Pap test every three
Not endatio Location of the lesion: inside or outside the T-zone, location of the lesion by
ACOG primary HPV years General
21 65 indicate ns as clock position. Size of the lesion: number of cervical quadrants the lesion
(2016) testing every principles
Can consider primary d** unvacci covers, size of the lesion in %age of cervix
three years
HPV testing every three nated
for ABNORMAL Grade 1 Thin acetowhite epithelium Fine mosaic
years for women
women age COLPOSCOPIC (minor) Irregular, geographic border Fine punctuation
women age 25 FINDINGS
25
Coarse mosaic - Coarse
Dense acetowhite epithelium
Grade 2 punctuation
Rapid appearance of acetowhitening
(major) Sharp border -Inner border sign
Cuffed crypt (gland) openings
Ridge sign

Non- Leukoplakia (keratosis, hyperkeratosis), erosion


specific Lugol's staining (Schiller's test): stained/non-stained
SUSPICIOUS Atypical vessels - Additional signs: fragile vessels, irregular surface, exophytic lesion,
FOR INVASION necrosis, ulceration (necrotic), tumor/gross neoplasm

Stenosis - Congenital anomaly


MISCELLANEO Congenital transformation zone - Condyloma
Post-treatment consequence
US FINDING Polyp (ectocervical/endocervical) - Inflammation
Endometriosis

CLASIFICACIN ANATOMO PATOLOGA


MEDIANTE BIOPSIA: RICHART
NIC 1 O DISPLASIA LEVE - NIC 2
MODERADA - NIC 3 y Ca in situ

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Primary tumor (T)
CNCER DE CRVIX TNM FIGO
categories stages
Definition

TRATAMIENTO TX Primary tumor cannot be assessed


T0 No evidence of primary tumor
Tis* Carcinoma in situ (preinvasive carcinoma)
T1 I Cervical carcinoma confined to uterus
Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a
T1a IA
maximum depth of 5.0 mm and a horizontal spread of 7.0 mm or less.
Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in
T1a1 IA1
horizontal spread
Measured stromal invasion more than 3.0 mm and not more than 5.0 mm in
T1a2 IA2
depth with a horizontal spread 7.0 mm or less
Clinically visible lesion confined to the cervix or microscopic lesion greater
T1b IB
than T1a/IA2
T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension
T1b2 IB2 Clinically visible lesion more than 4.0 cm in greatest dimension
Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower
T2 II
third of vagina
Tumor without parametrial invasion or involvement of the lower one-third
T2a IIA [1,2]
of the vagina
T2a1 IIA1 Clinically visible lesion 4.0 cm or less in greatest dimension
T2a2 IIA2 Clinically visible lesion more than 4.0 cm in greatest dimension
FIGO % 5 aos IIA 73.4 ESQUEMA TTO: T2b IIB Tumor with parametrial invasion
NIC 1: expectante Tumor extends to pelvic wall and/or involves lower third of vagina, and/or
IA1 97.5 IIB 65.8 T3 III
citologa semestral. causes hydronephrosis or nonfunctioning kidney
IA2 94.8 IIIA 39.7 Pronostico bueno. T3a IIIA Tumor involves lower third of vagina, no extension to pelvic wall
IB1 89.1 IIIB 41.5 NIC 2 Y 3: conizacion Tumor extends to pelvic wall and/or causes hydronephrosis or
(eleccin) y/o T3b IIIB
IB2 75.7 IVA 22.0 nonfunctioning kidney
histerectoma. Tumor invades mucosa of bladder or rectum, and/or extends beyond true
IVB 9.3 GESTANTE T4 IVA
pelvis (bullous edema is not sufficient to classify a tumor as T4)
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CNCER DE TERO 3er cncer ginecolgico Per
Mas fcte pases desarrollados
ASPECTOS GENERALES
DEFINICION
FACTORES DE RIESGO
CLASIFICACION 1. Edad avanzada
2. Postmenopausia
3. Raza blanca
4. Nuliparidad
5. Menarquia temprana
6. Menopausia tardia
7. SOP
8. Uso de tamoxifeno
9. DM, HTA, OBESIDAD

Cancer MLH1 MSH2 MSH6 PMS2


site Men Women Men Women Men Women Men Women
Any Lynch 25 to 47
44 to 79 %* 38 to 78 %* 65 %* 16 to 48 % 21 to 53 %
cancer %*
Colorectal 58 to 65 % 50 to 53 % 54 to 63 % 39 to 68 % 36 to 69 % 18 to 30 % 20 % 15 %
Endometri
NA 57 to 66 % NA 21 % NA 17 to 44 % NA 15 %
al
Ovarian NA 20 % NA 24 % NA 1%
Upper
urologic 2.1 % 0.4 % 20 % 9% 0.7 %
tract
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GRADO DE INVASIN MIOMETRIO - EDAD AVANZADA
CNCER DE TERO GRADO DE DIFERENCIACIN TUMORAL: HISTOLGICO PAPILAR SEROSO, CELULAS
CLARAS, ADENOESCAMOSO - RECEPTORES HORMONALES
DIAGNSTICO CITOLOGA PERITEONEAL POSITIVA - TAMAO TUMORAL > 2cm CA 125

CLINICA DIAGNOSTICO
Asintomticos ECO TV
Hemorragia uterina BIOPSIA ENDOMETRIAL
Dolor plvico DILATACION Y CURETAJE
Piometra HISTERESCOPIA+BIOPSIA

Degree of differentation of the adenocarcinoma

5 percent or less of a nonsquamous or


G1
nonmorular solid growth pattern
6 % to 50 percent of a nonsquamous or
G2
nonmorular solid growth pattern
More than 50 %of a nonsquamous or
G3
nonmorular solid growth pattern
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CNCER DE CRVIX
TRATAMIENTO
Subtotal/supracervical
Subtotal/supracervical hysterectomy. The uterus is removed. The
superior portion of the cervix is amputated, the remainder of the
cervix is conserved. Intrafascial hysterectomy is a subtype of subtotal
[1]
hysterectomy in which the uterosacral ligaments are conserved.
[2]
Piver-Rutledge-Smith Classification
Class l
Extrafascial hysterectomy. The fascia of the cervix and lower uterine segment, which
is rich in lymphatics, is removed with the uterus.
Class ll
Modified radical hysterectomy. The uterine artery is ligated where it crosses over the
ureter and the uterosacral and cardinal ligaments are divided midway towards their
attachment to the sacrum and pelvic sidewall, respectively. The upper one-third of
the vagina is resected.
Class lll
Radical hysterectomy. The uterine artery is ligated at its origin from the superior
vesical or internal iliac artery. Uterosacral and cardinal ligaments are resected at
their attachments to the sacrum and pelvic sidewall. The upper one-half of the
vagina is resected.
Class lV
Radical hysterectomy. The ureter is completely dissected from the vesicouterine
ligament, the superior vesical artery is sacrificed, and three-fourths of the vagina is
resected.
Class V
Radical hysterectomy. There is additional resection of a portion of the bladder or
distal ureter with ureteral reimplantation into the bladder.
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CNCER DE OVARIO
ASPECTOS GENERALES
4% cncer ginecolgico FACTORES DE RIESGO
CLASIFICACION Alta tasa de mortalidad 1. Edad avanzada
2. Nuliparidad
3. Endometriosis
4. Historia familiar
5. Oncogenes (BRCA 1-2)
EXTRAOVARIAN AND
OVARIAN TUBAL NONGYNECOLOGIC
EXTRATUBAL
BENIGN

FUNCTIONAL (PHYSIOLOGIC) CYST


CONSTIPATION
CORPUS LUTEAL CYST
APPENDICEAL ABSCESS
LUTEOMA OF PREGNANCY PARAOVARIAN CYST
DIVERTICULAR ABSCESS
THECA LUTEIN CYST PARATUBAL CYST
ECTOPIC PELVIC ABSCESS
POLYCYSTIC OVARIES UTERINE LEIOMYOMA
PREGNANCY BLADDER DIVERTICULUM
ENDOMETRIOMA (PEDUNCULATED OR
HYDROSALPINX URETERAL DIVERTICULUM
CYSTADENOMA CERVICAL)
PELVIC KIDNEY
BENIGN OVARIAN GERM CELL TUMOR TUBO-OVARIAN ABSCESS
PERITONEAL CYST
TIPO < 20 20-50 > 50 (EG, MATURE TERATOMA)
NERVE SHEATH TUMOR
BENIGN SEX CORD-STROMAL TUMOR
EPITELIO CELOMICO 29% 71% 81%
MALIGNANT OR BORDERLINE
CELULAS GERMINALES 59% 14% 6% EPITHELIAL CARCINOMA
EPITHELIAL APPENDICEAL NEOPLASM
EPITHELIAL BORDERLINE NEOPLASM
ESTROMA GONADAL 8% 5% 4% MALIGNANT OVARIAN GERM CELL
CARCINOMA METASTATIC BOWEL NEOPLASM
SEROUS TUBAL ENDOMETRIAL METASTASIS (EG, BREAST, COLON,
MESENQUIMA NO 4% 10% 9% TUMOR
INTRAEPITHELIAL CARCINOMA LYMPHOMA)
MALIGNANT SEX CORD-STROMAL
ESPECIFICO NEOPLASIA RETROPERITONEAL SARCOMA
TUMOR
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Primary tumor (T)
CNCER DE OVARIO TNM FIGO
TX Primary tumor cannot be assessed
Definition

DIAGNSTICO Y TTO T0
T1 I
No evidence of primary tumor
Tumor confined to ovaries or fallopian tubes
CLINICA Quiste folicular ECO DOPPLER Ca 125 Ca Tumor limited to one ovary (capsule intact) or fallopian tube; no tumor on
Quiste cuerpo luteo RMN/TAC 19.9, CEA, T1a IA ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal
Asintomticos Tumores LDH, AFP, washings
MARCADORES
Tumor palpable inflamatorios DD b HCG, Tumor limited to both ovaries (capsules intact) or fallopian tubes; no tumor
TUMORALES
Dolor plvico Quistes
H. tir T1b IB on ovarian or fallopian tube surface; no malignant cells in ascites or
Ascitis endometriales
peritoneal washings
Tumor limited to one or both ovaries or fallopian tubes, with any of the
IC
The following symptoms are much more likely to occur in following:
T1c IC1 Surgical spill
women with ovarian cancer than in women in the general IC2 Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface
[1,2]
population. These symptoms include : IC3 Malignant cells in the ascites or peritoneal washings
Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below
Bloating T2 II
pelvic brim) or peritoneal cancer*
Pelvic or abdominal pain T2a IIA Extension and/or implants on uterus and/or tube(s) and/or ovaries
T2b IIB Extension to other pelvic intraperitoneal tissues
Difficulty eating or feeling full quickly Tumor involves one or both ovaries or fallopian tubes, or peritoneal cancer, with
T3 III cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or
Urinary symptoms (urgency or frequency) metastasis to the retroperitoneal lymph nodes
IIIA Positive retroperitoneal lymph nodes and/or microscopic metastasis beyond pelvis
IIIA1 Positive retroperitoneal lymph nodes only (cytologically or histologically proven)
IIIA1 (i) Metastasis up to 10 mm in greatest dimension
T3a
IIIA1 (ii) Metastasis more than 10 mm in greatest dimension
Microscopic extrapelvic (above the pelvic brim) peritoneal involvement, with or without
IIIA2
positive retroperitoneal lymph nodes
Macroscopic peritoneal metastasis beyond pelvis up to 2 cm in greatest dimension, with or
T3b IIIB
without positive retroperitoneal lymph nodes

Macroscopic peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension


T3c IIIC (includes extension of tumor to capsule of liver and spleen without parenchymal
involvement of either organ), with or without positive retroperitoneal lymph nodes

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CNCER DE OVARIO
TRATAMIENTO
METASTASIS
CIRUGIA TTO
CITORREDUCCION Carcinomatosis
QUIMIOTERAPIA Linfatica
Hematogena

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Factor gentico Transicin de
PUBERTAD familiar - Factor cambios
gentico racial - biolgicos que
NORMAL Factor biogeogrfico permiten
- Factor adquirir la
socioeconmico capacidad
Otros factores reproductiva

Maduracion sexual nios Maduracion sexual nias

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MENOPAUSIA
ASPECTOS GENERALES DIAGNSTICO

CLINICA IRREGULARIDAD MENSTRUAL


Edad aproximada es de 50 aos BOCHORNOS
CEFALEA
IRRITABILIDAD
DEPRESION
INSOMNIO
PERDIDA DE MEMORIA

ATROFIA DE PIEL
ATROFIA UROGENITAL
INCONTINENCIA URINARIA
SEQUEDAD VAGINAL
DISMINUCION DE LA LIBIDO

COMPLICAIONES
ENFERMEDAD CV
OSTEOPOROSIS
DEMENCIA

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MENOPAUSIA
TRATAMIENTO
PREVENTIVO: EJERCICIOS - DIETA BALANCEADA
INICIAL: APOYO PSICOLOGICO - SUPLEMENTOS VITAMINICOS
- MEDICINA NATURAL - ACUPUNTURA
TRH (TERAPIA REEMPLAZO HORMONAL):
Estrgenos Progestgenos: Va oral
Estrgenos - Progestgenos: Transdrmicos
Tibolona (Gonadomimeticos)
Raloxifeno (Hidrocloruro de Raloxifeno)
DHEA

Hepatopatas aguda
Contraind. TRH Conectivopatas
Historia de IMA
Enf. Tromboembolica activa Historia de ACV
Cancer de mama-endometrio
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INFERTILIDAD y ESTERILIDAD
SISTEMATICO
Anamnesis y exploracin fsica: temperatura
basal.
Hormonas: P, luego otras. Serologa (rubeola,
VIH).
Ecografa transvaginal (2mm/da)
Seminograma: 2-7ml, ph>7.2, 20-120millones,
>50% progresivos o >25% rapidos. >15%
normales.
Histerosalpangiografia (OBSTRUCCION
TUBARICA)

INFERTILIDAD ESTERILIDAD FEMENINA INDIVIDUALIZADO


1. DEFECTOS CONGNITOS: ++fc. 1. TUBARICA: 40%. Congenito, Laparoscopia (ENDOMETRIOSIS)
Cromosomopatas. Trisomias 50%: endometriosis, infecciones, otras. Histeroscopia - Test poscoital - Anticuerpos
13,16,18,21,22 precoces. 45XO 20% (el ms TTO: microciruga, fecundacin antiespermatoide - Biopsia de endometrio
aislado) INVITRO si es bilateral.
2. FACTOR UTERINO: mioma submucoso o 2. OVRICA: 25%. Insuficiencia ltea, ESTUDIO
plipos. Tabicado (segundo trimestre). SOP, endometriosis, tumores, Genetica de pareja: cariotipo.
Asherman. congnitas. TTO: clomifeno 6 meses, HSG o histeroscopia.
3. FACTOR CERVICAL: incompetencia cervical progesterona 2da fase, Serologa lutica.
adquirida 95%, pasado semana 16. Dx: tallo Anticardiolipina y anticoagulante lupico.
bromocriptina.
Hegar en 2da fase. TTO: cerclaje 13-16s. Estudio fase lutea.
3. UTERINA: 13% (infertil>esteril). OTROS:
4. FACTOR ENDOMETRIAL: baja calidad, sfilis, Malformaciones. TTO: Qx. Evaluacion endocrina, seminigrama, tallo
clamydias. 4. OTRAS: cervical 12%, vulvo vaginal de Hegar, ecografa, urografa, cariotipo
5. FACTOR AUTOINMUNE, ENDOCRINO, 8%, inmunoligcas, psquica, del aborto, Dx preimplantacion, meiosis
MASCULINO, PSICOLGICO, SISTEMICO. generales, idiopticas 10%. testicular, trombofilias.

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NORMAL ABNORMAL UTERINE NEONATES
HUA MENSES BLEEDING ESTROGEN WITHDRAWAL
PREMENARCHAL
FREQUENCY 21 TO 35 D <21 DAYS OR >35 DAYS FOREIGN BODY
ASPECTOS GENERALES VARIATION FROM ONE TRAUMA, INCLUDING SEXUAL ABUSE
CONSISTENT CYCLE TO THE NEXT OF INFECTION
REGULARITY
FREQUENCY MORE THAN 20 DAYS IS URETHRAL PROLAPSE
CONSIDERED IRREGULAR SARCOMA BOTRYOIDES
OVARIAN TUMOR
HEAVY MENSES ARE
PRECOCIOUS PUBERTY
GENERALLY DEFINED AS
EARLY POSTMENARCHE
SOAKING A PAD OR
[1] OVULATORY DYSFUNCTION (HYPOTHALAMIC
5 TO TAMPON MORE THAN
IMMATURITY)
VOLUME 80 ML OF EVERY TWO HOURS OR
BLEEDING DIATHESIS
BLOOD AS A VOLUME OF
STRESS (PSYCHOGENIC, EXERCISE INDUCED)
BLEEDING THAT
PREGNANCY
INTERFERES WITH DAILY
ACTIVITIES INFECTION
REPRODUCTIVE-AGE
DURATION 5 DAYS BLEEDING FOR >5 DAYS OVULATORY DYSFUNCTION
PREGNANCY
CANCER
POLYPS, LEIOMYOMAS, ADENOMYOSIS
INFECTION
ENDOCRINE DYSFUNCTION (POLYCYSTIC OVARY
SYNDROME, THYROID, HYPERPROLACTINEMIA)
BLEEDING DIATHESIS
MEDICATION RELATED (EG, HORMONAL
CONTRACEPTION)
MENOPAUSAL TRANSITION
ANOVULATION
POLYPS, FIBROIDS, ADENOMYOSIS
CANCER
MENOPAUSE
ENDOMETRIAL POLYPS
CANCER
POSTMENOPAUSAL HORMONE THERAPY
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HUA
DIAGNSTICO
BLEEDING OTHER ASSOCIATED CLINICAL DIFFERENTIAL DIAGNOSIS POOR - FOLLICLE-STIMULATING
EVALUATION NUTRITION HYPOTHALAMIC HORMONE- LUTEINIZING
PATTERN FEATURES COMMON LESS COMMON
- PELVIC ULTRASOUND - SALINE OR INTENSE AMENORRHEA HORMONE
ENLARGED UTERUS ON EXAMINATION, UTERINE EXERCISE - ESTRADIOL
INFUSION SONOGRAPHY OR
DISCRETE MASSES MAY BE NOTED LEIOMYOMA
HYSTEROSCOPY (IF INTRACAVITARY) PREMATURE
FOLLICLE-STIMULATING
- DYSMENORRHEA HOT FLUSHES OVARIAN
REGULAR SECONDARY HORMONE
- ENLARGED, BOGGY UTERUS ON ADENOMYOSIS PELVIC ULTRASOUND INSUFFICIENCY
MENSES AMENORRHEA
EXAMINATION RECENT ON PELVIC EXAMINATION,
THAT ARE
HEAVY OR
- FAMILY HISTORY - BLEEDING HISTORY OF CERVICAL INSTRUMENT CANNOT BE
BLEEDING
DIATHESIS TESTING FOR BLEEDING DISORDER UTERINE OR STENOSIS PASSED THROUGH INTERNAL
PROLONGED DISORDER
- ANTICOAGULANT THERAPY CERVICAL CERVICAL OS
ENDOMETRIAL PROCEDURE
RISK FACTORS FOR UTERINE (ASHERMAN
CARCINOMA OR ENDOMETRIAL SAMPLING OR HYSTEROSCOPY
MALIGNANCY SYNDROME)
SARCOMA CHILDBIRTH.
- PELVIC ULTRASOUND
ENDOMETRIAL
- SALINE INFUSION SONOGRAPHY OR IATROGENIC
POLYP ACO / DIU
REGULAR HYSTEROSCOPY AUB
MENSES ENDOMETRIAL
RISK FACTORS FOR UTERINE
WITH CARCINOMA OR ENDOMETRIAL SAMPLING
MALIGNANCY
INTERMENST UTERINE SARCOMA
RUAL RECENT HISTORY OF UTERINE OR
BLEEDING CERVICAL PROCEDURE OR CHILDBIRTH, CHRONIC
ENDOMETRIAL SAMPLING
PARTICULARLY IF INFECTION WAS ENDOMETRITIS
PRESENT
OVULATORY
DYSFUNCTION:
TOTAL TESTOSTERONE AND/OR OTHER
HIRSUTISM, ACNE, AND/OR OBESITY PCOS ANDROGENS (MAY NOT BE INCREASED
IN ALL WOMEN WITH PCOS)
VARIABLE HYPERPROLACTIN
GALACTORRHEA PROLACTIN
EMIA
SD. TIROIDEO THYROID DISEASE THYROID FUNCTION TESTS
ENDOMETRIAL
RISK FOR MALIGNANCY CARCINOMA OR ENDOMETRIAL SAMPLING
UTERINE SARCOMA
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HUA
TRATAMIENTO
Table 2. Medical Treatment Regimens

Potential Contraindications
Suggested Dose and Precautions According to
Drug Dose Schedule FDA Labeling*
Conjugate 25 mg IV Every 46 Contraindications include, but are not limited, to
d equine hours for breast cancer, active or past venous thrombosis or
estrogren 24 hours arterial thromboembolic disease, and liver dysfunction
or disease. cardiovascular or thromboembolic risk factors.
ACO Monophasic 3/D X 7D Contraindications include, but are not limited to, cigarette
ACO that smoking (in women aged 35 years or older), hypertension,
contains 35 history of deep vein thrombosis or pulmonary embolism,
micrograms known thromboembolic isorders, cerebrovascular
of ethinyl disease, ischemic heart disease, migraine
estradiol with aura, current or past breast cancer, severe liver disease,
diabetes with vascular involvement, valvular heart disease
with complications, and major surgery with prolonged
immobilization.
MEDROXI 20 mg orallyThree Contraindications include, but are not limited to, active or
times per past deep vein thrombosis or pulmonary embolism, active or
day for 7 recent arterial thromboembolic disease, current or past
days breast cancer, and impaired liver function or liver disease.

Tranexami 1.3 g orally Three Contraindications include, but are not limited to, acquired
c acid or times per impaired color vision and current thrombotic or
10 mg/kg IV day for 5 thromboembolic disease. The agent should be used with
(maximum days caution in patients with a history of thrombosis (because of
600 (every 8 uncertain thrombotic risks), and concomitant administration
mg/dose) hours ) of combined oral contraceptives needs to be carefully
consider

Surgical options include dilation and curettage (D&C),


endometrial ablation, uterine artery embolization,
and hysterectomy.
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FACTORES DE RIESGO CLASIFICACION
MIOMA UTERINO
SIMPLE S/ O C/ ATIPIA
Edad N/A COMPLEJA S/ O C/ ATIPIA
Terapia estrogenica 2-10
ENDOMETRIAL
HIPERPLASIA

Menopausia tardia 2 TRATAMIENTO


Nuliparidad 2
DEPENDE:
SOP 3 ESTADO MENOPAUSICO
Obesidad 2-4 SI HAY ATIPIA O SI NO LA HAY
DM 2
HE S o C s/ ATIPIA Manejo del SUA
Tamoxifeno 2
HE S o C c/ATIPIA Manejo del SUA + Qx
Menarquia precoz N/A
Historia familiar N/A
DEGENERACION HIALINA
DEGENERACION QUISTICA
CALCIFICACION
INFECCION Y SUPURACION
NECROSIS
DEGENERACIN ROJA
DEGENERACION GRASOSA
DEGENERACION
SARCOMATOSA
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ENDOMETRIOSIS
RESUMEN

DEFINICIN EPIDEMIOLOGA
CLNICA
Endometrio fuera de la cavidad uterina. 10% mujeres. Feritles. Ciclos
(adenomiosis es endmetriosis cortos o menorragia. Tabaco
DOLOR 95%. Dismenorrea progresiva.
miometrial asintomtica) protege.
Dispareunia.
Alteracion menstrual 65%: poli+meno.
Infertilidad 41%: multifactorial. TTO ETIOPATOGENIA
Otros: distencin abdominal,
Laparoscopia: eleccin Desarrollo in situ. (Muller)
rectorragia, disuria, Ca125.
Ciruga radical. Teoria induccin:
Laparoscopa lesin en Medico: ACO, DIU levonorgestrel, mesnquima.
DX: quemadura de polvora. anlogos GnRH, Danazol, gestgenos. Teoria implante:
menstruacin retrgrada.

LOCALIZACIN
Ovario. Quiste achocolatado.
Ligamentos uterosacros, fosa
ovrica, Douglas.

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ITS
ASPECTOS GENERALES

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ITS
DIAGNSTICO

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ITS
TRATAMIENTO

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EPI CRITERIOS HAGER
MAYORES
Dolor espontneo en abdomen inferior.
ANTIBIOTICOTERAPIA
Dolor durante la movilizacin del crvix.
Infeccin del TGS Dolor anexial a la exploracin. A: AMBULATORIO
Historia de actividad sexual reciente. B: HOSPITALIZACION
FACTORES DE RIESGO Ecografa no sugestiva de otra
patologa. First-line regimens The CDC
HISTORIA SEXUAL
recommends any of the following
EDAD: 15-25 aos MENORES outpatient regimens, with or
Antecedente previo EPI Temperatura > 38C. without metronidazole (500 mg twice a
Leucocitosis > 10.500. day for 14 days) [1]:
Procedimientos: LU
VSG elevada. Ceftriaxone (250 mg intramuscularly
Usuaria de DIU (+++) in a single dose) plus doxycycline (100
Gram de exudado intracervical
ACO (---) mg orally twice a day for 14 days)
We prefer ceftriaxone
1 Chlamidia plus doxycycline in patients with mild to
ETS moderate PID. Metronidazole should
2 Gonococo be added for patients with Trichomonas
vaginalis or in those women with a
DIU Actinomices recent history of uterine
Israelii instrumentation.
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COMPARTIMIENTO ENTIDAD %
AMENORREA
I: Canal genital o tero. Asherman 7
ASPECTOS GENERALES
II: ovarios Cromosomopatas 10
III: hipfisis anterior Prolactinomas 7.5
PRIMARIAS IV SNC Anovulacin, anorexia, 10
GENITALES hipotiroidismo
Disgenesia gonadal: Turner,
pura, mixta. SECUNDARIAS ORDEN DE EXMENES
Rokitasnky. Uterino.
Himen imperforado. Insuficiencia ovrico. 1. bHCG gestacin
Feminizacin testicular o Morris. Tumores ovricos. 2. TSH-PRL etiolgico
HSC o sd adrenogenital. Hipo-hipog
Agenesia vagina. Hiperprolactinemia
3. Test progesterona
ANOREXIA/EJERCICIO Sd. Sheehan anovulacin
CENTRALES Tumores hipofisiarios. 4. E/P Anatmica genital
Psiquica, lesin H-h, pubertad Craneofaringioma
retrasada, hipo-hipog, Farmacos 5. FSH y LH falla ovrico
neurogerminales: Kallman, Enfermedades 6. GnRh (hipotlamo e
Laurence Moon Bield, Alstrom, Psiquica
Progeria, Prader Willi. Suprarrenal o tiroideo.
hipfisis)
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SOP
RESUMEN

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CONTRAINDICACIONES REDUCEN CA OVARIO Y
ABSOLUTAS ENDOMETRIO y COLON
Pac con riesgo CV REDUCEN ECTOPICOS.
Antec de TVP o Embolismo Pulm REDUCEN EPI
Qx Mayor x inmovilizacion DISMINUYEN LA
NATURALES HTA mal controlada
DISMENORREA.
REGULAN CICLO.
Billings DM con afectacion vascular DISMINUYEN EL
Ogino Vasculitis SANGRADO
Cardiopatias MENSTRUAL, MENOS
Sintotrmico Pac hepatopatas ANEMIA.
MELA Porfiria aguda intermitente MEJORAN
ARTIFICIALES Antecedentes de ictericia HIPERANDROGENISMO
(CIPROTERONA).
Barrera Embarazo
MEJORAN PATOLOGA
Hormonales Ca mama MAMARIA BENIGNA. ACO
Discrasia sanguinea CONTROL
Intrauterinos Sangrado genital anormal no OSTEOPOROSOS.
Quirrgicos filiado MEJORAN AR.

DIU COMPLICA CONTRAINDICACIONES


INSERCION: cuando?, dolor, perforacion, migracion, infeccion (1m Actinomices y ABSOLUTAS
polimicrobiano sd shock toxico Sf). Embarazo
EVOLUCION: gestacion (1% endometrial, 5% ectopico). 50% riesgo aborto, no EPI
MAF,.RETIRAR / descenso y expulsion (control en la 1ra menstruacion). / sangrado anmalo SUA
1m, salvo liberador de P. / dolor Tumor Malig Cervix o uterino

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DISTOPIAS
ASPECTOS GENERALES

00 00 - 00

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