04-25 PATH: Uterus & Fallopian Tubes Flashcards
1. Discuss the sx, dx and tx of uterine leiomyoma. 2. Differentiate the different types of endometrial hyperplasia. 3. Determine clinical risk factors for unopposed estrogens leading to endometrial hyperplasia and cancer. 4. Understand the etiology of salpingitis and the significance of hydrosalpinx, an important clinical sequela
- Discuss the sx, dx and tx of a uterine leiomyoma (uterine fibroid).
PRESENTATION
- abnl bleeding
- pelvic pressure
- lower urinary tract sx
- pelvic pain
- reproductive implications
DIAGNOSIS
Physical Exam
- Enlarged utereus, non-tender, firm, irreg contour
- Can palp by bimanual exam
- 12 utereus is > “12 weeks gestational size” can palp trans-abd
Labs
- Bleeding: H/H, coag panel
- Gyn: UA,
Imaging: U/S is best (MRI very accurate but $$$)
Pathology: Get Pap & endometrial bx
TREATMENT
Expectant Mgmt
Medical Mgmt
- NSAIDs
- OCPs
- GnRH analogues ($$$ & can only use 6 wks). Indicated for:
- ↓ size and sx before surgery
- Shrink uterine size to do transvag hysterectomy
- in the perimenopausal pt
- shrink submucosal fibroid to allow endoscopic resection
I.R. Mgmt
- Uterine artery embolization
Surgical Mgmt
- myomectomy
- hysterectomy
Benign Fibroids vs. Cancer
- Names for each
- Path changes
- Frequency of fibroids → cancer?
Benign Fibroma = Leiomyoma
- Bland spindle cells
- No mitoses
- No atypia
Cancer = Leiomyosarcoma
- Occurs in 1:1000 fibroids*
- Image here*
- Pleomorphic spindle cells
- Many mitoses
- Increased atypia
- Zonal necrosis
- Differentiate the different types of endometrial hyperplasia.
* Risk of Cancer
Simple Hyperplasia
Excess glands and stroma; irreg/crowded small glands
- Without Atypia (1% progress to adenoCA)
- With Atypia (8% progress to adenoCA)
as above, but indiv epithelial cells lining the glands have atypia:
- loss of polarity
- vesicular nuclei
- prominent nucleoli
Complex Hyperplasia
- Without Atypia (3% progress to adenoCA)
- Even more crowding, branched glands
- less stroma in between
- mitoses
- With Atypia (¡Likely already has adenoCA!)
- Non-confluent glands, mitotic figures, cytologic atypia
- Morphologic overlap with endometrioid adenoCA
- adenoCA just has no stroma in between glands at all
- Loss of PTEN gene expression
- Determine clinical risk factors for unopposed estrogens leading to endometrial hyperplasia and cancer.
Chronic, unopposed exposure to estrogen fuels endometrial hyperplasia (and cancer)
Causes
- Obesity
- PCOS
- Estrogen secreting ovarian tumors
- Iatrogenic
- Exogenous estrogens
- Tamoxifen
- Understand the etiology of salpingitis and the significance of hydrosalpinx, an important clinical sequela
Salpingitis
- usu. sequela of PID/STI (chlamydia and gonorrhea most commonly)
Hydrosalpinx
- dilated tube
- creates tubal factor infertility, so chances of getting pregnant are better if you remove it
- ?more easily torsed
The most common presenting symptom of endometrial cancer is:
- a.Abdominal pain
- b.Uterine mass
- c.Post menopausal bleeding
- d.Ureteral obstruction
- e.Bowel obstruction
c.Post menopausal bleeding
Sx, Dx and Tx of endometrial hyperplasia/adenocarcinoma?
Symptoms
Clinical symptom is bleeding
- Post menopausal bleeding
- Premenopausal irregular bleeding
Diagnosis
- biopsy
- D&C with or without hysteroscopy
**Treatment **- depends on atypia
Hyperplasia without atypia
- Progestins
Hyperplasia with atypia
- Hysterectomy
- Reasonable chance already cancer there, just missed on bx
Diagnostic Criteria for Salpingitis?
Salpingitis Diagnostic Criteria
- Abdominal tenderness with or without rebound
- Adnexal tenderness
- Cervical motion tenderness
- And 1 or more of the following
- T > 38.0
- WBC > 10,000
- Pelvic abscess on imaging
- Pus on culdocentesis or laparosocpy
What’s this?
endometrial adenocarcinoma
What’s this?
complex hyperplasia w/o atypia
Path dx?
complex hyperplasia w/ atypia
leiomyoma (fibroid)
leiomyosarcoma
simple hyperplasia w/ atypia
simple hyperplasia w/o atypia
