14: Upper GT disorders Flashcards
anatomic anomalies of the uterus are rare and result from problems in the fusion of ?
often associated with ?
the paramesonephric (müllerian) ducts
urinary tract anomalies (unilateral renal agenesis, pelvic or horseshoe kidneys, or irregularities in the collecting system) and inguinal hernias.
symptoms of uterine anomalies
amenorrhea, dysmenorrhea, cyclic pelvic pain, infertility, recurrent pregnancy loss, and premature labor.
uterine anomalies dx by
physical examination, pelvic ultrasound, CT, MRI, hysterosalpingogram, hysteroscopy, and laparoscopy.
fibroids
benign, monoclonal, estrogen-sensitive, smooth muscle tumors of unclear etiology found in 50% of reproductive-age women
- submucosal (heavy bleeding), *intramural (most common), or subserosal and can grow to great size, especially during pregnancy
- when symptomatic, they can cause heavy or prolonged bleeding (most common), pressure, pain, and infertility (rare)
- dx by pelvic US
fibroid incidence is 3-9x higher in what races?
other risk factors?
higher in black women compared to white, Asian, and Hispanic women
obese, nonsmoking, increased alcohol use, HTN, and perimenopausal women.
fibroid treatment
- in most cases, none
- can be treated temporarily with Provera, danazol, or GnRH analogs to decrease estrogen and shrink the tumors, or myomectomy to resect the tumors when future fertility is desired
- treated definitively by hysterectomy in the case of severe pain, when large or multiple, when causing pressure symptoms, or when there is evidence of postmenopausal or rapid growth.
endometrial hyperplasia is classified as simple or complex (without atypia) if ?
only architectural alterations (glandular crowding) exist
endometrial hyperplasia is classified as atypical simple or atypical complex if ?
cytologic (cellular) atypia is also present along with architectural alterations (glandular crowding)
endometrial hyperplasia is caused by ?
risk factors?
prolonged exposure to exogenous or endogenous estrogen in the absence of progesterone.
chronic anovulation, obesity, PCOS, granulosa-theca cell tumors, tamoxifen, nulliparity, late menopause, and unopposed estrogen use.
HTN, DM, Lynch II syndrome (HNPCC)-10x increase
Risk of malignant transformation in endometrial hyperplasia
1% in simple hyperplasia, 3% in complex hyperplasia, 10% in atypical simple hyperplasia, and 30% in atypical complex hyperplasia
(“penny, nickel, dime, quarter”)
endometrial hyperplasia is diagnosed with
if no atypia, how to treat?
EMB or D/C and if no atypia is present it is usually treated medically with progestin therapy for 3 to 6 months, followed by resampling of the endometrium.
recommended treatment for atypical complex hyperplasia
hysterectomy, as risk progressing to endometrial cancer is 30%
follicular cysts result from ?
how to manage?
unruptured follicles
-usually asymptomatic unless torsion occurs.
Management includes observation +/- OCPs to suppress future cyst formation, followed by repeat pelvic US
Corpus luteum cysts result from ?
s/s?
management?
an enlarged and/or hemorrhagic corpus luteum
- may cause a missed period or dull LQ pain. When ruptured, these cysts can cause acute abdominal pain and intra-abdominal hemorrhage.
- should resolve spontaneously or may be suppressed with OCPs if recurrent.
differential diagnosis for ovarian cysts
ectopic pregnancy, PID, torsed adnexa, tubo-ovarian abscess, endometriosis, fibroids, and ovarian neoplasms.
Any palpable ovarian or adnexal mass in a premenarchal or postmenopausal patient is suggestive of ? and should be investigated with ?
ovarian neoplasm
exploratory laparoscopy or laparotomy
Cysts that do not resolve spontaneously in ? require further evaluation and treatment with ?
60 to 90 days, track with serial pelvic US, CA-125 if risk for ovarian cancer (not dx)
cystectomy or oophorectomy (rarely) via laparoscopy or laparotomy.
All reproductive structures arise from the müllerian system except the ? and the ?
ovaries (which arise from the genital ridge)
lower one-third of the vagina (which arises from the urogenital diaphragm)
malfusion of paramesonephric ducts results in
septate uterus
increased incidence of müllerian anomalies in women who were exposed in utero to?
diethylstilbestrol (DES) from 1940 to 1971
-synthetic nonsteroidal estrogen that was indicated for gonorrheal vaginitis, atrophic vaginitis, menopausal symptoms, postpartum lactation, miscarriage prevention, and for advanced prostate and breast cancer.
uterine septa associated with ?
recurrent 1st trimester pregnancy loss (25%)
- lack adequate blood supply
- can be excised with operative hysteroscopy
bicornuate uterus associated with ?
2nd trimester pregnancy loss, malpresentation, PTL/PTD, require C-section to avoid uterine rupture
-limited size of uterine horn
Classification of Mullerian anomalies
Class I. Segmented müllerian agenesis or hypoplasia
Class II. Unicornuate uterus
Class III. Uterus didelphis
Class IV. Bicornuate uterus
Class V. Septate uterus
Class VI. Uterus with internal luminal changes
most common indication for surgery for women in the US
fibroids
-1/3 of all hysterectomies
leiomyomas vs adenomyosis
fibroids are surrounded by a pseudocapsule of compressed areolar tissue and smooth muscle cells (few blood/lymphatic vessels)
adenomyosis: more diffusely organized in the myometrium
how do low dose OCPs affect fibroids?
protective against the development of new fibroids but may stimulate existing fibroids.
-exception: girls who start OCPs btw 13 and 16
risk of fibroids decreases with
increasing parity, with oral contraception use, and injectable depot medroxyprogesterone acetate use.
most common symptom of fibroids
submucosal fibroids impinging on the endometrial cavity lead to abnormal uterine bleeding: menorrhagia, postcoital spotting, metrorrhagia, menometrorrhagia
-can lead to chronic iron-deficiency anemia, dizziness, weakness, and fatigue.
do fibroids cause pain?
pelvic pain is not usually a symptom
may have secondary dysmenorrhea or pressure-related symptoms: pelvic pressure, constipation, hydronephrosis, urinary retention, and venous stasis
do fibroids cause infertility?
Not typically.
Submucosal fibroids can impact implantation, placentation, and ongoing pregnancy, resection can increase conception rates in infertile females
if multiple, large (5-10cm) fibroids or located behind the placenta, may increase rates of
PTL/PTD, fetal malpresentation, dysfunctional labor, and Cesarean delivery.
fibroids on physical exam
nontender irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions that feel firm or solid on palpation.
how to diagnose fibroids
most common: pelvic US: show areas of hypoechogenicity
others: Hysterosalpingogram (HSG), saline infusion sonogram (sonohysterogram), and hysteroscopy
- MRI is especially helpful in distinguishing fibroids from adenomyosis
medical management of uterine leiomyomas (fibroids)
GO PAN AM
G: GnRH agonists (nafarelin acetate, leuprolide acetate depot, and goserelin acetate)
O: OCPs
P: Progestins (medroxyprogesterone acetate, Mirena IUD, norethindrone acetate)
A: Antifibrinolytics (tranexamic acid)
N: NSAIDs
A: Androgenic steroids (danazol and gestrinone)
M: Mifepristone
medical treatment of fibroids treat dysmenorrhea and abnormal bleeding but ? can shrink fibroids as well
GnRH agonists
-decrease circulating estrogen levels. Unfortunately, the tumors usually resume growth after the medications are discontinued.
UAE goal
decrease the blood supply to the fibroid, thereby causing ischemic necrosis, degeneration, and reduction in fibroid size
- may compromise uterus/ovaries
- not good for large/pedunculated fibroids
MRI-guided high-intensity ultrasound
uses MRI to locate individual fibroids that are then thermoablated with high-intensity ultrasound waves
-expensive and not widely available
myomectomy
sx resection of 1+ fibroids from uterine wall
- good for preserving fertility
- hysteroscopically, laparoscopically with and without robotic assistance, or abdominally
- fibroids recur in more than 60% of patients in 5 years and adhesions frequently form that may further complicate pain and infertility
indications for surgical intervention for fibroids
Abnormal uterine bleeding, causing anemia
Severe pelvic pain or secondary amenorrhea
Uterine size (>12 wk) obscuring evaluation of adnexa
Urinary frequency, retention, or hydronephrosis
Growth after menopause
Recurrent miscarriage or infertility
Rapid increase in size
definitive tx for leiomyomas
hysterectomy
- vag/lap for small
- TAH for large/multiple
Rapid growth of a fibroid tumor in postmenopausal women may be a sign of ? (extremely rare) or other ? and should be investigated immediately
leiomyosarcoma
pelvic neoplasia
endometrial polyps
localized benign overgrowths of endometrial glands and stroma over a vascular core
-women 40-50, taking tamoxifen (^risk endometrial polyps, cysts, cancer)
endometrial polyp s/s
abnormal vaginal bleeding: metrorrhagia, menorrhagia, menometrorrhagia, postcoital
how to evaluated polyps
US, sonohysterogram, and hysteroscopy-also therapeutic
-if 45+ evaluate with EMB
when/why to remove endometrial polyps
- remove in postmenopausal patients as they can mask bleeding from another sources such as endometrial hyperplasia (25%) or endometrial cancer (<1%)
- remove from premenopausal F if at risk of infertility, endometrial hyperplasia, and endometrial cancer
endometrial hyperplasia is ?
abnormal proliferation of both the glandular and stromal elements of the endometrium. In its earliest stages, the stimulation results in changes to the organization of the glands. In its later, more severe forms, the stimulation results in atypical changes in the cells themselves
-can lead to endometrial carcinoma
atypic includes these cytological changes
large nuclei with lost polarity, increased nuclear-to-cytoplasmic ratios, prominent nuclei, and irregular clumped chromatin
Risk Factors for Endometrial Hyperplasia (Mnemonic: ENDOMETRIUM)
E: Excess exogenous estrogen use without progesterone N: Nulliparity D: Diabetes mellitus O: Obesity M: Menstrual irregularity E: Elevated blood pressure T: Tamoxifen use R: Rectal cancer (personal history of hereditary nonpolyposis colorectal cancer) I: Infertility history U: Unopposed estrogen M: Menopause late (> age 55)
typical presentation of endometrial hyperplasia
long periods of oligomenorrhea or amenorrhea followed by irregular or excessive uterine bleeding.
- pelvic exam typically normal, uterus may be enlarged
- may show obesity, acanthuses, acne, hirsutism
endometrial hyperplasia diagnosis
thickened endometrial stripe on US
-need tissue diagnosis: D/C, EMB is best
when D/C (OR) over EMB (outpatient)?
insufficient tissue, patient discomfort, or cervical stenosis
-also if atypical complex hyperplasia on biopsy because approximately 30% of those patients will have a coexistent endometrial carcinoma
Theca lutein cysts
are large bilateral cysts filled with clear, straw-colored fluid.
-result from stimulation by abnormally high β-hCG (e.g., from a molar pregnancy, choriocarcinoma, or ovulation induction therapy).
Endometriomas
-from the growth of ectopic endometrial tissue within the ovary, aka “chocolate cysts,” -s/s of endometriosis such as pelvic pain, dysmenorrhea, dyspareunia, and infertility.
s/s when an ovarian cyst results in a torsed adnexa
waxing and waning pain, and nausea and vomiting
if reproductive age and cyst <7cm ?
observation w. f/u US, should resolve in 60-90 days, start on OCPs to prevent future cysts
-those that don’t resolve require valuation with cystectomy and (rarely) oophorectomy via laparoscopy or laparotomy.
reproductive-age women with cysts larger than 7 cm or that persist or that are solid or complex on ultrasound
probably not just a functional cyst, follow closely with MRI or sx exploration
an ovarian cyst greater than ? is concerning for ovarian torsion
4 cm
