217. Diseases of Uterus

Question 1

Leiomyoma

• epidemiology
• RF
• Pathophys (gene)
• Sx
• dx
• tx

Answer 1

MOST COMMON pelvic tumor in women (60-70% by age 50)
RF: higher age, early menarche, genetic (MED12 mutation, FH mutation), higher risk with diet (red meats), obesity, alcohol
PPhys: transformation of myocytes abnormal growth (MED12 mutation = regulates transcription initiation/elongation - regulates B-catenin/Wnt signaling)
Sx: depend on location (heavier bleeding, bulk/pressure sx, pain, infertility, recurrent pregnancy loss
Dx: US - well circumscribed lesion
SIS: separate walls to see fibroids better
Tx:
Medical: OCPs (lower bleeding), GnRH agonist (decrease size), TRANEXAMIC ACID (less bleeding without hormones)
Surgical: definitive = hysterectomy (most common indication); fertility-preserving = myomectomy, uterine artery embolization

Question 2

Endometriosis

• epi
• RF
• Etiology (2)
• Genes
• malignancy
• CP
• Dx
• tx

Answer 2

Epi: Common among repro-age women, VERY common in infertile women and women with pelvic pain
RF: anything with more cycles, mullerian anomalies
E: Retrograde menstruation theory, coelomic metaplasia
Genes:: most somatic mutations, some cancer-driving (ARID1a, PTEN, PIK3CA)
NOT A PREMALIGNANT LESION (low risk of malignant transformation to clear cell and endometrioid epithelial ovarian carcinoma)
CP: dysmenorrhea, dyspareunia, pelvic pain, endometrioma (ovarian mass), infertility, GI/GU sx
Dx: US (KEY for ovarian endometriomas!; unilocular cyst of homogenous low level echogenicity with poor/mild vascular flow); MRI (high accuracy for DEEP infiltrations)
Tx:
Medical: Analgesia (NSAIDs), Hormone manipulation (suppress ovaries with OCPs, P alone, GnRH agonist; Danazol- blocks E production, pit LH/FSH secretion; aromatase inhibition)
Surgical: ablation of implants, removal of endometrium, definitive = hysterectomy+BSO

Question 3

Adenomyosis

• what is it
• prevalence
• CP (2)
• gross
• US
• Tx

Answer 3

Ectopic presence of endometrioid glands + stroma within myometrium (non-cycling basale layer invades)
Prev: 20% women!
CP: menorrhagia, dysmenorrhea
Gross: no distinct lesion, diffuse soft spongy uterus
US: bulky uterus with no lesion and well-circumscribed border
Tx: Medical: OCPs, P-only, LNG-IUD (suppress menses)
Surgical: Hysterectomy

Question 4

Endometrial Polyps

• what is it
• CP
• prevalence
• RFs
• Dx
• Tx

Answer 4

focal, accentuated BENIGN HYPERPLASTIC growths with narrow base into endometrium
CP: most asx, irregular bleeding, post-mp bleeding
Prev: 6-25% (5% polyps malignant)
RF: Obesity, Metabolic Syndrome, Post-MP HRT (E only), TAMOXIFEN USE (breast Cancer tx)
Dx: US SIS - see polyp in cavity
Tx: surgical resection: hysteroscopic polypectomy vs. hysterectomy

Question 5

Endometrial Cancer

• epidemiology
• demographics
• assoc
• TYPE 1: cause, precursor, histo, genes, RF
• Type II: what it is, precursor, histo, genes
• CP
• Dx
• Tx

Answer 5

Epi: 4th most common ca among women (MOST COMMON GYN MALIGNANCY)
Demo: peaks age 60-70 (lifetime risk 1:37)
Assoc: obesity, PCOS, Lynch Syndrome

Type I: unopposed E, slow growing (low grade, superficial depth)

• precursor: atypical hyperplasia
• histo: endometrioid
• genes: PTEN, KRAS
• RF: circulating E levels = Obesity, E-secreting tumrs (GC ovarian cancer), anovulation (PCOS), exogenous E only replacement

Type II: rapid progression, high grade, deep invasion

• precursor: endometrial intraepithelial carcinoma
• histo: SEROUS CLEAR CELL
• Gene: p53 mutation
• high mortality

CP: abnormal vaginal bleeding ESP post-mp
Dx: endometrial biopsy
Tx: Surgical: hysterectomy + BSO (+/- radiation/chemo)
Non-surgical (NOT STANDARD): preserve fertility with P tx, pelvic radiation