Abnormal Uterine Bleeding (AUB) & Endometriosis (Sketchy) Flashcards
Lynch Syndrome
AKA hereditary nonpolyposis colorectal cancer (HNPCC), autosomal dominant genetic mutation that results in impaired DNA mismatch repair, increased risk of colorectal cancer, endometrial carcinoma (as well as endometrial hyperplasia), and ovarian cystadenocarcinoma. Given their increased risk of cancer, many females will elect to undergo a prophylactic hysterectomy and salpingo-oophorectomy. As a result of the high likelihood of progression to endometrial carcinoma, this patient should be offered treatment with a hysterectomy.
A 25-year-old female undergoing evaluation for infertility. She states that sexual intercourse with her husband is very painful and wonders if this is contributing to her inability to have children should make you consider what diagnosis?
This presentation is consistent with a diagnosis of endometriosis, which often presents with painful symptoms such as dysmenorrhea, dyspareunia, and dyschezia. Patients do not have abnormal uterine bleeding however. Endometriosis is caused by extravasation of endometrial tissue outside of the uterus and often affects the fallopian tubes and ovaries. Infertility can occur and is likely multifactorial owing in part to inflammation and adhesions within the fallopian tubes.
A 22-year-old female presents for evaluation after labs taken at a community health fair demonstrated anemia. She notes several years of heavy menstrual bleeding should make you consider what diagnosis?
This presentation would be concerning for a diagnosis of adenomyosis or uterine fibroids given that endometriosis is not associated with abnormal uterine bleeding. With adenomyosis and submucosal fibroids, patients may develop heavy menstrual bleeding that can result in iron deficiency anemia. Other presenting features of adenomyosis and fibroids can include painful menses, infertility, and recurrent miscarriages.
A 26-year-old female is undergoing evaluation increased urinary urgency should make you consider what diagnosis?
Urge incontinence and increased urinary urgency carries a wide differential diagnosis, including the presence of subserosal fibroids. Large anterior fibroids can result in urinary symptoms such as urgency or incomplete emptying as a result of bladder compression. Urinary urgency is not seen in patients with endometriosis.
A 68-year-old female presents for the evaluation of postmenopausal bleeding. Her medical history is remarkable for estrogen receptor positive breast cancer treated six years prior should make you consider what diagnosis?
This presentation is consistent with a diagnosis of endometrial hyperplasia or endometrial carcinoma – not endometriosis. Tamoxifen is frequently used in the treatment of estrogen receptor positive breast cancer given its’ antagonist properties at estrogen receptors in the breast. Unfortunately, it exerts partial agonist activity within the endometrium and can increase the risk of endometrial hyperplasia and endometrial carcinoma. Patients presenting with postmenopausal bleeding should undergo an endometrial biopsy in order to assess for endometrial disease.
Growth of the stratum basalis into the myometrium is the pathophysiology of which AUB?
pathophysiology of adenomyosis
Reverse menses through the fallopian tube is a hypothesis for which AUB?
formation of extrauterine endometrial tissue (endometriosis) - there are many hypothesis for this disorder
Vascular and lymphatic spread is a hypothesis for which AUB?
formation of extrauterine endometrial tissue (endometriosis) - there are many hypothesis for this disorder
Coelomic metaplasia (inappropriate differentiation of pluripotent stem cells) is a hypothesis for which AUB?
formation of extrauterine endometrial tissue (endometriosis) - there are many hypothesis for this disorder
A 30-year-old female presents for evaluation of infertility. Over the past 16 months, she notes that her and her husband have been trying to conceive and are having regular sexual intercourse. She has no prior pregnancies. She has experienced regular 30-day menstrual cycles throughout her life but notes significant dysmenorrhea lasting 3-4 days each cycle. Physical exam reveals a normal-sized uterus, however, bilateral adnexal masses are easily palpated. Which of the following would be the best way to definitively determine a diagnosis in this patient?
This patient most likely has endometriosis and definitive diagnosis would be achieved via laparoscopy demonstrating endometrial tissue outside of the uterus. In endometriosis, endometrial tissue and stroma are located outside of the uterus – most commonly in the ovaries, fallopian tubes, serosal surfaces of the intestines, and the rectal pouch of douglas. Patients typically present with cyclic pelvic pain and dysmenorrhea and some may complain of additional findings such as dyspareunia (pain with intercourse) and dyschezia (pain with defecation). Many patients will also experience infertility secondary to endometriosis. Physical exam may reveal an adnexal mass (often bilaterally) and a normal-sized uterus. Diagnosis is made via visualization of “powder burn” lesions on serosal surfaces and/or “chocolate cysts” (endometriomas) within the ovaries.
“powder burn” lesions on serosal surfaces and/or “chocolate cysts” (endometriomas) within the ovaries should make you consider what diagnosis?
Endometriosis
A 26-year-old female presents for the evaluation of dysmenorrhea. She reports regular 30 day cycles throughout her life but notes that they are accompanied by severe mid cycle pain and heavy menstrual bleeding for 3-4 days. She is currently on iron supplementation as a result of previously developing iron deficiency anemia. Her BMI is 22. The remainder of her medical history and review of systems is unremarkable. Physical exam reveals a diffusely enlarged, boggy uterus. Which of the following is the most likely underlying cause of this patient’s condition?
Extension of endometrial tissue into the myometrium is the underlying pathophysiology of adenomyosis. As a result, patients will develop myometrial hypertrophy which will present as a diffusely enlarged, soft, boggy uterus on physical exam. Symptoms of adenomyosis include painful menses and heavy menstrual bleeding – in some cases, this may also be complicated by the development of iron deficiency anemia. First line treatment is typically with GnRH agonists such as leuprolide; though severe cases may require hysterectomy or excision of an organized adenomyoma.
Physical exam finding of palpable uterine mass is most consistent with what diagnosis?
Uterine fibroids, otherwise known as leiomyoma, are the most common tumor in females and typically present as one or multiple palpable uterine masses on physical exam. These tumors are estrogen sensitive and will thus increase in size with pregnancy and will decrease in size following menopause. Many lesions are asymptomatic, however, patients may present with abnormal uterine bleeding and/or miscarriages. In some cases, bleeding may be severe enough to result in iron deficiency anemia. Patients with fibroids will have an irregularly enlarged, “lumpy bumpy” uterus due to the presence of these masses whereas patients with adenomyosis will have symmetric, uniform enlargement of the uterus.
A 24-year-old female presents for the evaluation of dysmenorrhea. She notes severe pain with menstruation each month and often misses 1-3 days of work mid cycle due to severe pain. She also complains of pain with defecation and pain with sexual intercourse, further noting that the latter contributed to a recent termination of a romantic relationship. She eventually undergoes diagnostic laparoscopy, which demonstrates multiple chocolate cysts on the ovaries and flesh colored nodules on the serosal surface of the intestines. What diagnosis are you considering and how would you treat it?
Endometriosis. OCPs are frequently used as first line pharmacotherapy for the treatment of endometriosis given that they can help reduce or eliminate menstrual flow. Additional treatment options can include surgical resection of specific lesions, hysterectomy, danazol, and progesterone therapy.
A 23-year-old female presents for the evaluation of light intermenstrual bleeding. Her cycles occur at regular 30 day intervals but she notes light bleeding and spotting throughout most of the month. Her medical history is remarkable for hypertension and obesity. Which of the following findings would be the most likely to result in progression to endometrial carcinoma in this patient?
Complex endometrial hyperplasia with atypia will progress to endometrial carcinoma in ~ 33% of cases and as such, would be the most concerning finding on this patient’s endometrial biopsy. In premenopausal patients, endometrial hyperplasia (and endometrial carcinoma) can present with light intermenstrual bleeding and/or heavy menstrual bleeding. A definitive diagnosis is obtained through an endometrial biopsy. Given that endometrial hyperplasia and endometrial carcinoma occur in large part due to unopposed estrogen exposure (relative to progesterone), treatment with OCP’s decreases the risk of both endometrial hyperplasia and endometrial carcinoma.
