Benign Uterine Abnormalities Flashcards
endometrial polyps - overview
*well-circumscribed, localized collection of the endometrial tissue within the uterine wall
*can be sessile or pedunculated
*common
*peak incidence: 40-49 years
*risk factors: age, hypertension, obesity, tamoxifen use
endometrial polyps - clinical presentation
*may be asymptomatic and just seen on exam
*may present with heavy menstrual bleeding, intermenstrual spotting, post-coital bleeding, infertility, or post-menopausal bleeding
*note - always on ddx for vaginal bleeding
endometrial polyps - physical exam
*sometimes can protrude from cervical os, making them visible on speculum exam
endometrial polyps - diagnosis
*hysteroscopy = gold standard
*transvaginal ultrasound
*saline infusion ultrasound
endometrial polyps - treatment
*hysteroscopic polypectomy (hysteroscope inserted into uterus, remove the polyp) +/- D&C (dilation & curettage)
*note - we treat because vaginal bleeding / spotting is associated with increased incidence of malignancy
hematometra - overview
*uterus distended with blood, secondary to OBSTRUCTION of a portion of the lower genital tract
*etiologies:
1. congenital uterine abnormalities: imperforate hymen, vaginal septum
2. acquired:
-senile atrophy
-post procedure synechia (scarring)
-cervical stenosis as a result of surgery / cryotherapy, endometrial ablation, cervical cancer, radiation
hematometra - presentation
*decreased menstrual bleeding
*increased pain after uterine or surgical procedure
*intermenstrual spotting
hematometra - diagnosis
*clinical + ultrasound: often enlarged/dilated uterus filled with echogenic material
hematometra - treatment
*hormonal suppression of endometrial activity
*excision of scar tissue & drainage of blood (hysteroscopy / D&C)
*hysterectomy
adenomyosis - overview
*presence of endometrial tissue (glands + stroma) in the MYOMETRIUM
*extension of glandular endometrial tissue from the basalis layer of endometrium into the uterine myometrium
*common
*risk factors: parity (multiple pregnancies, uterine surgery, trauma)
*can be diffuse or local
adenomyosis - clinical presentation & physical exam
*usually present with dysmenorrhea (pain with menses), menorrhagia (heavy periods), or dyspareunia (pain with penetration)
*physical exam:
-bimanual exam with diffusely enlarged (“globular”), soft (“boggy”) uterus
-tender exam during menstrual cycle
adenomyosis - diagnosis
*often coexistent with leiomyoma, endometriosis, endometrial hyperplasia
*imaging:
-transvaginal ultrasound
-MRI = gold standard
adenomyosis - treatment
- non-hormonal:
-NSAIDs
-tranexamic acid (antifibrinolytic) - hormonal:
-pill/patch/ring
-medroxyprogesterone acetate
-mirena - hysterectomy
leiomyoma (fibroids) - overview
*benign smooth muscle tumor of the MYOMETRIUM
*most common tumor in females
*can cause infertility in younger women
*risk factors: age, early menarche, low parity, tamoxifen use, obesity, heredity
leiomyoma (fibroids) - presentation
*heavy or abnormal menstrual bleeding
*dysmenorrhea (pain with menses)
*abdominal pressure/bloating
*low back / leg pain
*urinary symptoms
*most commonly seen in premenopausal women
leiomyoma (fibroids) - diagnosis
*physical exam: abdominal / bimanual exam - enlarged, firm, irregular uterus
*tumor is estrogen sensitive: size increases with pregnancy and decreases with menopause
*imaging: ultrasound
leiomyoma (fibroids) - treatment
- NSAIDs
- levonorgestrel IUD
- hormonal suppression: estrogen / progesterone receptors found in higher concentrations in myomas
- myomectomy
- hysterectomy
endometrial hyperplasia - overview
*abnormal endometrial gland proliferation usually caused by EXCESS ESTROGEN STIMULATION relative to progesterone
*increased risk of endometrial carcinoma
*risk factors: anovulatory cycles, menopausal hormone therapy, PCOS, granulosa cell tumor
post menopausal bleeding
*bleeding after menopause is NOT normal and requires an evaluation - must rule out endometrial carcinoma
*recall: menopause = 12 months of amenorrhea in a female 40-60 yo
*evaluation:
-history
-physical exam with pap smear & HPV testing
-transvaginal ultrasound vs. endometrial biopsy vs. D&C
endometriosis - overview
*endometrial tissue (glands / stroma) OUTSIDE THE UTERINE CAVITY
*usually in the pelvis/ovary (endometrioma)
*can also occur in multiple sites outside the pelvis such as bowel, diaphragm, peritoneum (“powder burn lesions”) and even pleural cavity
*benign
*estrogen-dependent
endometriosis - etiology
*unclear
*theories include:
-retrograde menstrual flow
-transportation of endometrial tissue via lymphatic system
-transformation of multipotent cells
endometriosis - risk factors
*incidence: 10% of reproductive age women
*risk factors:
-nulliparity
-prolonged exposure to endogenous estrogen (early menarche / late menopause)
-shorter menstrual cycles
-heavy menstrual bleeding
-obstruction of menstrual outflow
-low BMI, tall height
-physical/sexual abuse in childhood or adolescence
endometriosis - presentation
*usually presents during reproductive years
*classic triad = painful menstruation, painful sexual intercourse, infertility
*pelvic pain (dysmenorrhea, dyspareunia, dyschezia) - usually cyclic monthly pain, beginning 1-2 days before menses, persists during menses, improves after menses
*infertility
*ovarian mass
*sometimes incidental finding during surgey
*heavy menstrual bleeding
endometriosis - physical exam
*variable
*tender vaginal exam
*nodules in posterior fornix
*adnexal masses
*rarely visualized on cervix / vaginal mucosa
endometriosis - diagnosis
*definitively diagnosed by histological evaluation of a lesion biopsied during surgery (usually laparoscopic)
*nonsurgical evidence of endometriosis:
-ultrasound
-visual identification or other PE findings
-cystoscopic evaluation / biopsy of detrusor lesions
endometriomas - overview
*ovarian cyst formed when endometrial tissue within ovary bleeds, resulting in a hematoma
*often found bilaterally
*endometriomas have fibrotic walls, filled with chocolate-colored material (aka “chocolate cysts”)
*can observe or remove surgically (cyst alone vs. oophorectomy)
endometriosis - treatment
*medical: NSAIDs, tranexamic acid, GnRH agonists, danazol
*hormonal: combined OCPs, depo provera, levonogestrel IUDs
*surgical: hysterectomy, laparoscopic removal of lesions / lysis of adhesions
