Chapter 13 Benign Disorders of the Lower Genital Tract Flashcards
21 hydroxylase deficiency leads to
congenital adrenal hyperplasia. phenotypically demonstrated in the neonate with ambiguous genitalia, hyperandrogenism with salt wasting, hypotension, hyperkalemia, and hypoglycemia.dx is made by elevated 17alpha-hydroxyprogesterone. (1/40,000-50,000) pregnancies
25% of women with uterine septa may suffer from recurrent 1st trimester pregnancy loss. a bicornuate uterus is more commonly complicated by the limited size of the uterine horn rather than by blood supply.
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bicornuate and unicornuate uteri associated with
- second trimester pregnancy loss
- malpresentation
- preterm labor and delivery.
many uterine anomalies require no treatment, however, when defect causes significant symptoms such as pain, menstrual irregularities, or infertility, treatment options should be explored.
uterine septa can be excised with operative hysteroscopy once bicornuate uterus has been ruled out.
bicornuate uterus are able to carry pregnancy to fruition although
- preterm labor
- delivery
is a significant risk.
uterine leiomyomas / fibroids/ uterine myomas are
benign proliferations of smooth muscle cells of myometrium. Fibroids occur in women of childbearing age then REGRESS during menopause.
fibroids become problematic only when their location results in heavy/irregular bleeding or reproductive difficulties.
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submucosal
beneigh the endometrium. commonly associated with heavy/prolonged bleeding.
intramural
in the muscular wall of the uterus. (most common)
subserosal
beneath the uterine serosa.
fibroids are surrounded by
pseudocapsule , contains very few blood vessels and lymphatic vessels. As leiomyomas enlarge, they can outgrow their blood supply, infarct, and degenerate, causing pain.
most women with fibroids have no clinical symptoms. of those who do, they complain about
abnormal uterine bleeding, which is due most commonly to submucosal fibroids impinging on the endometrial cavity.
submucosal fibroids can impact implantation, placentation, and ongoing pregnancy. Resection of submucosal fibroids in patients diagnosed with infertility does lead to increased conception rates. Intramural and subserosal fibroids are unlikely to affect conception / pregnancy loss except when multiple fibroids are present.
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clinical symptoms of uterine leiomyomas mnemonic: FIBROIDS
F: Frequency and retention of urine, hydronephrosis
I: Iron deficiency anemia
B: bleeding abnormalities (menorrhagia, metrorrhagia, menometrorrhagia, postcoital spotting), bloating
R: reproductive difficulties. (dysfunctional labor, premature labor/delivery, fetal mal presentation, increased need for c/s)
O: obstipation and rectal pressure
I: Infertility failed implantation, spontaneous abortion
D: dysmenorrhea, dyspareunia
S: symptomless (most common)
when fibroids multiple, large (5-10cm), or located behind the placenta, they may
contribute to increased rates of preterm labor and delivery, fetal malpresentation, dysfunctional labor, c/s.
diagnostic evaluation:
pelvic us, HSG hysterosalpingogram, saline infusion sonogram (sonohysterogram) and hysteroscopy . MRI especially helpful in distinguishing fibroids from adenomyosis.
patient with actively growing fibroids should be followed every 6 months to monitor size and growth.
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medical therapies for leiomyomas. MNEOMINC: GO PAN AM
go pan am
G: Gnrh agonists (nafarelin acetate, leuprolide acetate depot, and goserelin acetate)
O: Oral contraceptive pills
P: Progestins (medroxyprogesterone acetate, Mirena IUD, norethindrone acetate)
A: Antifibrinolytics (tranexamic acid)
N: Nonsteroidal antiinflammatory drugs
A: androgenic steroids (danazol and gestrinone)
M: mifeprixtone.
indications for surgical intervention for uterine leiomyomas
- abnormal uterine bleeding, causing anemia
- severe pelvic PAIN or 2ndary amenorrhea
- uterine size (>12wk)obscuring evaluation of adnexa
- Urinary frequency, retention/ hydronephrosis
- growth after menopause
- recurrent miscarriage / infertility
- rapid increase in size
disadvantage of myomectomy
fibroids recur in more than 60% of pts in 5 years. adhesions frequently form that may further complicate pain and infertility.
endometrial polyps account for __ of all cases of postmenopausal bleeding
25%
best evaluation of polyps
ultrasound, sonohysterogram, hysteroscopy. as with any other etiology for abnormal bleeding, women 45 and older with abnormal bleeding from endometrial polyps should be evaluated with endometrial bx prior to removal.
continuous endogenous or exogenous estrogen stimulation in the ABSENCE of progesterone , simple endometrial proliferation can advance to
endometrial hyperplasia.
most common exogenous source is estrogen hormone replacement without progesterone. in obese women, excess adipose tissue results in increased
peripheral conversion of androgens to estrogens. this excess endogenous estrogen stimulation can then stimulate overgrowth of endometrium resulting in endometrial hyperplasia and even cancer.
changes do not necessarily involve entire endometrium, but rather may develop
focal patches. if left untreated, endometrial hyperplasia can progress to endometrial carcinoma and can also coexist alongside endometrial carcinoma
simple hyperplasia
complex hyperplasia
abnormal proliferation of GLANDULAR endometrial elements without proliferation of STROMAL elements. 3% of these lesions progress to carcinoma if left untreated.
atypical simple hyperplasia
cellular atypia and mitotc figures in addition to glandular crowding and complexity. these lesions progress to carcinoma in about 10% of cases if untreated.
atypical complex hyperplasia
most severe form of endometrial hyperplasia. progresses to carcinoma in approximately 30% of untreated cases.
endometrial hyperplasia typically occurs in
menopausal / perimenopausal women, but may also occur in premenopausal women who have prolonged oligomenorrhea and/ or obesity, such as those with PCOS.
tamoxifen has weak estrogenic agonist activity which
increases risk of endometrial hyperplasia by stimulating endometrial lining.
women with Lynch II aka ___ have more than 10x increased lifetime risk of endometrial hyperplasia and cancer
hereditary nonpolyposis colorectal cancer.
tissue diagnosis is required for diagnosis of endometrial hyperplasia. D&C was once the gold standard for sampling the endometrium, now
endometrial biopsies (EMBs) enjoy a 90%-95% accuracy rate without operative and anesthetic risks.
focal endometrial lesions are more commonly missed with EMB, up to
18% of samples.
d&C in operating room is required to rule out endometrial hyperplasia and carcinoma, for women > ___ and for younger women with risk factors for hyperplasia and cancer
45
___ is also recommended in pts with atypical complex hyperplasia on bx because approximately ____ will have a coexistent endometrial carcinoma
d&C, 30%
simple and complex hyperplasia WITHOUT atypia can be treated medically with
progestin therapy. progesterone reverse endometrial hyperplasia by activating progesterone receptors, resulting in stromal decidualization and thinning of endometrium.
atypical hyperplasia on initial EMB is further evaluated with
D&C, in the OR given significant risk of having coexistent endometrial cancer / developing endometrial cancer.
treatment of choice for women with endometrial hyperplasia with atypia who do not desire future fertility.
hysterectomy
in younger pts trying to preserve fertility, a
longer term progestin management and weight loss are recommended first. repeat EMB performed at 3 months. if persistent , progestin dose increased.
persistence after __ months is predictive of failure and __ is recommended.
9 months, hysterectomy.
most follicular cysts resolve spontaneously in
60-90 days
corpus luteum cysts common functional cysts that occur during luteal phase, they are formed when corpus luteum
fails to regress after 14days and becomes enlarged.
theca lutein cysts
large BILATERAL cysts filled with clear straw-colored fluid. result from stimulation by abnormally high bhcg
endometriomas
arise from growth of ectopic endometrial tissue within the ovary.
