Chapter 37 Management of Diseases of the Uterus and Endometrium Flashcards
levonorgestrel containing intrauterine contraception and oral progestins therapy can be an alternative to hysterectomy to treat
endometrial hyperplasia
in advanced cancers, the addition of PACLITAXEL to DOXORUBICIN and CISPLATIN improved the survival compared to just doxorubicin and cisplatin
TRUE
in patients <50 with endometrial cancer, 9% were found to carry a germline Lynch syndrome - associated mutation
true
_% of caucasians and _% of african american women have leiomyomas
70% caucasians
80% african americans
most patients present with increased uterine bleeding, pelvic pressure, and pain or reproductive dysfunction
true
submucosal fibroids associated with _ pregnancy rates primarily are the result of decreased implantation
decreased
intramural fibroids associated with more __ and slightly lower pregnancy rates
miscarriage
leiomyomas during pregnancy increase the risk of malpresentation, cesarean delivery and preterm delivery
true
diagnosis: physical finding of an enlarged mobile uterus
true
routine radiologic assessment not required ; but..
confirms presence of a leiomyoma versus an adnexal mass
TV US has high sensitivity and specificity of detecting leiomyomas in uteri less than __ size
10 weeks in size
__ also has high sensitivity and specificity of detecting leiomyomas. it is better at detecting multiple and larger leiomyomas
MRI
2 most common symptoms for which women seek treatment for leiomyomas are
abnormal uterine bleeding (usually heavy / prolonged) and
pelvic pressure
Medical treatment of leiomyomas:
- contraceptive steroids (estrogen and progestin or progestin alone) ->short term relief.
- gonadotropin releasing hormone (GnRH) agonists can decrease volume of leiomyomas by 35% to 65% within 3 months of treatment but will recur within several months after cessatio of treatment; if treatment is continued for more than 6 months, add back therapy should be considered to minimize bone loss and vasomotor symptoms.
sequential regimen gives maximal results for GnRH. why?
GnRH agonist first used to achieve down-regulation, then add contraceptive steroids after 1-3 months of therapy. however, addition of progestin results in an increase in uterine volume up to 95% of baseline at 24 mths.
Aromatase inhibitors block ovarian and peripheral estrogen production and decrease estradiol after 1 day of treatment;
small studies shown a reduction in leiomyoma size and symptoms.
Uterine artery emboliation (UAE) embolization occurs via transcutaneous __ artery approach resulting in leiomyoma devascularization and involution; uterine arteries are embolized using polyvinyl alcohol particles of triascryl gelatin microspheres
femoral artery
Endometrial hyperplasia
peaks in early 50s without atypia
early 60s with atypia. diagnosis: heavy, prlonged, frequent (35 yrs.
dx of endometrial hyperplasia:
- endometrial bx. detection rate for endometrial carcinoma 99.6%, and 91% for premenopausal and postmenopausal women. detection for atypical hyperplasia, pipelle most sensitive at 81%
- Dilation and curettage (D&C
- Saline infused sonography endometrial sampling.
progression to endometrial cancer is _%for simple hyperplasia without atypia _%for complex hyperplasia without atypia _%for simple hyperplasia with atypia _%for complex hyperplasia with atypia
1%for simple hyperplasia without atypia
3%for complex hyperplasia without atypia
8%for simple hyperplasia with atypia
29%for complex hyperplasia with atypia
Treatment: depends more on presence of atypia and menopausal status; simple or complex hyperplasia does not determine treatment as much as atypia
true
__ reverse endometrial hyperplasia by activation of progesterone receptors, which results in stromal decidualization and subsequent thinning of the endometrium; progestins also decrease estrogen and progesterone receptors and activate hydroxylase enzymes to convert estradiol to its less active metabolite estrone
progestins
response rate highest in women __ atypia and with therapy of 12-14 days per month
without atypia with therapy 12-14 days/ month. regression has been seen in 80% of treated patients; levonorgestrel containing intrauterine contraception is also effective.
in premenopausal patients with atypia: if atypia found on initial endometrial biopsy, further evaluation with a D&C may be indicated given high concurrent risk of carcinoma
true.
if maintaining fertility is desired, treatment is:
medroxyprogesterone acetate or megestrol acetate 80mg bid; levonorgestrel containing IUC is also effective option for treating hyperplasia in premenopausal women
postmenopausal women without atypia: treatment:
medroxyprogesterone acetate 10mgdaily x 3 months with f/u endometrial bx after cessation of drug therapy
postmenopausal women WITH atypia treatment:
if hysterectomy is not an option, continuous oral megestrol acetate 80mg twice daily or levonorgestrel
the most common presentation of endometrial cancer is
abnormal uterine bleeding
diagnosis of endometrial cancer
endometrial biopsy with pipelle or dilation and curettage in women older than 35 years of age with anovulatory uterine bleeding to r/o endometrial hyperplasia or cancer based on acog guidelines.
Leiomyosarcoma 50% of patients with disease limited to the uterus have recurrence within 2 years, 5 year survival rates of
<50%
diagnosis of leiomyosarcomas:
after a myomectomy / hysterectomy for fibroids. new / enlarging pelvic mass, abnormal uterine bleeding, and pelvic pain.
rapidly growing fibroids is NOT a risk factor for leiomyosarcoma
true
27% of hysterectomies performed for rapidly growing fibroids are found to be leiomyosarcomas
true
in patients younger than 50 years of age with endometrial cancer, _% found to carry a germline Lynch syndrome associated mutation
9% found to have Lynch syndrome associated mutation.
1/2 of women, gyn cancer PRECEDED development of colon cancer by an average of _ years (ovarian cancer) or _ years (endometrial cancer presenting first)
5.5 years for ovarian cancer
11 years for endometrial cancer
BEFORE development of ovarian cancer
median age for germline Lynch syndrome mutation swas
44 years.
women with 1st degree relative with Lynch syndrome associated cancer had 43% chance of having germline Lynch mutation compared with women without an affected 1st degree relative
true