Disorders of Menstruation and the Uterus Flashcards
1
Q
1. What is amenorrhea? Describe what would consitute amenorrhea in the following ages: 2. By age 15 in presence of what? 4 3. At age 13 in the absence of what? 4. At age 12-13 evaluate what?
A
- DEFINITION: No history of any menses
- normal growth and secondary sexual characteristics
- secondary sexual characteristics
- evaluate cyclic menstrual pain
(inperforate hymen)
2
Q
Amenorrhea: Primary
Etiologues?
5
A
- Chromosomal abnormality (gonadal dysgenesis, Turner’s syndrome) 50%
- Hypothalamic hypogonadism 20%
- Mullerian agenesis (absence of uterus, cervix and vagina 15%
- Transverse vaginal septum or imperforate hymen 15%
- Other:
- CAH,
- PCOS,
- androgen insensitivity
3
Q
Amenorrhea: Primary
Hx findings?
9
A
1, cyclic pelvic pain,
- other stages of puberty,
- headaches,
- virilization,
- galactorrhea,
- medications,
- stressors, weight change
- illness
- FH of delayed puberty
4
Q
Amenorrhea: Primary
Possible Exam findings?
3
A
- Tanner Staging (Breast development is a marker for Estrogen = Ovary)
- Pelvic exam to confirm patent hymen and presence of vagina
- Signs of Turner’s (low hairline, web neck, widely spaced nipples with shield chest)
5
Q
Amenorrhea: Primary
1. Initial Lab?
- Further lab based upon what? 2
- What could these furthers labs be? 5
- Initial imaging? 1
A
- FSH
- FSH and
- presence or absence of breast development and uterus
- could include
- karyotype,
- testosterone,
- TSH,
- prolactin and
- pregnancy test - Initial imaging: ultrasound to confirm uterus
6
Q
Amenorrhea: Secondary 1. RULE OUT WHAT? 2. Ovarian causes? 2 3. Hypothalamic causes? 3 (What is decreased in hypothalamic causes?)
A
- PREGNANCY
- OVARIAN 40%
- PCOS 20%
- Primary Ovarian Insufficiency (PCO) less than 40 yo - HYPOTHALAMIC
-Weight loss and exercise
-Nutritional deficiencies: low body fat; celiac
-Emotional stress or illness
(FUNCTIONAL (decreased GnRH))
7
Q
Amenorrhea: Secondary
- Nonfunctional hypothalamic causes? 1
- Pituitary causes? 4
- Uterine causes? 2
A
1. Hypothalamic Infiltrative tumors (rare)
- Pituitary
- Hyperprolactinoma
- Other causes of elevated prolactin
- Injury to pituitary
- Hypothyroidism - Asherman’s syndrome (acquired scarring of cavity)
- Tuberculosis
8
Q
What are some injuries to the pituitary that would cause secondary amenorrhea?
3
A
- Sheehan’s syndrome,
- radiation,
- infiltrative disease like hemochromatosis
9
Q
Amenorrhea: Secondary
Hx questions?
9
A
- Menstrual hx
- Exercise and eating patterns,
- Medications that may increase prolactin
- Stress
- Post partum hemorrhage
- Radiation to head
- Headaches
- Hot flashes
- Uterine surgeries
10
Q
Amenorrhea: Secondary
exam? 4
Initial labs? 6
A
- BMI,
- hirsutism
- galactorrhea
- UTERINE SIZE
- pregnancy test,
- FSH,
- TSH,
- prolactin,
- possibly testosterone and
- DHEA-S
11
Q
What is dysmenorrhea?
A
Painful periods
12
Q
- Describe what primary dysmenorrhea is?
- How does it typically present? 3
- Describe what secondary dysmenorrhea is? Associated with which dz processes? 3
A
- Primary: No obvious cause, typically
- begins in adolescence as -
- crampy,
- midline lower abdominal pain
- associated with onset of menses - Secondary: Symptoms attributed to specific problem like
- endometriosis,
- adenomyosis or
- fibroids or PID
13
Q
Dysmenorrhea: Primary
Risk factors?
8
A
- Age less than 30
- BMI less than 20
- Smoking
- Menarche less than 12
- Irregular/prolonged/heavy menses
- Hx of sexual assault
- Family hx
- Younger age of first child and higher parity lower risk
14
Q
- Dysmenorrhea: Primary
PP? - Uterine ischemia results in what?
A
- Prostaglandins released with endometrial sloughing induce contractions
- anaerobic metabolites which stimulates type C pain neurons
15
Q
Dysmenorrhea: Primary
Presentation?
4
A
- Pain begins after ovulatory cycles established
- May start 1-2 days before menses; gradually diminishes over 12-72 hours
- Unilateral pain or non-cyclic pain suggests other dx
- Nausea, diarrhea, headache may be present
16
Q
Dysmenorrhea: Primary
Dx?
4
A
- No physical exam findings
- No lab abnormalities
- No imaging study findings
- Dx by history and normal exam
17
Q
Dysmenorrhea: Primary
- General evaluation?
- What things suggest secondary causes? 5
A
- EVALUATION: Focus on exclusion of secondary dysmenorrhea:
- Onset of symptoms >25
- Nonmidline pain
- Dyspareunia
- Progression of symptoms
- Abnormal uterine bleeding suggest secondary causes
18
Q
Dysmenorrhea: Primary
Firstline Rx?
4
A
- Self-care: heating pad, exercise and relaxation techniques
- NSAIDs
- Suppression of menses with contraceptive hormones
- Limited data and small studies report reduced cramps with diet and supplements: low fat-vegetarian diet;3-4 dairy servings/day; vit E 2 days before thru 1st 3days of menses; 1-2 gm fish oil/d; Vit B1 100 mg/d; vit B6 200 mg/d
19
Q
Dysmenorrhea: Secondary
Causes?
10
A
- Endometriosis 2. Adenomyosis
- Fibroids 4. Ovarian cysts
- Intrauterine/pelvic adhesions
- Obstructive endometrial polyps
- Obstructive mullerian anomalies
- Cervical stenosis 9. IUD
- Pelvic congestion syndrome
20
Q
Abnormal Uterine Bleeding (AUB)
Basic labs? 5
A
- CBC
- Prolactin
- TSH
- Pregnancy test
- Chlamydia testing when indicated
21
Q
Abnormal Uterine Bleeding: Diff Dx
9
A
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy
- Coagulation
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
22
Q
Abnormal Uterine Bleeding: Terms
- Polymenorrhea?
- Menorrhagia?
- Metrorrhagia?
- Oligomenorrhea?
A
- cycles less than 24 days
- heavy menstrual bleeding
- bleeding between periods
- cycles> 35 days
23
Q
Abnormal Uterine Bleeding:Coagulation
20 % of women presenting with heavy menstrual bleeding have an underlying bleeding disorder
SUCH AS?
A
VonWillebrand’s
24
Q
Abnormal Uterine Bleeding: Coagulation
IN ADDITION TO HEAVY MENSTRUAL PERIODS, REFER FOR HEMATOLOGIC EVALUATION :
- If also have one of the following?
3 - Refer with two of the following? 3
A
- Hx of postpartum hemorrhage
- Hx of unexplained bleeding with surgery
- Hx of bleeding with dental work
- Frequent gum bleeding
- Epistaxis or unexplained bruising 2X a month
- Family Hx of bleeding
25
Abnormal Uterine Bleeding: Ovulatory
1. Caused by what as a result of anovulation or oligo-ovulation?
2. What may cause this?
1. chronic unopposed estrogen influence
2.
- Hyperandrogenic (PCOS)
- Hypothalamic dysfunction (anorexia)
- Thyroid disease
- Elevated prolactin
- Medications
- Iatrogenic
- Premature ovarian insufficiency
26
What is PMS and PMDD?
1. PMS = Premenstrual Syndrome
2. PMDD = Premenstrual Dysphoric Disorder
- Severity of symptoms are disruptive at home/social situations/at work
- Cyclic physical and/or behavioral symptoms that recur in the luteal phase and first few days of menses. (Present for at least 3 months)
27
PMS and PMDD: Risk Factors
| 4
1. Genetics: variation of estrogen receptor alpha gene
2. History of traumatic events/anxiety disorder/higher daily hassle scores
3. Lower education
4. Smoking
28
PMS and PMDD: Pathophysiology
Theories?
2
1. Abnormal response to normal concentrations of estrogen and progesterone
2. Cyclic changes in circulating estrogen and progesterone trigger an abnormal serotonin (neurotransmitter) response
29
PMS and PMDD
1. Usually starts when?
2. Must cause significant what?
1. Usually start in 20’s
| 2. Must cause significant distress or interference with normal activities
30
PMS and PMDD: Symptoms
| Physical symtpoms? 6
PHYSICAL
1. Abdominal bloating
2. Extreme fatigue
3. Breast pain
4. Headache
5. Hot flashes
6. Dizziness
31
PMS and PMDD
| Behavioral 4
1. Mood swings
2. Irritability/anger
3. Depression/hopelessness/self-critical
4. Anxiety/tension/feeling on edge
32
For dx of PMDD must have at least one of the above and a total of 1.__ symptoms, 2.__ of which can be from an expanded DSM-5 criteria.
3. These symptoms should have been present when?
1. 5
2. 4
3. for most of the preceding year in a cyclic pattern with menses
33
PMS and PMDD: Evaluation
1. Confirm what first?
2. Lab? 2
3. Have patient complete what?
1. Confirm regular menses and cyclic pattern of symptoms
2. Lab: No specific test. Consider TSH and CBC
3. Have patient complete a prospective symptom inventory
34
PMS and PMDD: Treatment
1. Mild? 2
2. Moderate-Severe? 1
MILD
1. Exercise and relaxation techniques
2. No strong data that vitamins or supplements exceed the placebo response
MODERATE-SEVERE
1. SSRIs
-Fluoxetine, sertraline, extended release paroxetine all have FDA approval
60-70% response; try different SSRI
35
PMS and PMDD: Treatment
| Refractory to SSRI? 3
Induce anovulation with
1. continuous/short pill-free interval OC (Evidence strongest for drospirenone)
2. GnRH agonist
3. Surgery with BSO (and hysterectomy)
36
Endometriosis
1. What is it?
Psychological impact of the 2.___________ experienced by the patient is compounded by the possibility of 3._______?
Endometriosis has a prevalence rate of 20-50% in 4.________ women and as high as 80% in women with 5._________.
Common, poorly understood, and extremely debilitating benign gynecological condition.
1. Cells that behave like the lining the uterus (endometrium) grow in other areas of the body, causing pain, irregular bleeding, and possible infertility.
2. severe pain
3. infertility
4. infertile
5. chronic pelvic pain
37
Endometriosis
| Who can be affected by this? 2
1. Affects menstruating women.
| 2. Postmenopausal endometriosis may be encountered in women who are on estrogen replacement therapy (ERT).
38
Occasionally, if ERT is administered after total abdominal hysterectomy, endometriosis can be stimulated in an what?
ovarian remnant.
39
Endometriosis
Etiology and pathophysiology of endometriosis is not well understood.
Theories (and describe them)? 3
1. Retrograde menstruation
- Endometrial cells loosened during menstruation may "back up" through the fallopian tubes into the pelvis. Once there, they implant and grow in the pelvic or abdominal cavities.
2. Halban Theory: vascular and lymphatic dissemination
3. Meyer Theory: metaplasia of multipotential cells
40
Each month ovaries produce hormones that stimulate the cells of the endometrium to multiply and prepare for a fertilized egg. The lining swells and gets thicker.
If these cells are outside the uterus, endometriosis results.
Why is this a problem? 3
1. Unlike cells normally found in the uterus that are shed during menstruation, the ones outside the uterus stay in place.
2. Cells bleed a little bit, but they heal and are stimulated again during the next cycle.
3. Ongoing process leads to symptoms of endometriosis and can cause adhesions on the tubes, ovaries, and surrounding structures in the pelvis.
41
Endometriosis
Risk factors?
6
1. FH: Women who have a mother or sister with endometriosis are six times more likely to develop endometriosis
2. Starting menstruation at an early age
3. Never having had children
4. Frequent menstrual cycles
5. Periods that last 7 or more days
6. Imperforate hymen, which blocks the flow of menstrual blood
42
Endometriosis:
1. What is the main symptom?
2. The degree of what has no correlation with the degree of pain or other symptomatic impairment?
3. Pain does correlate with the depth of what?
4. _______ disease is generally believed to be more painful than ________ disease.
1. Pain is the main symptom for women with endometriosis.
2. visible endometriosis
3. tissue infiltration.
4. Midline, lateral
43
Endometriosis
| Symptoms: Pain can include? 4
1. Painful periods
2. Pain in the lower abdomen or pelvic cramps that can be felt for a week or two before menstruation
3. Pain in the lower abdomen felt during menstruation (the pain and cramps may be steady and dull or severe)
4. Pain during or following sex
44
Endometriosis: Pain
| Acute exacerbations believed to be caused by what?
believed to be caused by chemical peritonitis due to leakage of old blood from an endometriotic cyst.
45
Anatomic spread for endometriosis:
1. Most common?
2. How does it spread to here? 2
1. Ovary is the most common site
2. Spread to the ovary is believed to be
- lymphatic, although superficial implants may be due to
- retrograde menstrual flow because the ovaries are in a dependent part of the pelvis.
46
Endometriosis: Lesions can vary in size from spots to large endometriomas.
1. Describe a classic lesion?
2. What happens if the intracystic pressure rises and the cyst perforates? 2
3. __________ response causes adhesions that further increase the morbidity of the disease.
1. classic lesion is a chocolate cyst of the ovary that contains old blood that has undergone hemolysis (endometriosis in the ovary or endometrioma)
2.
- spilling its contents within the peritoneal cavity
- causing the severe abdominal pain typically associated with endometriosis exacerbations.
3. inflammatory
47
Endometriosis
Complications?
4
1. Infertility
2. Chronic or long-term pelvic pain that interferes with social and work activities
3. Large cysts in the pelvis (endometriomas)
4. Depression (secondary to chronic pain and infertility)
48
Endometriosis
Pelvic exam findings?
4
1. Tenderness upon examination is best detected at the time of menses.
2. Nodularity of the uterosacral ligaments and the cul-de-sac may be found.
3. Uterus may be fixed in retroversion, owing to adhesions.
4. Occasionally, a bluish nodule may be seen in the vagina due to infiltration from the posterior vaginal wall.
49
Endometriosis: Imaging?
| 3
1. US
2. MRI
3. Pelvic Laparoscopy
50
Describe what US show us for endometriosis?
| 2
1. Transvaginal sonography is a useful method of identifying the classic chocolate cyst of the ovary.
2. typical appearance is that of a cyst containing low-level homogenous internal echoes consistent with old blood.
51
1. What is the primary diagnostic tool for endometriosis?
2. Classic lesions are what color? 2
3. Can also be what color? 3
4. What other lesions are also indicative? 2
1. Pelvic Laparoscopy
2. classic lesions are
- blue-black or have a
- powder-burned appearance.
3. can be
- red,
- white, or
- nonpigmented.
4.
- Peritoneal defects and
- adhesions are also indicative.
52
Endometriosis
Treatment depends on the following factors? 4
Treatments? 5
1. Age
2. Severity of symptoms
3. Severity of disease
4. Desire to maintain uterus
1. GnRH analogs
2. OCP
3. Medroxyprogestone acetate
4. Danazol
5. Aromatase inhibitors
53
Describe how long you should use the following and which drugs are in each:
1. GnRH analogs?
2. OCP?
3. Medroxyprogestone acetate?
4. Danazol
5. For aromatase inhibitors: MOA?
- Used when?
- What is the drug called?
1.
a. Used for 6 months to suppress ovulation
b. Lupron
2.
a. Used for 6- months to suppress ovulation
b. BCP’s
b. Vaginal ring
b. Patch
3.
a. Used for 6-9 months (May need oral estrogen for breakthru bleedings)
b. Provera,
b. Depo-Provera
4. Danazol
a. Used for 4-6 months
(Lowest dose necessary to suppress ovulation)
a. Weight gain
a. Hirsutism
a. Acne
5. Block the synthesis of estrogen
- Used if endometriosis is resistant to other therapies
- Letrozole
54
1. Whats the most common gynecological cancer in the US?
2. Prog?
3. Mean age?
1. Endometrial Cancer
2. 70% are Stage I at Dx with 5 year survival 90%
3. Mean age at Dx 63
55
Endometrial Cancer: Pathophysiology
1. What is type 1?
2. Describe its severity?
3. Precursor?
4. What is type 2?
5. Prognosis?
6. More common in what populations? 2
1. Type I: ENDOMETRIOD ADENOCARCINOMA
- Most common (75%)
2. Low grade and usually confined to uterus at Dx
3. Precursor: endometrial intraepithelial neoplasia (atypical endometrial hyperplasia):
- 30-50% undiagnosed, coexisting cancer
4. Type II: papillary serous/clear cell
5. Poorer prognosis
- High grade; likely to have spread beyond uterus at time of Dx
6. More common in black women and smokers
56
Endometrial Cancer: Risks
| 6
1. Unopposed estrogen
2. Type II diabetes or HTN: Independent of obesity
3. Age: 85% > 50 yo; only 5% younger than 40
4. SERM: Tamoxifen (prophylaxis or tx of breast ca)
5. Genetics
6. Smoking
57
What genetic syndromes would cause risk of endometrial cancer? 2
1. Lynch syndrome (hereditary nonpolyposis colorectal cancer)
(Increased risk of colon, ovarian and type I endometrial cancer)
-10% dx with endometrial under age 50 have Lynch syndrome
2. Cowden syndrome (13-19% lifetime risk)
Consider referral for genetic testing
58
With smoking what type of endometrial cancer would be more prominant?
2
59
What would cause a decreased risk of endometrial cancer?
| 3
Use of
- combination oral contraceptives,
- medroxyprogesterone acetate or
- levonorgestrel IUD
60
Endometrial Cancer
S/S:
1. Most common symptom?
2. What would make this different? 2
3. What would advanced disease cause?
4. Screening?
1. Abnormal bleeding – 80% of cases
2.
- Postmenopausal bleeding
- Irregular menses or intermenstrual bleeding
3. Advanced disease
Abdominal pain/bloating/early satiety/change in bowel or bladder habits
4. none
61
Endometrial Cancer: Diagnosis
1. What is the method of choice for histologic evaluation?
2. How could we measure thickness?
1. Endometrial biopsy
| 2. Vaginal probe ultrasound to measure endometrial thickness
62
Vaginal probe ultrasound to measure endometrial thickness
1. USed in who?
2. How does this help us? 2
No value for who?
1. In postmenopausal women:
- Endometrial stripe (EMS) less than 4: endometrial biopsy not needed
- EMS > 4: need endometrial biopsy
NO diagnostic value in premenopausal women
63
Enodmetrial Cancer treatment?
| 3
1. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with surgical staging
2. Adjuvant chemotherapy with advanced cancer
3. Adjuvant vaginal brachytherapy if high risk for recurrence
64
What adjunct therapy would we use for Total abdominal hysterectomy and bilateral salpingo-oophorectomy with surgical staging?
2
1. Peritoneal washings for cytology
| 2. Pelvic and para-aortic lymph node sampling (may eliminate need for adjuvant tx)
65
Endometrial cancer prognosis based on?
| 3
Based on surgical staging:
1. depth of myometrial invasion,
2. tumor type and grade,
3. tumor spread to include lymph nodes
66
Endometrial Cancer
1. How can we detect is early? 2
2. Prevention? 2
Early detection
Evaluate
1. abnormal menstrual bleeding
2. ALL postmenopausal uterine bleeding
Prevention
Younger women with chronic anovulation are at risk for endometrial hyperplasia
-Oral contraceptives or
-cyclic progestin therapy can reduce risk
67
Uterine Fibroids: Leiomyoma or Myomas
1. Most common _____ tumor?
2. Most women have no symptoms or need for surgery but fibroids are the most common cause for What?
3. Describe what they are?
4. They are dependent on what?
5. Rarely occur when? 2
6. Grow larger during what?
1. Most common pelvic tumor in women
- By age 50: 70% white and 80% black women
2. hysterectomy
3. Benign, monoclonal smooth muscle tumors of myometrium
4. Estrogen dependent
5. rarely occur before menarche or after menopause; usually shrink after menopause
6. grow larger during pregnancy
68
Uterine fibroids: Risk Factors
| 5
1. Race- More common in black women and present with symptoms earlier
2. Family history
3. Menarche prior to age 10
4. Nulliparity
5. Significant red meat or ham consumption
69
Uterine Fibroids: Signs and Symptoms
| 7
1. Heavy/prolonged menstrual flows
2. Postmenopausal bleeding and intermenstrual bleeding not expected
3. Location of fibroid influences bleeding: submucosal
4. Pelvic pain/pressure/prolapse
5. Urethral obstruction with hydronephrosis
6. Degeneration or torsion
7. Infertility/miscarriage or preterm labor
70
Uterine Fibroids
What may you find on the pelvic exam?
5
1. Uterus usually irregularly enlarged and somewhat asymmetric
2. May be tender
3. Unlike adenomyosis, the fibroid uterus firm
4. May be mistaken for adnexal mass if situated laterally
5. If mass moves with the uterus, likely to be a leiomyoma
71
Uterine Fibroids: Differential Dx
1. Enlarged uterus? 3
2. Asymmetric uterus or pelvic mass?
3
1.
- Pregnancy
- Adenomyosis
- Uterine neoplasm (Uterine sarcoma rare)
2.
- Tubo-ovarian inflammatory mass
- Diverticular inflammatory mass
- Ovarian tumor
72
Uterine Fibroids: Evaluation
1. Labs? 3
2. Imaging? 3
3. Histology?
1. Lab
- Evaluate for anemia
- UA if has urinary symptoms
- Pregnancy test if appropriate
2. Imaging studies
-Usually complete pelvic sono (not just vaginal probe)
Consider
-saline-enhanced sono or
-hysteroscopy if submucosal fibroid suspected
3. Histologic confirmation usually not needed
73
Uterine Fibroids: Medical Management
1. Heavy bleeding? 4
2. When goal is size reduction (but effect does not persist after tx)? 4
1.
- Trial of oral contraceptive, progestin implants or levonorgestrel IUD (latter not with distortion of endometrial cavity)
- Tranexamic acid (Lysteda), an antifibrinolytic
- Endometrial ablation
- Uterine artery ablation
2.
-Presurgical reduction in size
Surgical risk high
- GnRH agonist (like leuprolide or Lupron)
- Selective Progesterone Receptor Modulators (SPRMs) (Ulipristal or Mifepristone (appropriate doses not available in US))
- Aromatase Inhibitors (block conversion of androgen to estrogen)- Anastrozole
74
What do we have to remember about Tranexamic acid (Lysteda), an antifibrinolytic used for Uterine Fibroids that cause heavy bleeding? 2
1. Use up to five days during menses
| 2. Do not combine with combined oral contraceptives
75
What does lupron do and how long can you use it?
creates “temporary menopause”; because of bone loss, use limited to 3-6 months
76
Uterine Fibroids: Surgical Options
| 2
1. MYOMECTOMY
| 2. HYSTERECTOMY
77
When would you do a myomectomy for uterine fibroids?
| 4
1. Desire to preserve fertility
2. Solitary pedunculated myoma
3. Myoma protruding into uterine cavity
4. Location of the myoma appears to be interfering with fertility or pregnancy loss
78
Uterine Fibroids: Surgical Options
Hysterectomy indications?
4
1. Rapid enlargement of the uterus may mean possible malignancy
2. Heavy uterine bleeding or pain not responding to medical methods or minimally invasive procedures
3. Completed childbearing and have significant symptoms with desire for definitive tx
4. Uterine growth after menopause
79
What is Adenomyosis?
A condition in which endometrial tissue exists within and grows into the uterine wall.
80
Adenomyosis: Pathophysiology
2
What types are there? 2
1. Presence of endometrial glands and stroma in the myometrium
2. Induction of hypertrophy and hyperplasia of myometrium
1. Generalized: Uniform uterine enlargement
2. Focal or nodular: Uterus may be normal size but asymmetric
81
Adenomyosis: Risk Factors 1
Often coexists with what? 2
More common in parous women
Often coexists with
- endometriosis (11%) or
- fibroids (50%)
82
Adenomyosis: Signs and Symptoms
1. Present at what age?
2. Severity of symptoms proportional to what?
3. Symptoms? 4
1. Symptoms generally present age 35-50
2. Severity of symptoms proportional to depth and volume of myometrial involvement
3.
- Secondary (acquired) dysmenorrhea (25%)
- Menorrhagia (60%)
- Uterine enlargement, generally symmetric and no larger than 12-14 weeks
- Uterine tenderness before and during menses
83
Adenomyosis: Diagnosis? 3
Treatment?
3
1. Diagnosis
- Definitive dx with hysterectomy
- MRI
- Ultrasound
2. Treatment
- Hormone manipulation:
- Uterine artery embolization
- Hysterectomy
84
What hormones could you use for treatment of Adenomyosis?
| 3
1. progestins,
2. aromatase inhibitors,
3. continuous oral contraception
85
Adenomyosis: hysterectomy indicated for who?
| 4
1. severe, symptomatic adenomyosis
2. severe dysmenorrhea
3. menorrhagia
4. enlarged uterus greater than 10 weeks size
86
Endometrial Polyps: Epidemiology & Pathology & Risk Factors
1. Frequency increases with what?
2. What is it?
3. Increased estrogen is a risk factor: What could cause this? 3
1. Frequency increases with age
2. Localized hyperplastic overgrowth of endometrial glands and stroma around a vascular core; may contain smooth muscle
3. Increased estrogen:
- Tamoxifen (SERM)
- Obesity
- Menopausal hormone treatment
87
Endometrial Polyps: Signs and symptoms
| 3
1. Abnormal bleeding: 64- 88% of women with polyps
2. Incidental finding on imaging (ultrasound)
3. 12-14% of women with “benign endometrial cells” on pap smear
88
1. Endometrial Polyps: Evaluation? 2
2. Diff Diagnosis? 2
3. Dx is by what?
1. Evaluation
-On exam, no specific findings unless prolapsed thru external os of cervix
-Transvaginal sono
(Consider saline infusion sonogram)
2. Differential Dx:
- Fibroid (submucosal)
- Endometrial hyperplasia or cancer (thickened endometrial stripe)
3. Diagnosis is by histology
89
Endometrial Polyps: Management?
Hysteroscopic removal
90
Endometrial Polyps: Management
1. Which polyps should we remove?
2. If they are asymptomatic and premenopausal which polyps should we remove? 3
3. Postmenopausal and asymptomatic?
1. All symptomatic polyps (bleeding)
2. Asymptomatic and Premenopausal
- Risk factors for hyperplasia/endometrial cancer
- Multiple or >1.5 cm diameter (unlikely to regress)
- Infertility (limited data)
3. Postmenopausal
- Remove all as higher risk for malignancy
91
What is unterine prolapse?
Weakening of pelvic floor muscles and ligaments creating inadequate support for the uterus and /or vaginal tissues
92
Uterine Prolapse: Risk Factors
| 5
1. Multiple vaginal deliveries, particularly large infants, prolonged second stage or instrument delivery
2. Family history
3. Postmenopausal
4. Obesity, chronic cough, frequent straining with BM
5. Repetitive heavy lifting
93
Uterine Prolapse: Evaluation
| 3
1. PELVIC EXAM
2. Pelvic ultrasound only if uterine enlargement or adnexal mass warrants
3. Urologic evaluation if indicated
94
Uterine Prolapse: Clinical Presentation
| 8
1, Sensation of heaviness or pressure in the pelvis
2. Tissue bulging at introitus/protruding from the vagina is only symptom specific to prolapse****
3. Urinary difficulties, such as urine leakage or urine retention
4. Trouble having a bowel movement
5. Low back pain
6. Sensation of sitting on a small ball
7. Sexual concerns: difficulty with penetration, awareness of decreased vaginal tone
8. Symptoms often less bothersome in the morning and increase with prolonged standing or activity
95
Uterine Prolapse
Sequelae
3
1. Ulcers
Friction of exposed tissue on underwear may lead to ulceration of tissue and spotting/bleeding, rarely infection
Prolapse of other pelvic organs.
2. Cystocele (prolapsed bladder ) bulges into the vagina and can lead to difficulty in urinating/ urinary retention/increased risk of urinary tract infections.
3. Rectocele (prolapsed rectum) resulting from weakness of connective tissue overlying the rectum may lead to difficulty having bowel movements.
96
Uterine Prolapse
Questions to ask the pt?
11
1. What symptoms are you experiencing?
2. When did you first notice these symptoms and are they increasing?
3. Are you having any pain? If yes, how severe is the pain?
4. Do you have urine leakage (urinary incontinence), frequency or sensation of not emptying your bladder well?
5. Have you had a chronic or severe cough?
6. Does your work or daily activities involve heavy lifting?
7. Do you strain during bowel movements?
8. Is there a family history of prolapse?
9. Did you have children born vaginally? How large was your largest? Any difficult deliveries?
10. Do you plan to have children in the future?
11. Do you have any other concerns?
97
Uterine Prolapse: Evaluation
What would we see on the pelvic exam?
4
1. Look and feel for position of uterus in vagina
2. Ask patient to “bear down”/cough
3. Evaluate for uterine enlargement or adnexal mass
4. Perform rectovaginal exam to evaluate for rectocele
98
Uterine Prolapse:
1. When we look and feel for position of vagina where should we feel?
2. When we ask the pt to bear down or cough what should we look for?
2
1. Describe location in relation to hymen (“About ½ down vaginal vault”)
2.
- Observe for further drop of cervix or vaginal tissues as well as urinary incontinence
- If tissues are not bulging as dramatically as patient describes, consider exam of patient standing
99
Uterine Prolapse: Management
Treatment?
5
1. Education and reassurance
2. Achieve and maintain a healthy weight
to minimize the effects of being overweight on supportive pelvic structures
3. Perform Kegel exercises
to strengthen pelvic floor muscles.
4. Avoid heavy lifting and straining
to reduce abdominal pressure on supportive pelvic structures.
5. Address factors contributing to valsalva
- Chronic cough, constipation
100
Uterine Prolapse: Pessaries
Vaginal pessary should be offered to all symptomatic women
1. Fitting can be made regardless of what?
2. Generally made of what?
3. Designed for what?
4. Maintance of the device?
1. Fitting can be successful regardless of degree of prolapse
2. Generally made of silicone
3. Designed to hold the prolapsed tissue in place
4. Need to be remove the device and cleaned with soap and water periodically
101
Uterine prolapse: Drawbacks to pessaries?
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1. Inability to get a good fit
2. Woman’s comfort or ability to insert and remove may be limited
3. Irritation/ulceration of vaginal tissues
4. Odor/discharge develops if not regularly removed and cleansed
5. Pessary may interfere with sexual intercourse.
102
Uterine Prolapse: Surgery
Multiple approaches influenced by what?
7
1. Desire to maintain uterus
2. Desire to maintain ability to have intercourse
3. Surgical risk
4. Presence of urinary
5. Degree of vaginal prolape
6. Hx of prior procedures
7. Approach to address underlying problem of apical support
