DISORDERS OF MENSTRUATION & THE UTERUS Flashcards
WHAT IS UTERINE PROLAPSE
- Pelvic floor muscles & ligaments stretch & weaken –> inadequate support for the uterus –> the uterus descends into vaginal canal
this often affects postmenopausal women who’ve had one or more vaginal deliveries
CAUSES OF UTERINE PROLAPSE
o Pregnancy & trauma during childbirth
⦁ large babies
⦁ difficult labor & delivery
o Loss of muscle tone
⦁ aging
⦁ reducing amounts of circulating estrogen after menopause
o in rare cases, uterine prolapse may be caused by a tumor in the pelvic cavity
o some conditions such as obesity, chronic constipation, and COPD
⦁ put strain on muscles / CT in pelvis and may play a role in development of uterine prolapse
o Genetics may also play a role in strength of supporting tissues
⦁ women of northern European descent = higher incidence of prolapse than women of asian & african descent
SYMPTOMS OF UTERINE PROLAPSE
⦁ sensation of heaviness or pulling in pelvis
⦁ tissue protruding from vagina
⦁ urinary difficulties - urine leakage or urine retention
⦁ trouble having a bowel movement
⦁ low back pain
⦁ feeling as if sitting on a small ball, or something is falling out of the vagina
⦁ symptoms that are less bothersome in the morning & worsen as the day goes on
UTERINE PROLAPSE SEQUELAE
ulcers
other organ prolapse
⦁ Ulcers - part of vaginal lining may be displaced by prolapsed uterus, & also protrude outside the body. Friction-> vaginal sores (ulcers). Rare causes - sores become infected
⦁ Prolapse of other pelvic organs (Cystocele, Rectocele)
UTERINE PROLAPSE - PHYSICAL EXAM
- look & feel for uterus in vagina
- have patient bear down
- kegel maneuver
UTERINE PROLAPSE IMAGING?
- imaging isn’t really needed for uterine prolapse
- can do ultrasound if needed
TREATMENT FOR UTERINE PROLAPSE
o Lifestyle Changes
⦁ achieve & maintain healthy weight
⦁ perform kegel exercises to strengthen pelvic floor muscles
⦁ avoid heavy lifting & straining
o ERT - estrogen replacement therapy - may help limit further weakness of muscles/other CT that support uterus
o Vaginal Pessary
⦁ fits inside vagina - designed to hold the uterus in place. can be temporary or permanent. comes in many shapes & sizes. Measurements are needed for placement. Patient to remove device & clean with soap and water frequently
o Surgery
⦁ Uterine suspension surgery
⦁ Hysterectomy
ADENOMYOSIS is commonly confused with
fibroids
PATHOPHYS OF ADENOMYOSIS
- the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge
- the lining = located in the uterine muscle layer is responsive to hormonal changes, and with menses, some blood may be trapped –> severe cramps & heavy bleeding
TREATMENT OF ADENYMYOSIS
OCPs, NSAIDS, hysterectomy
- may treat with combination OCPs to help with menorrhagia & dysmenorrhea
- if symptoms are mild = NSAIDS
- hysterectomy for ⦁ severe, symptomatic adenomyosis ⦁ severe dysmenorrhea ⦁ menorrhagia ⦁ enlarged uterus greater than 10 weeks size
DIAGNOSIS OF ADENOMYOSIS
- the uterus becomes diffusely enlarged
- menorrhagia (heavy)
- dysmenorrhea (painful)
- endometrial biopsy is often normal
**MRI = most sensitive test for adenomyosis, but is often not ordered due to expense
Ultrasound may suggest the diagnosis, but is less sensitive & specific (thickened wall of uterus can be mistaken for fibroids)
SYMPTOMS OF ADENOMYOSIS
painful, heavy periods
most sensitive test for adenomyosis
MRI - but is often not ordered due to expense
can do ultrasound - but not as good (initial test)
LEIOMYOMA
- UTERINE FIBROIDS = LEIOMYOMA
- benign uterine smooth muscle tumor
- Estrogen dependent* - so may shrink when women enter menopause
- rarely occur before menarche or after menopause
Grow larger during pregnancy (just like cysts in breast)
- rarely malignant
- Most common indication for pelvic surgery in women
Most common indication for pelvic surgery in women
leiomyomas
leiomyomas are _________ dependent
estrogen
just like with endometriosis
LEIOMYOMAS & PREGNANCY
- can interfere with fetal growth/nutrition
- leiomyomas increase the risk of
⦁ spontaneous abortion during 1st & 2nd trimesters
⦁ preterm labor
WHEN DO LEIOMYOMAS REQUIRE TREATMENT
- most don’t cause symptoms, and don’t require treatment
WHEN DO LEIOMYOMAS REQUIRE TREATMENT ⦁ large enough to cause pressure on other organs - such as the bladder ⦁ growing rapidly ⦁ causing abnormal bleeding ⦁ causing problems with fertility
“boggy uterus”
adenomyosis
symmetric & soft & tender
vs leiomyomas = assymetric, firm, nontender
LEIOMYOMA SYMPTOMS
most = asymptomatic
⦁ Heavy menstrual flow ⦁ bleeding between periods ⦁ pain ⦁ pelvic pressure ⦁ stress incontinence ⦁ infertility ⦁ urethral obstruction
FIBROIDS ARE CLASSIFIED BY LOCATION
- location affects symptoms
⦁ fibroids inside the uterine cavity = cause bleeding between periods & severe. cramping
⦁ submucosal fibroids = menorrhagia
LOCATION OF FIBROIDS
⦁ intracavitary = in the uterine cavity (cause cramping & bleeding between periods)
⦁ submucous = partially in uterine cavity = menorrhagia
⦁ intramural = within the uterine wall
⦁ subserous = outside wall of the uterus
submucous myomas can be removed by
hysteroscopic resection
easiest fibroid type to remove via laparoscopy
subserous myoma
SUBSEROUS MYOMAS
⦁ located on the outside wall of the uterus
⦁ may even be connected to the uterus by a stalk (pedunculated fibroid)
⦁ do not need treatment unless they grow large
⦁ those on a stalk can twist and cause pain
⦁ this type of fibroid = easiest to remove via laparoscopy
LEIOMYOMA PELVIC EXAM
- uterus = irregularly enlarged & usually somewhat asymmetrical (adenomyosis = symmetrical)
- may be tender, and may assume very large sizes
- unlike adenomyosis, the fibroid uterus is very firm (not boggy)
- may be mistaken for an adnexal mass if situated laterally
- if the mass moves with the uterus = likely a leiomyoma
DIAGNOSTIC TESTS FOR LEIOMYOMA
1) transvaginal US
2) hysteroscopy –> endometrial biopsy
initial = US? definitive = hysteroscopy?
LEIOMYOMA TREATMENT
MEDROXYPROGESTERONE
⦁ Medroxyprogesterone ⦁ GnRH - agonist - Lupron or Synarel ⦁ oral iron preparation - reevaluate every 3-6 months to check change in uterine size - monintor Hgb & Hct frequently
MYOMECTOMY INDICATIONS
⦁ uterus is > 12 weeks size
⦁ solitary pedunculated myoma
⦁ nature or location of the myoma appears to be interfering with fertility
⦁ myoma is causing pregnancy loss
⦁ rapid growth carries the possibility of malignant sarcoma transformation
if uterus < 12 weeks size = can perform _________ for uterine myomas
if uterus > 12 weeks size = perform __________
hysterectomy = definitive treatment
myomectomy - done to preserve fertility
most common cause for hysterectomy
uterine fibroids
what conditions are estrogen dependent
leiomyomas
endometriosis
Endometriosis is associated with ___________ & ______________
chronic pelvic pain
infertility
what is endometriosis
when endometrial cells grow in other parts of the body
SYMPTOMS OF ENDOMETRIOSIS
causes debilitating pain, irregular bleeding, and infertility
endometriosis occurs in menstruating women, however
⦁ postmenopausal endometriosis may occur in women who are on estrogen RT
⦁ occasionally, pts with a hysterectomy can develop endometriosis in an ovary
ETIOLOGY & PATHOPHYS OF ENDOMETRIOSIS
- not well understood
- possibly due to retrograde menstruation
⦁ endometrial cells that are loosened during menstruation may “back up” through the fallopian tubes into the pelvis. There, they implant and grow in the pelvic or abdominal cavities
RISK FACTORS FOR ENDOMETRIOSIS
⦁ family hx
⦁ early menarche
⦁ nulliparity** - never having had kids
⦁ frequent menstrual cycles (periods that last > 7 days), problems such as a closed hymen - blockes flow of menstrual blood during period, tall/thin ppl with low BMI
- less prevalent in hispanics & black populations
MAIN SYMPTOMS OF ENDOMETRIOSIS
⦁ dysmenorrhea**
⦁ pelvic pain
⦁ dyspareunia
symptoms of endometriosis
o MAIN SYMPTOMS ⦁ dysmenorrhea** ⦁ pelvic pain ⦁ dyspareunia o OTHERS ⦁ bowel upset (constipation, diarrhea) ⦁ bowel pain ⦁ infertility ⦁ ovarian mass/tumor ⦁ dysuria ⦁ other urinary problems
most common area of anatomic spread in endometriosis
ovaries
1) ovaries
2) anterior (area behind the vagina) & posterior cul de sac (area behind the rectum)
3) posterior broad ligaments
4) uterus (outside)
5) fallopian tubes
6) sigmoid colon
7) appendix
8) round ligaments
PATHOPHYSIOLOGY OF PAIN WITH ENDOMETRIOSIS
- lesions can vary in size from spots to large endometriomas
- classic lesion = chocolate cyst of the ovary - contains old blood and has undergone hemolysis (endometriosis in the ovary); the intracystic pressure rises, cyst perforates, spilling contents within peritoneal cavity, causing severe abdominal pain. Inflammatory responses cause adhesions, which further increase the morbidity of the disease
COMPLICATIONS WITH ENDOMETRIOSIS
Infertility
Chronic or long-term pelvic pain that interferes with social and work activities
Large cysts in the pelvis (endometriomas)
Depression
DEFINITIVE DIAGNOSIS OF ENDOMETRIOSIS
LAPAROSCOPY
powder burn appearance with laparoscopy
endometriosis
chocolate cyst
endometrioma
- from endometriosis involving the ovaries - usually filled with old blood - appears chocolate colored
endometriosis treatment
NSAIDS OCPs Leuprolide - GnRH agonist Medroxyprogesterone Danazol (testosterone)
⦁ NSAIDS
⦁ OCPs (birth control pills; vaginal ring & estrogen patch not well studied)
⦁ GnRH agonists (like with leiomyoma, after medroxyprogesterone)
⦁ Progestin only treatment (medroxyprogesterone acetate)
⦁ surgery for failure of above treatments or for severe cases
GnRH agonists for endometriosis
also used for leiomyomas after medroxyprogesterone
⦁ Leuprolide (Lupron)
⦁ Nafarelin (Synarel)
- suppresses ovarian estrogen production (basically induces menopause)
- endometriosis suppresses GnRH, so give GnRH agonist for tx
- menses resumes 2-3 months after therapy is stopped
Danazol
testosterone
tx for endometriosis - “pseudomenopause”
leuprolide
GnRH agonist
for endometriosis
and leiomyomas
PRIMARY AMENORRHEA
- PRIMARY AMENORRHEA = Failure to experience menarche
⦁ by age 15 with normal growth & 2ndary sex characteristics
⦁ by age 13 without 2ndary sex characteristics - refer to endocrinologist and/or gynecologist
SECONDARY AMENORRHEA
a menstruating woman who hasn’t had her period for 3-6 months, or for the duration of 3 of her regular cycles
most common cause of amenorrhea
pregnancy
CAUSES OF AMENORRHEA
⦁ pregnancy (MOST COMMON CAUSE)
⦁ hypothalmic - pituitary dysfunction
⦁ ovarian dysfunction
⦁ alteration of genital outflow tract
ovarian dysfunction = PCOS
most common ovarian syndrome contributing to amenorrhea
PCOS
AMENORRHEA SECONDARY TO HYPOTHALAMIC-PITUITARY
- without stimulus from ovarian hormones, GnRH is not released, and anterior pituitary fails to release FSH & LH
- without FSH/LH = no follicular development/ovulation, therefore no corpus luteum development –> no estrogen/progesterone production –> no menstruation
most common cause of AMENORRHEA SECONDARY TO HYPOTHALAMIC-PITUITARY
functional
- weight loss
- obesity
- excessive exercise
TYPES OF AMENORRHEA SECONDARY TO HYPOTHALAMIC-PITUITARY DYSFUNCTION
o FUNCTIONAL
⦁ most common hypothalamic-pituitary cause
⦁ weight loss, excessive exercise, obesity
o DRUG INDUCED
⦁ marijuana, antidepressants, psychoactive drugs
o NEOPLASTIC
⦁ pituitary tumor
⦁ hypothalamic hamartoma
o PSYCHOGENIC
⦁ chronic anxiety
⦁ anorexia
o OTHER
⦁ head injury
⦁ chronic medical illness
⦁ hypothyroidism
WORK-UP FOR HYPOTHALAMIC-PITUITARY DYSFUNCTION
⦁ TSH = Low or high
⦁ FSH = low
⦁ LH = low
⦁ Prolactin = Normal unless prolactin secreting adenoma or hypothyroidism
AMENORRHEA SECONDARY TO OVARIAN DYSFUNCTION
- ovarian follicles are exhausted or resistant to stimulation by FSH/LH –> not releasing estrogen or progesterone… so FSH & LH levels RISE
SIGNS/SYMPTOMS = of estrogen deficiency
low estrogen, high FSH/LH
AMENORRHEA SECONDARY TO ALTERATION OF GENITAL OUTFLOW TRACT
primary amenorrhea
most common causes of primary amenorrhea
⦁ Imperforate hymen
⦁ absence of uterus or vagina
others = chromosomal anomalies, abnormal development, etc.
WORK-UP FOR AMENORRHEA
Progesterone challenge test = 10-14 day course of progesterone
⦁ if bleeding occurs within a week = establishes that pt had enough estrogen & a patent outflow tract, and therefore has a disorder of ovulation
⦁ if no bleeding occurs = establishes that either inadequate estrogen or anatomic abnormality
with progesterone challenge test, if bleeding occurs = disorder of
ovulation
if bleeding occurs within a week = establishes that pt had enough estrogen & a patent outflow tract, and therefore has a disorder of ovulation
most common gynecologic cancer in US***
ENDOMETRIAL CANCER
most common type of endometrial cancer
ENDOMETROID ADENOCARCINOMA
2 types of endometrial cancer cell types
type I = endometroid adenocarcinoma
type II = papillary serous / clear cell
TYPE I = ENDOMETROID ADENOCARCINOMA (most common type of endometrial cancer)
o TYPE I = ENDOMETROID ADENOCARCINOMA
⦁ most common type of endometrial cancer**
⦁ low grade - usually confined to the uterus at diagnosis
⦁ precursor = endometrial intraepithelial neoplasia (atypical endometrial hyperplasia)
TYPE II = PAPILLARY SEROUS/CLEAR CELL (endometrial cancer)
⦁ worse prognosis than type I (endometroid adenocarcinoma)
⦁ high grade = likely to have spread beyond uterus at time of dx
⦁ more common in black women & smokers***
TYPE I VS TYPE II ENDOMETRIAL CANCER
type I = better prognosis
type II = worse prognosis
type I = usually confined to uterus at dx
type II = usually spread beyond uterus at dx
type I = precursor = endometrial intraepithelial neoplasia (atypical endometrial hyperplasia)
type II = more common in black women & smokers
RISKS FOR ENDOMETRIAL CANCER
Unopposed estrogen
Chronic anovulation
PCOS
Obesity (conversion of androgens to estrone in adipocytes)
Nulliparity or low parity
Exogenous use of estrogen without progesterone
Risk increases with duration
Type II diabetes or HTN: ? Independent of obesity
Age: 85% ≥ 50 yo; only 5% younger than 40
SERM: Tamoxifen (prophylaxis or tx of breast ca)
Genetics (LYNCH & Cowden syndrome)
Smoking
LYNCH SYNDROME is a risk factor for
endometrial cancer
LYNCH SYNDROME = hereditary colorectal cancer = increased risk of type I endometrial cancer, ovarian & colon cancer
smoking = increased risk of endometrial cancer type ______
LYNCH syndrome = increased risk of endometrial cancer type _____
2 = smoking
1 = lynch
DECREASED RISK OF ENDOMETRIAL CANCER
⦁ OCP
⦁ medroxyprogesterone acetate
⦁ levonorgestrel IUD (mirena)
most common sign/symptom of endometrial cancer
abnormal bleeding
SIGNS/SYMPTOMS OF ENDOMETRIAL CANCER
⦁ Abnormal bleeding – 80% of cases
- Postmenopausal bleeding - Irregular menses or intermenstrual bleeding
⦁ Advanced disease = Abdominal pain/bloating/early satiety, change in bowel or bladder habits
advanced disease = GI symptoms
screening for endometrial cancer
there is no recommended routine screening for endometrial cancer
diagnostic test of choice for endometrial cancer
endometrial biopsy
DIAGNOSTICS FOR ENDOMETRIAL CANCER
vaginal probe ultrasound = has no diagnostic value in premenopausal women
⦁ in postmenopausal women = look for endometrial stripe; if endometrial stripe is < or = 4 = don’t need biopsy. If EMS > 4 = need endometrial biopsy
TREATMENT FOR ENDOMETRIAL CANCER
- total abdominal hysterectomy & bilateral salpingo-oophorectomy
- perhaps chemo and/or radiation
Younger women with ___________ are at risk for endometrial hyperplasia
Oral contraceptives or cyclic progestin therapy can reduce risk
chronic anovulation
Oral contraceptives or cyclic progestin therapy can reduce risk
STRUCTURAL CAUSES FOR ABNORMAL UTERINE BLEEDING
STRUCTURAL CAUSES OF ABNORMAL UTERINE BLEEDING (PALM)
⦁ polyp
⦁ adenomyosis (menorrhagia)
⦁ leiomyomata (fibroids –> heavy & bleeding between periods)
⦁ Malignancy
NONSTRUCTURAL CAUSES OF ABNORMAL UTERINE BLEEDING (COEIN)
⦁ Coagulopathy ⦁ Ovulatory dysfunction* ⦁ Endometrial ⦁ Iatrogenic ⦁ Not yet classified
examples of anovulatory bleeding
⦁ Irregular or infrequent periods ⦁ Flow light to excessively heavy ⦁ Amenorrhea ⦁ Oligomenorrhea ⦁ Metorrhagia (Uterine bleeding at irregular intervals with excessive bleeding or > 7 days)
Lack of follicular development / formation of corpus lutem
⦁ no progesterone
⦁ prolonged unopposed estrogen –> excessive proliferation of endometrium –> endometrial instability –> erratic bleeding
⦁ recurrent anovulation = increases risk of ENDOMETRIAL CANCER**
Women with suspected recurrent anovulatory cycles
⦁ Those who are likely perimenopausal ⦁ Increased volume or duration of bleeding ⦁ Periods more often than every 21 days ⦁ Intermenstrual spotting ⦁ Postcoital bleeding
WHEN TO PERFORM AN ENDOMETRIAL BIOPSY
⦁ Adolescents who are obese and have 2-3 years of untreated anovulatory bleeding
⦁ 35 or younger with one or more of the following
⦁ Diabetes, family hx of colon cancer, infertility
⦁ Nulliparity, obesity, tamoxifen use
⦁ Older than 35 with suspected anovulatory bleeding
⦁ Bleeding not responsive to medical therapy
**if biopsy histology is normal, and bleeding is unresponsive to treatment =
do transvaginal US
If high risk = do biopsy first
if not high risk = can do US first
IMAGING FOR OVULATORY ABNORMAL UTERINE BLEEDING (menorrhagia)
transvaginal ultrasound
labs for OVULATORY ABNORMAL UTERINE BLEEDING (menorrhagia)
B-Hcg
CBC
TSH
Test for bleeding disorder if risk factors
RISK FACTORS FOR BLEEDING DISORDERS
- fam hx of bleeding disorder
- menses lasting 7+ days with flooding or impairment of activities with most periods
- hx of treatment for anemia
- hx of excessive bleeding with tooth extraction, delivery, miscarriage or surgery
- vWD = most common***
EVAL = CBC, PT, PTT
TREATMENT FOR OVULATORY AUB
- if normal imaging & no bleeding disorder found
⦁ Medroxyprogesterone (provera)
⦁ or Mirena (IUD)
⦁ or NSAIDS
TREATMENT FOR ANOVULATORY AUB
⦁ Combination oral contraceptive = ethinyl estradiol
⦁ Or cyclic progesterone = Medroxyprogesterone acetate (Provera)
____________and _____________ are the most common causes of postmenopausal bleeding
Endometrial atrophy
endometrial polyps
but need to rule out endometrial cancer
IMAGING FOR POSTMENOPAUSAL BLEEDING
BIOPSY
associated symptoms with dysmenorrhea may include
associated symptoms may include: N/V, diarrhea, headache, dizziness
PRIMARY DYSMENORRHEA
- excess prostaglandins –> painful uterine muscle activity
⦁ onset = late teens - early 20’s - symptoms usually decline with age
SECONDARY DYSMENORRHEA
⦁ symptoms attributed to specific problem
⦁ more common with increasing age
⦁ endometriosis, adenomyosis, adhesions, PID, leiomyomata
TREATMENT FOR PRIMARY DYSMENORRHEA
NSAIDS = 1st line!
2nd line = contraceptives
non pharm tx = heat, exercise
SYMPTOMS OF PMS/PMDD
⦁ abdominal bloating ⦁ extreme fatigue ⦁ breast pain ⦁ headache ⦁ hot flashes ⦁ dizziness
BEHAVIORAL SYMPTOMS OF PMS/PMDD
⦁ irritability / anger
⦁ depression / hopelessness / self-critical
⦁ anxiety / tension / feeling on edge
in order to diagnose PMDD
must have at least 1 behavioral symptom and a total of 5 symptoms
TREATMENT OF PMS/PMDD
mild
⦁ Exercise and relaxation techniques
⦁ No strong data that vitamins or supplements exceed the placebo response
mod-severe
⦁ SSRIs
if not responding to SSRI
⦁ OC
⦁ GnRH agonist : when there is too much estrogen. GnRH agonist drug binds to GnRH receptors instead of letting GnRH bind (blocks receptor sites) –> decreases estrogen
