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WOMEN'S HEALTH > DISORDERS OF MENSTRUATION & THE UTERUS > Flashcards

DISORDERS OF MENSTRUATION & THE UTERUS Flashcards

1
Q

WHAT IS UTERINE PROLAPSE

A
  • 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

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2
Q

CAUSES OF UTERINE PROLAPSE

A

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

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3
Q

SYMPTOMS OF UTERINE PROLAPSE

A

⦁ 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

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4
Q

UTERINE PROLAPSE SEQUELAE

A

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)

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5
Q

UTERINE PROLAPSE - PHYSICAL EXAM

A
  • look & feel for uterus in vagina
  • have patient bear down
  • kegel maneuver
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6
Q

UTERINE PROLAPSE IMAGING?

A
  • imaging isn’t really needed for uterine prolapse

- can do ultrasound if needed

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7
Q

TREATMENT FOR UTERINE PROLAPSE

A

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

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8
Q

ADENOMYOSIS is commonly confused with

A

fibroids

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9
Q

PATHOPHYS OF ADENOMYOSIS

A
  • 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
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10
Q

TREATMENT OF ADENYMYOSIS

A

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
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11
Q

DIAGNOSIS OF ADENOMYOSIS

A
  • 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)

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12
Q

SYMPTOMS OF ADENOMYOSIS

A

painful, heavy periods

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13
Q

most sensitive test for adenomyosis

A

MRI - but is often not ordered due to expense

can do ultrasound - but not as good (initial test)

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14
Q

LEIOMYOMA

A
  • 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
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15
Q

Most common indication for pelvic surgery in women

A

leiomyomas

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16
Q

leiomyomas are _________ dependent

A

estrogen

just like with endometriosis

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17
Q

LEIOMYOMAS & PREGNANCY

A
  • can interfere with fetal growth/nutrition
  • leiomyomas increase the risk of
    ⦁ spontaneous abortion during 1st & 2nd trimesters
    ⦁ preterm labor
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18
Q

WHEN DO LEIOMYOMAS REQUIRE TREATMENT

A
  • 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
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19
Q

“boggy uterus”

A

adenomyosis

symmetric & soft & tender

vs leiomyomas = assymetric, firm, nontender

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20
Q

LEIOMYOMA SYMPTOMS

A

most = asymptomatic

⦁	Heavy menstrual flow
⦁	bleeding between periods
⦁	pain
⦁	pelvic pressure
⦁	stress incontinence
⦁	infertility
⦁	urethral obstruction
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21
Q

FIBROIDS ARE CLASSIFIED BY LOCATION

A
  • location affects symptoms
    ⦁ fibroids inside the uterine cavity = cause bleeding between periods & severe. cramping
    ⦁ submucosal fibroids = menorrhagia
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22
Q

LOCATION OF FIBROIDS

A

⦁ 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

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23
Q

submucous myomas can be removed by

A

hysteroscopic resection

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24
Q

easiest fibroid type to remove via laparoscopy

A

subserous myoma

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25
Q

SUBSEROUS MYOMAS

A

⦁ 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

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26
Q

LEIOMYOMA PELVIC EXAM

A
  • 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
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27
Q

DIAGNOSTIC TESTS FOR LEIOMYOMA

A

1) transvaginal US
2) hysteroscopy –> endometrial biopsy

initial = US?
definitive = hysteroscopy?
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28
Q

LEIOMYOMA TREATMENT

A

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
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29
Q

MYOMECTOMY INDICATIONS

A

⦁ 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

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30
Q

if uterus < 12 weeks size = can perform _________ for uterine myomas

if uterus > 12 weeks size = perform __________

A

hysterectomy = definitive treatment

myomectomy - done to preserve fertility

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31
Q

most common cause for hysterectomy

A

uterine fibroids

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32
Q

what conditions are estrogen dependent

A

leiomyomas

endometriosis

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33
Q

Endometriosis is associated with ___________ & ______________

A

chronic pelvic pain

infertility

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34
Q

what is endometriosis

A

when endometrial cells grow in other parts of the body

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35
Q

SYMPTOMS OF ENDOMETRIOSIS

A

causes debilitating pain, irregular bleeding, and infertility

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36
Q

endometriosis occurs in menstruating women, however

A

⦁ postmenopausal endometriosis may occur in women who are on estrogen RT

⦁ occasionally, pts with a hysterectomy can develop endometriosis in an ovary

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37
Q

ETIOLOGY & PATHOPHYS OF ENDOMETRIOSIS

A
  • 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
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38
Q

RISK FACTORS FOR ENDOMETRIOSIS

A

⦁ 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
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39
Q

MAIN SYMPTOMS OF ENDOMETRIOSIS

A

⦁ dysmenorrhea**
⦁ pelvic pain
⦁ dyspareunia

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40
Q

symptoms of endometriosis

A 
o MAIN SYMPTOMS
⦁	dysmenorrhea**
⦁	pelvic pain
⦁	dyspareunia
o OTHERS
⦁	bowel upset (constipation, diarrhea)
⦁	bowel pain
⦁	infertility
⦁	ovarian mass/tumor
⦁	dysuria
⦁	other urinary problems
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41
Q

most common area of anatomic spread in endometriosis

A

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

42
Q

PATHOPHYSIOLOGY OF PAIN WITH ENDOMETRIOSIS

A
  • 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
43
Q

COMPLICATIONS WITH ENDOMETRIOSIS

A

Infertility
Chronic or long-term pelvic pain that interferes with social and work activities
Large cysts in the pelvis (endometriomas)
Depression

44
Q

DEFINITIVE DIAGNOSIS OF ENDOMETRIOSIS

A

LAPAROSCOPY

45
Q

powder burn appearance with laparoscopy

A

endometriosis

46
Q

chocolate cyst

A

endometrioma

  • from endometriosis involving the ovaries - usually filled with old blood - appears chocolate colored
47
Q

endometriosis treatment

A 
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

48
Q

GnRH agonists for endometriosis

also used for leiomyomas after medroxyprogesterone

A

⦁ 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
49
Q

Danazol

A

testosterone

tx for endometriosis - “pseudomenopause”

50
Q

leuprolide

A

GnRH agonist

for endometriosis
and leiomyomas

51
Q

PRIMARY AMENORRHEA

A
  • 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
52
Q

SECONDARY AMENORRHEA

A

a menstruating woman who hasn’t had her period for 3-6 months, or for the duration of 3 of her regular cycles

53
Q

most common cause of amenorrhea

A

pregnancy

54
Q

CAUSES OF AMENORRHEA

A

⦁ pregnancy (MOST COMMON CAUSE)
⦁ hypothalmic - pituitary dysfunction
⦁ ovarian dysfunction
⦁ alteration of genital outflow tract

ovarian dysfunction = PCOS

55
Q

most common ovarian syndrome contributing to amenorrhea

A

PCOS

56
Q

AMENORRHEA SECONDARY TO HYPOTHALAMIC-PITUITARY

A
  • 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
57
Q

most common cause of AMENORRHEA SECONDARY TO HYPOTHALAMIC-PITUITARY

A

functional

  • weight loss
  • obesity
  • excessive exercise
58
Q

TYPES OF AMENORRHEA SECONDARY TO HYPOTHALAMIC-PITUITARY DYSFUNCTION

A

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

59
Q

WORK-UP FOR HYPOTHALAMIC-PITUITARY DYSFUNCTION

A

⦁ TSH = Low or high
⦁ FSH = low
⦁ LH = low
⦁ Prolactin = Normal unless prolactin secreting adenoma or hypothyroidism

60
Q

AMENORRHEA SECONDARY TO OVARIAN DYSFUNCTION

A
  • 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

61
Q

AMENORRHEA SECONDARY TO ALTERATION OF GENITAL OUTFLOW TRACT

A

primary amenorrhea

most common causes of primary amenorrhea
⦁ Imperforate hymen
⦁ absence of uterus or vagina

others = chromosomal anomalies, abnormal development, etc.

62
Q

WORK-UP FOR AMENORRHEA

A

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

63
Q

with progesterone challenge test, if bleeding occurs = disorder of

A

ovulation

if bleeding occurs within a week = establishes that pt had enough estrogen & a patent outflow tract, and therefore has a disorder of ovulation

64
Q

most common gynecologic cancer in US***

A

ENDOMETRIAL CANCER

65
Q

most common type of endometrial cancer

A

ENDOMETROID ADENOCARCINOMA

66
Q

2 types of endometrial cancer cell types

A

type I = endometroid adenocarcinoma

type II = papillary serous / clear cell

67
Q

TYPE I = ENDOMETROID ADENOCARCINOMA (most common type of endometrial cancer)

A

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)

68
Q

TYPE II = PAPILLARY SEROUS/CLEAR CELL (endometrial cancer)

A

⦁ 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***

69
Q

TYPE I VS TYPE II ENDOMETRIAL CANCER

A

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

70
Q

RISKS FOR ENDOMETRIAL CANCER

A

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

71
Q

LYNCH SYNDROME is a risk factor for

A

endometrial cancer

LYNCH SYNDROME = hereditary colorectal cancer = increased risk of type I endometrial cancer, ovarian & colon cancer

72
Q

smoking = increased risk of endometrial cancer type ______

LYNCH syndrome = increased risk of endometrial cancer type _____

A

2 = smoking

1 = lynch

73
Q

DECREASED RISK OF ENDOMETRIAL CANCER

A

⦁ OCP
⦁ medroxyprogesterone acetate
⦁ levonorgestrel IUD (mirena)

74
Q

most common sign/symptom of endometrial cancer

A

abnormal bleeding

75
Q

SIGNS/SYMPTOMS OF ENDOMETRIAL CANCER

A

⦁ 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

76
Q

screening for endometrial cancer

A

there is no recommended routine screening for endometrial cancer

77
Q

diagnostic test of choice for endometrial cancer

A

endometrial biopsy

78
Q

DIAGNOSTICS FOR ENDOMETRIAL CANCER

A

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

79
Q

TREATMENT FOR ENDOMETRIAL CANCER

A
  • total abdominal hysterectomy & bilateral salpingo-oophorectomy
  • perhaps chemo and/or radiation
80
Q

Younger women with ___________ are at risk for endometrial hyperplasia
Oral contraceptives or cyclic progestin therapy can reduce risk

A

chronic anovulation

Oral contraceptives or cyclic progestin therapy can reduce risk

81
Q

STRUCTURAL CAUSES FOR ABNORMAL UTERINE BLEEDING

A

STRUCTURAL CAUSES OF ABNORMAL UTERINE BLEEDING (PALM)
⦁ polyp
⦁ adenomyosis (menorrhagia)
⦁ leiomyomata (fibroids –> heavy & bleeding between periods)
⦁ Malignancy

82
Q

NONSTRUCTURAL CAUSES OF ABNORMAL UTERINE BLEEDING (COEIN)

A 
⦁	Coagulopathy
⦁	Ovulatory dysfunction*
⦁	Endometrial
⦁	Iatrogenic
⦁	Not yet classified
83
Q

examples of anovulatory bleeding

A 
⦁	Irregular or infrequent periods
⦁	Flow light to excessively heavy
⦁	Amenorrhea
⦁	Oligomenorrhea
⦁	Metorrhagia (Uterine bleeding at irregular intervals with excessive bleeding or > 7 days)
84
Q

Lack of follicular development / formation of corpus lutem

A

⦁ no progesterone
⦁ prolonged unopposed estrogen –> excessive proliferation of endometrium –> endometrial instability –> erratic bleeding
⦁ recurrent anovulation = increases risk of ENDOMETRIAL CANCER**

85
Q

Women with suspected recurrent anovulatory cycles

A 
⦁	Those who are likely perimenopausal
⦁	Increased volume or duration of bleeding
⦁	Periods more often than every 21 days
⦁	Intermenstrual spotting
⦁	Postcoital bleeding
86
Q

WHEN TO PERFORM AN ENDOMETRIAL BIOPSY

A

⦁ 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

87
Q

**if biopsy histology is normal, and bleeding is unresponsive to treatment =

A

do transvaginal US

If high risk = do biopsy first
if not high risk = can do US first

88
Q

IMAGING FOR OVULATORY ABNORMAL UTERINE BLEEDING (menorrhagia)

A

transvaginal ultrasound

89
Q

labs for OVULATORY ABNORMAL UTERINE BLEEDING (menorrhagia)

A

B-Hcg
CBC
TSH
Test for bleeding disorder if risk factors

90
Q

RISK FACTORS FOR BLEEDING DISORDERS

A
  • 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

91
Q

TREATMENT FOR OVULATORY AUB

- if normal imaging & no bleeding disorder found

A

⦁ Medroxyprogesterone (provera)
⦁ or Mirena (IUD)
⦁ or NSAIDS

92
Q

TREATMENT FOR ANOVULATORY AUB

A

⦁ Combination oral contraceptive = ethinyl estradiol

⦁ Or cyclic progesterone = Medroxyprogesterone acetate (Provera)

93
Q

____________and _____________ are the most common causes of postmenopausal bleeding

A

Endometrial atrophy

endometrial polyps

but need to rule out endometrial cancer

94
Q

IMAGING FOR POSTMENOPAUSAL BLEEDING

A

BIOPSY

95
Q

associated symptoms with dysmenorrhea may include

A

associated symptoms may include: N/V, diarrhea, headache, dizziness

96
Q

PRIMARY DYSMENORRHEA

A
  • excess prostaglandins –> painful uterine muscle activity

⦁ onset = late teens - early 20’s - symptoms usually decline with age

97
Q

SECONDARY DYSMENORRHEA

A

⦁ symptoms attributed to specific problem
⦁ more common with increasing age
⦁ endometriosis, adenomyosis, adhesions, PID, leiomyomata

98
Q

TREATMENT FOR PRIMARY DYSMENORRHEA

A

NSAIDS = 1st line!

2nd line = contraceptives

non pharm tx = heat, exercise

99
Q

SYMPTOMS OF PMS/PMDD

A 
⦁	abdominal bloating
⦁	extreme fatigue
⦁	breast pain
⦁	headache
⦁	hot flashes
⦁	dizziness
100
Q

BEHAVIORAL SYMPTOMS OF PMS/PMDD

A

⦁ irritability / anger
⦁ depression / hopelessness / self-critical
⦁ anxiety / tension / feeling on edge

101
Q

in order to diagnose PMDD

A

must have at least 1 behavioral symptom and a total of 5 symptoms

102
Q

TREATMENT OF PMS/PMDD

A

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

WOMEN'S HEALTH (13 decks)

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