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Reproductive > Endometrial Disorders + Cancer B&B > Flashcards

Endometrial Disorders + Cancer B&B Flashcards

1
Q

what is the effect of of estrogen vs progesterone on the endometrium?

A

estrogen stimulates growth (drives proliferative phase)

Progesterone stimulates secretary activity (drives secretory phase, progesterone withdraw = menstruation)

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2
Q

What is the most common cause of dysfunctional uterine bleeding?

A

abnormal menstrual bleeding not due to a structural cause (“functional”)

Most commonly caused by an anovulatory cycle - no corpus luteum formation, therefore, no switch from estrogen to progesterone secretion… unopposed growth from estrogen leads to irregular bleeding

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3
Q

what is acute endometritis caused by?

A

aka pregnancy-related endometritis: caused by bacterial infection after delivery or miscarriage

C-section is key risk factor (prophylactic antibiotics given)

presents with fever, abdominal pain, uterine tenderness

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4
Q

how is acute endometritis classically treated?

A

aka pregnancy-related endometritis: caused by bacterial infection after delivery or miscarriage (higher risk with C-section)

classic tx: clindamycin + gentamycin (broad-spectrum because it can be caused by almost any bacteria)

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5
Q

Following a cesarean section at-home delivery (with no medical personnel present), a woman presents to her physician with fever, abdominal pain, and uterine tenderness. What is the most likely cause of her symptoms?

A

acute/pregnancy-related endometritis: caused by bacterial infection after delivery or miscarriage

C-section is key risk factor (prophylactic antibiotics given)

tx: clindamycin + gentamycin

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6
Q

how does RPOC (retained products of conception) present?

A

placental/fetal tissue remaining in uterus after delivery causes uterine bleeding and pelvic pain as tissue becomes necrotic

Prone to infection by flora from the service or vagina —> leads to acute endometritis (fever, abdominal pain, uterine tenderness)

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7
Q

what are the usual causes of pelvic inflammatory disease (PID)? (2)

A

chlamydia or gonorrhea

cause ascending infection that can involve uterus (chronic endometritis), fallopian tubes (salpingitis), and ovaries (oophoritis)

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8
Q

what is the biopsy hallmark of chronic endometritis?

A

plasma cells - not normal finding, indicates chronic inflammation

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9
Q

what are endometrial polyps caused by?

A

hyperplastic growth of glands/stroma that project from endometrium (“exophytic mass”)

usually benign + asymptomatic, may cause painless uterine bleeding - can be surgically removed (prevent infection, small chance of malignancy)

common near menopause, associated with tamoxifen use - associated with unopposed estrogen

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10
Q

hyperplastic growth of glands/stroma that project from endometrium (“exophytic mass”)

A

endometrial polyps: usually benign + asymptomatic, may cause painless uterine bleeding - can be surgically removed (prevent infection, small chance of malignancy)

common near menopause, associated with tamoxifen use - associated with unopposed estrogen

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11
Q

explain why tamoxifen is associated with endometrial polyps

A

tamoxifen: SERM (selective estrogen receptor modulator) that is competitive antagonist in breast but agonist in bone/uterus

unopposed estrogen activity can lead to endometrial polyps (hyperplastic growth of glands/stroma)

may lead to endometrial cancer

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12
Q

where does endometriosis commonly occur?

A

endometriosis: endometrial tissue outside of the uterus (glands and stroma)

commonly in ovary/fallopian tubes, uterosacral ligaments, rectovaginal septum, or pelvic peritoneum (these structures are all near the uterus)

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13
Q

what are some of the theories regarding why endometriosis occurs?

A

endometriosis: endometrial tissue outside of the uterus, etiology unknown but theories:

retrograde flow - movement of menstrual tissue through the fallopian tubes

metastasis - endometrial tissue spreads via venous/lymphatics

metaplasia - coelomic epithelium (lines organ/body cavities) develops into endometrial tissue

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14
Q

What are the symptoms of endometriosis and why do these occur?

A

endometriosis: endometrial tissue outside of the uterus which is hormone sensitive (grows with estrogen, atrophies with progesterone withdrawal)

—> cyclic pelvic pain
—> dysmenorrhea/menorrhagia (painful & heavy bleeding of ectopic tissue)
—> infertility (due to ovarian/fallopian lesions)
—> dyspareunia (painful intercourse), dyschezia (painful defecation), dysuria

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15
Q

How is endometriosis diagnosed?

A

normal uterus size, uterus may be retroverted (tipped backwards), chocolate cyst in ovary (blood filled)

biopsy of lesion for definitive diagnosis

+/- nodules in posterior fornix or ovarian mass

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16
Q

how is endometriosis typically treated?

A

definitive: surgical removal of ectopic tissue (reserved for severe symptoms)

NSAIDs to reduce inflammation

first line: oral contraceptive pills (progestin suppress ovarian function and endometrial growth)

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17
Q

leuprolide

A

GnRH agonist, binds receptors in pituitary —> down-regulation of GnRH receptors & pituitary desensitization —> decreased LH/FSH —> decreased estrogen production from ovaries

can be used to treat endometriosis

18
Q

danazol

A

steroid with weak androgen and progesterone activity —> inhibits LH surge and suppresses ovarian function (anovulation)

can be used to treat endometriosis, but rarely used due to side effects - high androgens, low estrogen (hot flashes), pseudotumor cerebri (intracranial HTN)

19
Q

What is the cause of adenomyosis and how does it present?

A

hyperplasia of basal endometrium into myometrium

presents with globular/diffusely enlarged uterus and heavy/painful menstruation

often co-exits with endometriosis (can treat the same), definitive treatment is hysterectomy

20
Q

Pt is a 42yo F presenting with heavy and painful periods. Laparoscopy reveals a globular, diffusely enlarged uterus. A biopsy is done which reveals basal endometrium within the myometrium. What is the diagnosis, and how will you treat her?

A

adenomyosis: hyperplasia of basal endometrium into myometrium

often co-exits with endometriosis and can be treated the same

definitive treatment is hysterectomy, but this depends if the woman has completed childbearing

21
Q

Benign tumor of myometrium that occurs in pre-menopausal woman due to growth stimulated by estrogen

A

leiomyoma, aka fibroid - usually presents with multiple tumors and resolves at menopause (decreased estrogen production)

discrete/round/firm tumors, histology shows smooth muscle cell proliferation

usually asymptomatic, may cause irregular bleeding

22
Q

Pt is a 49yo F (pre-menopause) presenting with irregular bleeding which has been heavier and longer than normal. Otherwise she is asymptomatic. PE is notable for several palpable pelvic masses. A biopsy is taken which shows proliferation of smooth muscle cells. What is the most likely diagnosis?

A

leiomyoma, aka fibroid: benign tumor of myometrium due to growth stimulated by estrogen

usually resolves at menopause (decreased estrogen production)

23
Q

contrast leiomyoma and leiomyosarcoma

A

leiomyoma: aka fibroid, benign tumor of myometrium, presents in pre-menopausal women with multiple tumors

leiomyosarcoma: malignant tumor of myometrium, presents in post-menopausal women as a single large mass, arises de novo (NOT progression of fibroids)

24
Q

Pt is a 63yo F (post-menopause) presenting to her OBGYN for an annual exam. A single large pelvic mass is palpated and a biopsy is taken, which reveals smooth muscle proliferation of the myometrium. What is the likely diagnosis?

A

leiomyosarcoma: malignant tumor of myometrium, presents in post-menopausal women as a single large mass, arises de novo (NOT progression of fibroids)

25
Q

What is the cause of endometrial hyperplasia and in which patients does it usually occur?

A

absence of progesterone allows for unopposed estrogen stimulation of the endometrium (pre-malignant to endometrial carcinoma)

usually occurs in peri/postmenopausal woman

PTEN inactivation in ~50% of high-risk lesions

26
Q

how do each of the following cause endometrial hyperplasia?
a. Obesity
b. PCOS.
c. Tamoxifen.
d. Ovarian granulosa cell tumor.

A

These are all sources of estrogen

a. Obesity - increased conversion of androgens to estrogens (estrone)
b. PCOS - obesity/anovulation
c. Tamoxifen - estrogen agonist
d. Ovarian granulosa cell tumor - secretes estrogen

unopposed estrogen stimulation of endometrium causes endometrial hyperplasia

27
Q

How is low risk versus high-risk endometrial hyperplasia treated?

A

absence of progesterone allows for unopposed estrogen stimulation of the endometrium (pre-malignant to endometrial carcinoma)

low risk —> progestins (opposes estrogen, reverses hyperplasia and improves bleeding)

high risk (complex, atypical histology) —> hysterectomy

28
Q

what is the most common gynecological cancer and in which patients does it most often present?

A

endometrial carcinoma - typically post-menopausal women (~60yo) because anovulation increases estrogen exposure

often preceded by endometrial hyperplasia

presents with abnormal uterine bleeding

29
Q

With what type of hysterectomy is endometrial carcinoma typically treated?

A

total abdominal hysterectomy

most common gynecological carcinoma, presents in postmenopausal women with abnormal uterine bleeding

30
Q

Contrast the two types of endometrial carcinoma

A

classified histologically

Type I, endometriod (80%): estrogen-dependent hyperplasia, resembles endometrium

Type II, serous/sporadic: estrogen-independent, arises from atrophic endometrium post-menopause (65-75yo), 90% with p53 mutation, undifferentiated, poor prognosis (more aggressive)

31
Q

Pt is a 71yo F (post-menopause) undergoing a biopsy for a suspicious uterine mass. Biopsy shows undifferentiated pink, serous material that is negative for estrogen but positive for a p53 mutation. What is the most likely diagnosis?

A

Type II, serous/sporadic endometrial carcinoma: estrogen-independent, arises from atrophic endometrium post-menopause, 90% with p53 mutation

pink/serous biopsy, undifferentiated, poor prognosis (more aggressive)

32
Q

what is the most common non-colon malignancy that occurs in patients with HNPCC?

A

HNPCC = hereditary non-polyposis colorectal cancer / Lynch Syndrome

due to germ-line mutation in DNA mismatch repair genes

lifetime risk up to 70% for endometrial cancer

33
Q

menorrhagia vs metrorrhagia

A

menorrhagia = profuse/prolonged menstrual bleeding

metrorrhagia = irregular bleeding between menses

34
Q

what are the differential diagnosis for uterine bleeding? (hint, mnemonics!)

A

structural issues: PALM
Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy* and hyperplasia

functional issues: COIN
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified

*15-20% of post-menopausal bleeding is due to cancer, therefore must always be ruled out

35
Q

how does endometrial hyperplasia appear histologically?

A

increased proliferation of endometrial glands relative to stroma

36
Q

what is the number one risk factor for type 1 endometrial cancer?

A

1 risk factor is unopposed estrogen exposure - exogenous (tamoxifen), obesity (high aromatase activity), PCOS (chronic anovulation), nulliparity (no pregnancies)

Type I, endometriod: estrogen-dependent hyperplasia, resembles endometrium

oral contraceptives are protective (source of progesterone)

30-80% have silenced PTEN gene

37
Q

how does type 1 endometrial cancer spread, and where does it typically metastasize to?

A

Type I, endometriod: estrogen-dependent hyperplasia, resembles endometrium (85% are adenocarcinomas - glandular)

spread via direct myometrial invasion, metastasizes to lungs, bone, liver

38
Q

describe the histology of type 2 endometrial cancer

A

Type II, serous/sporadic: estrogen-independent, arises from atrophic endometrium post-menopause, p53 mutation, poor prognosis

papillary architecture resembling serous/clear cell carcinoma, psammoma bodies (calcifications) often present, marked nuclear atypia, always undifferentiated

all type 2 EC are considered high grade!

39
Q

what molecular genetics are associated with type 1 versus type 2 endometrial cancer?

A

Type I, endometriod: estrogen-dependent hyperplasia, associated with PTEN silencing and Lynch Syndrome (HNPCC)

Type II, serous/sporadic: estrogen-independent, arises from atrophic endometrium post-menopause, associated with p53 mutation and aneuploidy

40
Q

how should abnormal uterine bleeding be evaluated?

A

pelvic exam necessary but findings may be normal (normal cervix/ uterine size)

evaluation of endometrium is necessary - trans-vaginal ultrasound, endometrial biopsy

Reproductive (29 decks)

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