Gynecology - Uterine Leiomyoma(fibroids), endometrial cancer and endometrial hyperplasia Flashcards
What is a uterine leiomyoma?
Benign smooth muscle neoplasm originating from the myometrial cells. Usually clinically insignificant, but very common.
What is the most common benign tumor in women?
Uterine leiomyoma
What does a uterine leyiomyoma look like?
Gross: Elliptical, pearly white and firm, of a rubbery consistency and covered by a distinct connective tissue.
Histo: Elongated smooth muscle cells aggregated in bundles. Minimal to no mitotic activity. Lack of vascular organization.
What are Leiomyomas sensitive to?
Estrogen and Progesterone
What is characteristics of leiomyoma considering its environment?
It creates a hyperestrogenic environment. Relative to normal myometrium:
- Leiomyoma cells contain more estrogen receptors
- Leiomyoma cells convert less estradiol to estrone
- Leiomyoma cells contain more aromatase enzyme
Risk factors of uterine leiomyoma?
- Women in mid-age
- Black race
- Primary relative hx
- Overweight
- Early menarche
- PCOS
! Risk DECREASES with parity, giving birth at an early age, and likely decreases with use of COCs !
Symptoms of uterine leiomyoma?
Most are asymptomatic.
- Menorrhagia w/pelvic pressure (most common)
- Dysmenorrhea
- Chronic pelvic comfort
- Acute pain less common, but can happen
- Can cause infertility
What happens if there is a sudden pelvic pain in leiomyoma?
Due to degeneration of a leiomyoma
Types of degeneration of uterine leyiomyoma?
- Hyaline
- Liquefaction
- Mucoid
- Fatty
- Red (carneous)
- Calcification
- Sarcomatous (malignant)
Uterine leiomyoma on physical examination?
Uterine enlargement w/irregular contour. Should be nontender or minimally tender.
Sonography is the imaging modality of choice. Leiomyomas may be hyperechoic or hypoechoic, but they will appear as discrete masses.
Medically managing uterine leiomyoma
As most fibroid are minimally symptomatic, they may be managed by pt education and annual surveillance.
Medical therapy:
- NSAIDS for dysmenorrhea/pain
- COCs for pain, menorrhagia
- LNG-IUS (Mirena) for pain, menorrhagia
- GnRH agonists are effective for a variety of fibroid-related sx.
Surgically managing
- Uterine artery embolization
- Myomectomy (may be performed laporascopically, hysteroscopically, or open) - Particularly used if fertility is the main issue of concern.
- Hysterectomy.
What is the most common cancer of the female genital tract?
Endometrial cancer
What is the most common type of endometrial carcinoma?
Adenocarcinomas (75%). These arise from endometrial hyperplasia caused by a hyperestrogenic environment.
Risk factors for endometrial carcinoma?
- Hyperestrogenism
- High dose menopausal estrogens (10-22x RR)
- Obesity (2-4x)
- Nulliparity (2x)
- Early menarche
- Late menopause
- Use of tamoxifen
- PCOS - Medical conditions: type 2 DM, hypertension, gllbladder disease, lynch syndrome
- White race
- Higher SES
- Older age
Histologic variants of endometrial cancer, and which is most common?
- Endometrial adenocarcinoma (75%)
- Serous carcinoma (5-10%)
- Clear cell carcinoma (<5%)
- Mucinous carcinoma
- Mixed type
- Undifferentiated (rare)
- Squamous cell carcinoma (extremely rare)
Type 1 endometrial carcinoma?
Endometrial adenocarcinoma (75%)
Type 2 endometria carcinoma?
Serous carcinoma + Clear cell carcinoma
Se tabell om type 1 og type 2
i endometrial cancer filmen 15.43
What is the most common presentation of endometrial carcinoma?
Abnormal uterine bleeding
- Premenopausal: menorrhagia, intermenstrual spotting
- Postmenopausal: any bleeding.
What is the imaging test of choice, and what can you see?
Transvaginal sonography.
- In postmenopausal: a thickened endometrial stripe is suspicious for endometrial adenocarcinoma
- In premenopausal: TVS is less useful as the endometrial thickness can vary depending on where she is in her cycle.
What should be done after diagnosing endometrial carcinoma?
- TAH + BSO
- Peritoneal washing
- Pelvic and para-aortic lymphadenectomy
- Once removed, the uterus should be opened and assessed for degree of myometrial invasion.
Also order C-xray + Ca-125
Stage I of endometrial cancer is:
Stage I: Tumor confined to corpus uteri
- Stage 1a: < 50% myometrial invasion
- Stage 1b: > 50% myometrial invasion
Stage II of endometrial cancer:
Stage II: Tumor invades cervical stroma but does not extend beyond the uterus
Stage III of endometrial cancer:
Stage III: Local and/or regional spread of the tumor
- Stage 3a: invades serosa, adnexae or peritoneum
- Stage 3b: Vaginal and/or parametrial involvement
- Stage 3c: Metastasis to pelvic or para-aortic nodes
Stage IV of endometrial cancer:
Stage IV: Metastasis to bowel or bladder or beyond
- Stage IVa: Metastasis to bowel or bladder mucosa
- Stage IVb: Distant metastasis including abdominal structures and/or inguinal lymph nodes.
Treatment of stage I endometrial cancer
TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy
- Remove uterus!
Otherwise, no treatment.
Treatment of stage II endometrial cancer
TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy
- Remove uterus!
+ Radiation!
Treatment of stage III endometrial cancer
TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy
- Remove uterus!
+ Chemotherapy and radiation!
Treatment of stage IV endometrial cancer
TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy
- Remove uterus!
+ Chemotherapy and radiation!
What is the chemotherapy protocol in endometrial carcinoma?
The TAP protocol + added progestins.
T - Taxol (Paclitaxel)
A - Adriamycin (doxorubicin)
P - Platinum (cisplatin)
What is endometrial hyperplasia?
endometrial thickening with a proliferation of irregularly sized and shaped glands.Endometrial biopsy is the test of choice when endometrial hyperplasia is suspected.
Risk factors of endometrial hyperplasia
Hyperestrogenism
Postmenopausal women
May be a precancerous lesion
Medical conditions: type 2 DM, hypertension, gallbladder disease
Symptoms of endometrial hyperplasia?
Abnormal uterine bleeding = most common presentation.
Premenopausal: menorrhagia, intermenstrual spotting
Postmenopausal women: any bleeding
Imaging test of choice for endometrial hyperplasia?
Transvaginal sonography. The thickness of the endometrium is the primary determinant in wheter or not you go forward with a biopsy.
What is the criteria to do a biopsy in post vs premenopausal women if suspected endometrial hyperplasia?
Postmenopausal:
- Endometrial stripe < 5mm: likely endometrial atrophy
- Endometrial stripe > 5 mm: likely endometrial hyperplasia
Premenopausal women:
- Normal endometrium can vary from 4mm to more than 16mm.
- Indications for biopsy are: > 40, risk factors for endometrial carcinoma, significant intermenstrual bleeding or failure of medical treatment for abnormal bleeding.
Histological terms of endometrial hyperplasia:
- Simple: normal arcitecture, but with increased glands and stroma
- Complex: changes in arcitecture
- Atypia: changes in the nuclear structure of the cells
Which histologic term is the worst, and what is % risk of cancer-progression?
Complex with atypia - 29% progress to cancer
Treating endometrial hyperplasia?
- Tx depends on age and wheter or not there is atypia
- MDPA (medroxyprogesterone acetate) or megestrol is the medical treatment of choice.
- NO atypia:
- Premenopaus: MDPA 10-20 mg for 12-14d per month for 3-6m
- Postmen: MDPA 2.5mg continuously
ATYPIA:
- Hysterectomy
- If preservation of fertility is desired, high dose MDPA may be started.
