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Internal medicine > Gynecology - Uterine Leiomyoma(fibroids), endometrial cancer and endometrial hyperplasia > Flashcards

Gynecology - Uterine Leiomyoma(fibroids), endometrial cancer and endometrial hyperplasia Flashcards

1
Q

What is a uterine leiomyoma?

A

Benign smooth muscle neoplasm originating from the myometrial cells. Usually clinically insignificant, but very common.

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2
Q

What is the most common benign tumor in women?

A

Uterine leiomyoma

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3
Q

What does a uterine leyiomyoma look like?

A

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.

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4
Q

What are Leiomyomas sensitive to?

A

Estrogen and Progesterone

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5
Q

What is characteristics of leiomyoma considering its environment?

A

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
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6
Q

Risk factors of uterine leiomyoma?

A
  • 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 !
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7
Q

Symptoms of uterine leiomyoma?

A

Most are asymptomatic.

  • Menorrhagia w/pelvic pressure (most common)
  • Dysmenorrhea
  • Chronic pelvic comfort
  • Acute pain less common, but can happen
  • Can cause infertility
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8
Q

What happens if there is a sudden pelvic pain in leiomyoma?

A

Due to degeneration of a leiomyoma

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9
Q

Types of degeneration of uterine leyiomyoma?

A
  • Hyaline
  • Liquefaction
  • Mucoid
  • Fatty
  • Red (carneous)
  • Calcification
  • Sarcomatous (malignant)
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10
Q

Uterine leiomyoma on physical examination?

A

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.

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11
Q

Medically managing uterine leiomyoma

A

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.
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12
Q

Surgically managing

A
  1. Uterine artery embolization
  2. Myomectomy (may be performed laporascopically, hysteroscopically, or open) - Particularly used if fertility is the main issue of concern.
  3. Hysterectomy.
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13
Q

What is the most common cancer of the female genital tract?

A

Endometrial cancer

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14
Q

What is the most common type of endometrial carcinoma?

A

Adenocarcinomas (75%). These arise from endometrial hyperplasia caused by a hyperestrogenic environment.

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15
Q

Risk factors for endometrial carcinoma?

A
  1. Hyperestrogenism
    - High dose menopausal estrogens (10-22x RR)
    - Obesity (2-4x)
    - Nulliparity (2x)
    - Early menarche
    - Late menopause
    - Use of tamoxifen
    - PCOS
  2. Medical conditions: type 2 DM, hypertension, gllbladder disease, lynch syndrome
  3. White race
  4. Higher SES
  5. Older age
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16
Q

Histologic variants of endometrial cancer, and which is most common?

A
  1. Endometrial adenocarcinoma (75%)
  2. Serous carcinoma (5-10%)
  3. Clear cell carcinoma (<5%)
  4. Mucinous carcinoma
  5. Mixed type
  6. Undifferentiated (rare)
  7. Squamous cell carcinoma (extremely rare)
17
Q

Type 1 endometrial carcinoma?

A

Endometrial adenocarcinoma (75%)

18
Q

Type 2 endometria carcinoma?

A

Serous carcinoma + Clear cell carcinoma

19
Q

Se tabell om type 1 og type 2

A

i endometrial cancer filmen 15.43

20
Q

What is the most common presentation of endometrial carcinoma?

A

Abnormal uterine bleeding

  • Premenopausal: menorrhagia, intermenstrual spotting
  • Postmenopausal: any bleeding.
21
Q

What is the imaging test of choice, and what can you see?

A

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.
22
Q

What should be done after diagnosing endometrial carcinoma?

A
  1. TAH + BSO
  2. Peritoneal washing
  3. 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
23
Q

Stage I of endometrial cancer is:

A

Stage I: Tumor confined to corpus uteri

  • Stage 1a: < 50% myometrial invasion
  • Stage 1b: > 50% myometrial invasion
24
Q

Stage II of endometrial cancer:

A

Stage II: Tumor invades cervical stroma but does not extend beyond the uterus

25
Q

Stage III of endometrial cancer:

A

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
26
Q

Stage IV of endometrial cancer:

A

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.
27
Q

Treatment of stage I endometrial cancer

A

TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy

  • Remove uterus!
    Otherwise, no treatment.
28
Q

Treatment of stage II endometrial cancer

A

TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy

  • Remove uterus!
    + Radiation!
29
Q

Treatment of stage III endometrial cancer

A

TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy

  • Remove uterus!
    + Chemotherapy and radiation!
30
Q

Treatment of stage IV endometrial cancer

A

TAH + BSO
Pelvic/para-aortic lymphadenectomy
Removal of any visible malignancy

  • Remove uterus!
    + Chemotherapy and radiation!
31
Q

What is the chemotherapy protocol in endometrial carcinoma?

A

The TAP protocol + added progestins.
T - Taxol (Paclitaxel)
A - Adriamycin (doxorubicin)
P - Platinum (cisplatin)

32
Q

What is endometrial hyperplasia?

A

endometrial thickening with a proliferation of irregularly sized and shaped glands.Endometrial biopsy is the test of choice when endometrial hyperplasia is suspected.

33
Q

Risk factors of endometrial hyperplasia

A

Hyperestrogenism
Postmenopausal women
May be a precancerous lesion
Medical conditions: type 2 DM, hypertension, gallbladder disease

34
Q

Symptoms of endometrial hyperplasia?

A

Abnormal uterine bleeding = most common presentation.

Premenopausal: menorrhagia, intermenstrual spotting

Postmenopausal women: any bleeding

35
Q

Imaging test of choice for endometrial hyperplasia?

A

Transvaginal sonography. The thickness of the endometrium is the primary determinant in wheter or not you go forward with a biopsy.

36
Q

What is the criteria to do a biopsy in post vs premenopausal women if suspected endometrial hyperplasia?

A

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.
37
Q

Histological terms of endometrial hyperplasia:

A
  1. Simple: normal arcitecture, but with increased glands and stroma
  2. Complex: changes in arcitecture
  3. Atypia: changes in the nuclear structure of the cells
38
Q

Which histologic term is the worst, and what is % risk of cancer-progression?

A

Complex with atypia - 29% progress to cancer

39
Q

Treating endometrial hyperplasia?

A
  • 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.

Internal medicine (16 decks)

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