ICL 9.2: Benign diseases of the Uterus Flashcards
how often is a normal menstrual cycle?
24-35 days
how long does a menstrual cycle last?
4-8 days
how much blood loss is normal during menstraution?
there really isn’t a “normal” amount but 30-60 cc is usual
a tampon only holds 5 mm (10-12 for super tampon)
what are the structural causes of abnormal uterine bleeding?
PALM
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
what are the nonstructural causes of abnormal uterine bleeding?
COINE
Coagulopathy Ovulatory disfunction IUD/drugs NOS Endometrial causes
what are the common causes of abnormal uterine bleeding in different age ranges?
13-18 years old: AUB due to persist an ovulation, normal physiology!
19-39 years pregnancy, structural lesions, anovulatory cycles, hormonal contraception, endometrial hyperplasia
40-menopause: anovulatory cycles, endometrial hyperplasia, leiomyoma
what are endometrial polyps?
hyper plastic overgrowths of endometrial glands and stroma with a vascular core
95% are benign
what are the risk factors for endometrial polyps?
- age
- tomaxifen
- obesity
- Lynch and Cowden syndrome
what are the clinical symptoms of endometrial polyps?
- intermenstral bleeding
- infertility
if your polyps are minimizing the SA where an embryo can implant, that can cause infertility so removing the polyp is important
probably won’t find anything on PE but also it could prolapse through he cervical os sometimes
when would you do an endometrial biopsy for polyps?
if the patient is older than 45 and has abnormal uterine bleeding, do a biopsy
if they’re less than 45 but with comorbitidies, do a biopsy too
how do you treat endometrial polyps?
if they’re greater than 1 cm in size, post-menopausal, infertile etc. take the polyp out
hormonal treatment isn’t beneficial on polyps are 1+ cm but they’re good for less than 1 cm polyps
when is adenomyosis?
displaced endometrial tissue within the myometrium that acts like normal endometrial tissue so it responds to hormones!
it can be localized or diffuse
we have no idea how it happens…but we do know it’s associated with increased parity (child birth), uterine surgery
common in 40-50 years old
what are the risk factors for adenomyosis?
- uterine surgery
- childbirth (c-section or D&C)
- 40-50 years old
what is the clinical presentation of adenomyosis?
- pain with bleeding
- pain outside of bleeding
- cramping
- enlarged, boggy uterus on PE (it’ll feel like your cheek while a normal uterus feels more like the side of your nose)
pain with PE
how do you treat adenomyosis?
- hormonal medication to regulate bleeding
- uterine artery embolization to block blood flow to uterus but not good for someone who wants future pregnancies
- wedge resection of uterus (better for people who want children)
- hysterectomy
what is a leiomyoma?
the most common pelvic tumor!! increased incidence in AA women with symptoms developing at an earlier age
prevlanec increases with age during reproductive years
what are the risk factors for leiomyoma?
- AA
- nulliparity
- early menarche
- diet; increased red meat, vitamin D deficiency
- alcohol
- genetics
- HTN
what are the clinical symptoms of leiomyoma?
- heavy menstral bleeding or intermenstrual bleeding
- bulk related symptoms around where the fibroid is located
- pain
- infertility
what is the FIGO subclassifications system for leiomyomas?
submucosa (SM): 0-2 cause bleeding
other (O): 3-8
3-5 are associated with infertility because the fibroids decrease SA of uterus and decrease implantation probability
would you get an MRI for a leiomyoma?
eh usually not unless
- you need ti for surgical planning
- if you plan to refer to radiology for uterine fibroid embolization
how do you treat a leiomyoma?
- remove the fibroid with hysteroscopic myomectromy
you stick something into the uterus from the cervix and break the fibroid off and suck it up into the tube
- laparoscopic myomectomy
cut through serosa to get to fibroid then inject vasopressin and pop the fibroid out and then stitch it closed
what is uterine fibroid embolization?
radiology will place catheter through femoral or radial artery to find the blood vessels going directly to the fibroid and place an embolic agent that decreases blood flow to the fibroid
overtime they degenerate and become calcified and symptoms get better over time – great for intramural fibroids but not good for someone actively hemorrhaging since this takes time
can cause pain because you’re causing ischemia
what is biggest risk factor for hyperplasia/Endometrial Intraepithelial Lesion/Malignancy?
anything that causes unopposed estrogen so null parity, early menarche, early menopause, increased BMI, PCOS
more adipocytes means increased aromatase which converts androstenedione to estrone which throws your HPI axis off and you don’t go through a hormone withdraw bleed and the cells just continue to proliferate and cells will shed whenever they want to
what imaging do you do for malignant uterus?
4 mm+ endometrial strip on US means they have a way higher risk of malignant uterine condition
what is endometrial intraepithelial neoplasia?
there’s more glands than stroma
how is benign vs. malignant uterine neoplasms classified?
simple hyperplasia without atypia or complex hyperplasia without atypia = benign endometrial hyperplasia –> BENIGN
simple hyperplasia with atypia or complex hyperplasia with atypia = EIN (endometrial intraepithelial neoplasia) –> PRE-MALIGNANT
how do you treat hyperplasia/endometrial intraepithelial lesion/malignancy?
- progestins: medroxyprogesterone, megestrole acetate, levongeosterole iUD
- surgical
- remove exogenous sources of estrogen
what are the generalized features of congenital uterine anomalies?
- teen w/amenorrhea with 2° sex characteristics
- cyclic pain
- outflow tract obstruction with retained menstrual fluid
- recurrent spontaneous abortion Infertility
what causes congenital uterine anomalies?
usually normal karyotype so it’s likely multifactorial
what are the complications associated with CUA?
- renal
duplex collecting ducts, horshoe kidney, etc.
- skeleta
- inguinal hernia
testing and imaging for CUA?
- Ultrasound (2D, 3D)
2. saline infused sonogram
Hysterosalpingogram
CT abdomen/pelvis
MRI (non-contrast)
Operative
- Laparoscopy
- Hysteroscopy
what is a vertical fusion defect?
defective fusion of caudal end of Mullerian duct and urogenital sinus of from defective vaginal canalization –> transverse vaginal septum, segmental vaginal agenesis, and/or cervical agenesis or dysgenesis; vagina may or may not be obstructed
12 yo female with cyclic pelvic pain x 3 months
premenarchal
physical exam: on-acute abdomen, bluish bulge at introitus
ultrasound normal uterus & ovaries
distended hematocolpos up to 14 cm
imperforate hymen
- normal
- imperforate
- microperforate
- cribriform
- septate
what is the presentation of an imperforate hymen?
can present as teen or birth
at birth:bulging introitus, mucocolpos (vaginal secretions from maternal estradiol)
teen: amenorrhea, cyclic pain, hematocolpos = hymen bluish tinge
how do you treat an imperforate hymen?
- surgical excision after estrogen stimulation
2. vaginal dilators
how do you diagnose an imperforate hymen?
- bulging membrane on valsalva
- U/S, MRI
- check for skeletal & renal malformations
what are the complications of an imcomplete imperforate hymen?
hematocolpos can be a seed for infection
14 yo pevic pain worsening over last 4 months
blind-ending pouch on digital exam
palpable pelvic mass
no bulging at outlet, normal external genitalia
transvaginal ultrasound/MRI: hematocolpos & hematometria
transverse vaginal septum
what is a transverse vaginal septum?
vertical fusion and/or canalization of urogenital sinus and Mullerian ducts
symptoms: mucocolpos, hematocolpos
mostly found in upper 1/3 vagina, < 1 cm thick
Physical Exam: nml ext genitalia, blind pouch vagina, mass can be palpated above examining finger on rectoabdominal exam
how do you treat and diagnose a transverse vaginal septum?
Dx: U/S MRI
Tx: septum resection with anastomosis of upper & lower vagina
pregnancy – good outcome (can do SVD or C/D)
17 yo female with primary amenorrhea
Tanner stage 5 breasts & external genitalia
No real vaginal canal
Pubertal gonadotropin levels, normal BMI, normal endocrine labs, 46 XX, normal testosterone
Ultrasound & MRI conflicting results
Diagnostic Laparoscopy
Small rudimentary bulbs - no functional endometrium, normal ovaries
mullerian agenesis
what is Mullerian agenesis?
embryologic growth failure of the mullerian duct
Hox-9, 10, 11, 13 are expressed along the length of müllerian ducts. Alteration of HOX genes may give rise to müllerian anomalies
difficult to differentiate: imperforate hymen/ TVS/ androgen insensitivity/ 17 α hydroxylase deficiency
no uterus present
normal female phenotype
normal ovaries and ovarian function
normal female Karyotype
how do you treat Mullerian genesis?
restore normal sexual function
- proper timing for vaginoplasty/dilation when the patient can participate in the decision making and they want to be sexual active
- vaginal dilators
what are lateral fusion defects?
most common type of müllerian defects
resulting organs are either asymmetric or symmetric and obstructed or non-obstructed
result from failure of formation of one müllerian duct, migration of a duct, fusion of the müllerian ducts
18 yo female
Menarche age 12
CC: difficulty removing tampon, & seems to leak around her tampon
PE: apparent longitudinal vaginal septum
Surgery: resection of septum and discovery of bicollis
Uterus Didelphys
failure of fusion leading to 2 completely separate uretus with 2 cervix
no communication between the 2 cavities
75% of cases longitudinal vaginal septum present
what is a septate uterus?
lack resorption of septum after fusion
usually presents asymptomatically but can have infertility, SAB’s
P.E. may appear normal
