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Repro Week 1 > ICL 9.2: Benign diseases of the Uterus > Flashcards

ICL 9.2: Benign diseases of the Uterus Flashcards

1
Q

how often is a normal menstrual cycle?

A

24-35 days

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2
Q

how long does a menstrual cycle last?

A

4-8 days

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3
Q

how much blood loss is normal during menstraution?

A

there really isn’t a “normal” amount but 30-60 cc is usual

a tampon only holds 5 mm (10-12 for super tampon)

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4
Q

what are the structural causes of abnormal uterine bleeding?

A

PALM

Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia

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5
Q

what are the nonstructural causes of abnormal uterine bleeding?

A

COINE

Coagulopathy
Ovulatory disfunction
IUD/drugs
NOS
Endometrial causes
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6
Q

what are the common causes of abnormal uterine bleeding in different age ranges?

A

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

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7
Q

what are endometrial polyps?

A

hyper plastic overgrowths of endometrial glands and stroma with a vascular core

95% are benign

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8
Q

what are the risk factors for endometrial polyps?

A
  1. age
  2. tomaxifen
  3. obesity
  4. Lynch and Cowden syndrome
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9
Q

what are the clinical symptoms of endometrial polyps?

A
  1. intermenstral bleeding
  2. 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

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10
Q

when would you do an endometrial biopsy for polyps?

A

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

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11
Q

how do you treat endometrial polyps?

A

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

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12
Q

when is adenomyosis?

A

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

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13
Q

what are the risk factors for adenomyosis?

A
  1. uterine surgery
  2. childbirth (c-section or D&C)
  3. 40-50 years old
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14
Q

what is the clinical presentation of adenomyosis?

A
  1. pain with bleeding
  2. pain outside of bleeding
  3. cramping
  4. 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

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15
Q

how do you treat adenomyosis?

A
  1. hormonal medication to regulate bleeding
  2. uterine artery embolization to block blood flow to uterus but not good for someone who wants future pregnancies
  3. wedge resection of uterus (better for people who want children)
  4. hysterectomy
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16
Q

what is a leiomyoma?

A

the most common pelvic tumor!! increased incidence in AA women with symptoms developing at an earlier age

prevlanec increases with age during reproductive years

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17
Q

what are the risk factors for leiomyoma?

A
  1. AA
  2. nulliparity
  3. early menarche
  4. diet; increased red meat, vitamin D deficiency
  5. alcohol
  6. genetics
  7. HTN
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18
Q

what are the clinical symptoms of leiomyoma?

A
  1. heavy menstral bleeding or intermenstrual bleeding
  2. bulk related symptoms around where the fibroid is located
  3. pain
  4. infertility
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19
Q

what is the FIGO subclassifications system for leiomyomas?

A

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

20
Q

would you get an MRI for a leiomyoma?

A

eh usually not unless

  1. you need ti for surgical planning
  2. if you plan to refer to radiology for uterine fibroid embolization
21
Q

how do you treat a leiomyoma?

A
  1. 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

  1. laparoscopic myomectomy

cut through serosa to get to fibroid then inject vasopressin and pop the fibroid out and then stitch it closed

22
Q

what is uterine fibroid embolization?

A

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

23
Q

what is biggest risk factor for hyperplasia/Endometrial Intraepithelial Lesion/Malignancy?

A

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

24
Q

what imaging do you do for malignant uterus?

A

4 mm+ endometrial strip on US means they have a way higher risk of malignant uterine condition

25
Q

what is endometrial intraepithelial neoplasia?

A

there’s more glands than stroma

26
Q

how is benign vs. malignant uterine neoplasms classified?

A

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

27
Q

how do you treat hyperplasia/endometrial intraepithelial lesion/malignancy?

A
  1. progestins: medroxyprogesterone, megestrole acetate, levongeosterole iUD
  2. surgical
  3. remove exogenous sources of estrogen
28
Q

what are the generalized features of congenital uterine anomalies?

A
  1. teen w/amenorrhea with 2° sex characteristics
  2. cyclic pain
  3. outflow tract obstruction with retained menstrual fluid
  4. recurrent spontaneous abortion Infertility
29
Q

what causes congenital uterine anomalies?

A

usually normal karyotype so it’s likely multifactorial

30
Q

what are the complications associated with CUA?

A
  1. renal

duplex collecting ducts, horshoe kidney, etc.

  1. skeleta
  2. inguinal hernia
31
Q

testing and imaging for CUA?

A
  1. Ultrasound (2D, 3D)
2. saline infused sonogram
 Hysterosalpingogram
 CT abdomen/pelvis
 MRI (non-contrast)
 Operative
    - Laparoscopy
    - Hysteroscopy
32
Q

what is a vertical fusion defect?

A

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

33
Q

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

A

imperforate hymen

  1. normal
  2. imperforate
  3. microperforate
  4. cribriform
  5. septate
34
Q

what is the presentation of an imperforate hymen?

A

can present as teen or birth

at birth:bulging introitus, mucocolpos (vaginal secretions from maternal estradiol)

teen: amenorrhea, cyclic pain, hematocolpos = hymen bluish tinge

35
Q

how do you treat an imperforate hymen?

A
  1. surgical excision after estrogen stimulation

2. vaginal dilators

36
Q

how do you diagnose an imperforate hymen?

A
  1. bulging membrane on valsalva
  2. U/S, MRI
  3. check for skeletal & renal malformations
37
Q

what are the complications of an imcomplete imperforate hymen?

A

hematocolpos can be a seed for infection

38
Q

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

A

transverse vaginal septum

39
Q

what is a transverse vaginal septum?

A

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

40
Q

how do you treat and diagnose a transverse vaginal septum?

A

Dx: U/S MRI

Tx: septum resection with anastomosis of upper & lower vagina

pregnancy – good outcome (can do SVD or C/D)

41
Q

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

A

mullerian agenesis

42
Q

what is Mullerian agenesis?

A

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

43
Q

how do you treat Mullerian genesis?

A

restore normal sexual function

  1. proper timing for vaginoplasty/dilation when the patient can participate in the decision making and they want to be sexual active
  2. vaginal dilators
44
Q

what are lateral fusion defects?

A

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

45
Q

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

A

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

46
Q

what is a septate uterus?

A

lack resorption of septum after fusion

usually presents asymptomatically but can have infertility, SAB’s

P.E. may appear normal

Repro Week 1 (27 decks)

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