Menstrual and Uterine disorders Flashcards
what 3 processes do we need to have normal menses?
- intact HPO axis
- endometrium responsive to hormal stimulation
- intact outflow tract from internal to external genitalia
what is Primary Amenorrhea
Absence of menses…
- By age 13 (if sexual development also impaired)
- By age 15 (if normal sexual development)
MCC of primary amenorrhea? other causes?
genetic or anatomic abnormality
- 50% - abnml chromosomes → gonadal dysgenesis - ovarian insufficiency due to premature depletion of oocytes
- 20% - Hypothalamic hypogonadism
- Other:
- GU - absent genitalia; transverse vaginal septum; imperforate hymen
- Endo - pituitary disease; androgen insensitivity
definition of Secondary Amenorrhea
Absence of menses for >3 cycles or 6 consecutive months in a previously menstruating pt
MCC of secondary amenorrhea?
other causes?
- pregnancy
- Other common causes - galactorrhea, PCOS, hypothalamic or pituitary disease, adrenal hyperplasia
- Less common - premature ovarian failure, drug-induced
- Rare - Other endocrine disease (DM, thyroid, adrenal), cirrhosis, renal failure, malnutrition
3 main categories of causes of amenorrhea?
- Hypothalamic-Pituitary Dysfunction
- Ovarian causes
- Anatomic Causes
what can cause Hypothalamic-Pituitary Dysfunction that ultimately causes amenorrhea?
- GnRH deficiency
- Pituitary dysfunction
- Hyperprolactinemia
- Sheehan’s syndrome - postpartum
pituitary necrosis due to hypovolemia - Surgical destruction
- Infiltrative diseases
ovarian causes that causes amenorrhea
- Gonadal dysgenesis
- Ovarian failure
- Abnormal steroid enzymes - Unable to produce hormones
- Ovarian resistance - Follicles do not respond to gonadotropins
- Polycystic Ovarian Syndrome (PCOS)
3 types of ovarian failure?
- Primary - directly due to ovaries
- Secondary - due to hypothalamic or pituitary disease
- Premature - onset of menopause in women <40 y/o
anatomic causes that causes amenorrhea?
- Mullerian Dysgenesis - congenital absence of uterus and upper ⅔ of vagina; May ovulate and have normal secondary sex characteristics
- Vaginal agenesis
- Transverse vaginal septum
- Imperforate hymen
- Asherman’s syndrome - uterine synechiae (adhesions); Often due to dilation and curettage
w/u for primary amenorrhea if (+) 2o sex characteristics
- Evaluate anatomy → PE, US; check karyotype
- Pregnancy test
Ovaries are producing estrogen
w/u for primary amenorrhea if (-) 2o sex characteristics
- Evaluate anatomy
- Check prolactin and TSH
- Check LH and FSH
- Low → hypothalamic/pituitary disease, stress, low weight/malnutrition = MRI
- High → ovarian failure = Check karyotype
Ovaries aren’t producing estrogen
w/u for secondary amenorrhea
- Physical exam +/- imaging
- Pregnancy test
- TSH and Prolactin
- If abnormal TSH → thyroid disease
- If abnormal prolactin → pituitary imaging - Progesterone Challenge Test
- If bleeding occurs, endometrium is intact but progesterone is lacking
- Anovulation - no production of progesterone by corpus luteum - Estrogen + Progesterone Challenge Test
- No bleed → unresponsive endometrium or blockage of outflow
- If bleeding occurs, suspect hypogonadism - FSH and LH
- If high → primary/premature ovarian failure
- If low → secondary ovarian failure
complications of amenorrhea
- Infertility
- Lack of normal physical sexual development
- Osteoporosis and fractures
- Endometrial hyperplasia and carcinoma
tx for amenorrhea
- Correction of underlying disease
- If desiring pregnancy - ovulation induction
- Letrozole (Femara), clomiphene (Clomid)
- Less common - dopamine agonist, gonadotropins - If not desiring pregnancy - estrogen/ progesterone
- Maintain bone density, reduce genital atrophy or other menopausal s/s
- Many women do well on COC
Painful menstruation that inhibits normal activity and requires medication
Dysmenorrhea
3 types of Dysmenorrhea
- Primary - no organic, demonstrable cause
- Secondary - presence of another disorder that could cause s/s (endometriosis, adenomyosis, PID, cervical stenosis, fibroids, endometrial polyps)
- Membranous - due to passage of a cast of the endometrium through an undilated cervix (rare)
Dysmenorrhea is associated with _____ activity during ovulatory cycle
Abnormal uterine contractions → dec blood flow to uterus → uterine hypoxia
Leukotrienes also contribute
Psych factors may also be involved
prostaglandin
clinical findings of Dysmenorrhea
Pain - hallmark characteristic
- intermittent intense cramps or dull, continuous ache
- at menses or up to 1-2 d prior; Subsides 12-72 hrs after menses begins
- MC recurs
- lower abdomen and suprapubic region; lower back and/or thighs possible
- Impact on ADLs
- N/V/D, malaise, and/or HA
- No significant pelvic disease on PE - pelvic tenderness possible
tx of dysmenorrhea
- NSAIDs; acetaminophen, consider short-term codeine/opioid if severe
- Continuous heat to abdomen - as effective as ibuprofen, more than acetaminophen
- Hormonal Contraceptives - if no relief from NSAIDs
- Other - Exercise, TENS unit, Ca, Mg
- refractory - surgery
what is Psychoneuroendocrine disorder
- Restricted to luteal phase of menstrual cycle
- Biologic, psychological, and social parameters
- Poorly understood; not associated with pathologic hormone levels - Serotonergic dysfunction and decreased GABA levels found
PMs and PMDD MC at what age?
late 20s to early 30s
Up to 75% of women experience
Non-Pharmacologic tx for for mild-moderate PMS/PMDD
- Change in eating habits
- Avoid or limit - caffeine, alc, tobacco, chocolate, sodium
- small freq meals high in complex carbs - Aerobic exercise, stress management and/or CBT
- Chasteberry, Calcium carbonate (bloating, food cravings, pain), Mg (water retention), Vitamin B6 and vitamin E
medications for mild-moderate PMS/PMDD
- NSAIDs - headache, breast or abdominopelvic pain
- Spironolactone - cyclic edema
- Bromocriptine (dopamine agonist) - breast pain
tx for severe PMS/PMDD
- SSRIs - first-line
- Hormonal contraception - Often use contraceptives with drospirenone ( Yaz, Yasmin, Beyaz)
- consider alprazolam
- Refractory - GnRH agonists - Can induce “medical menopause”
- Definitive - BL oophorectomy +/- hysterectomy
Encompasses both abnormal menstrual bleeding and bleeding due to underlying causes or diseases
Pregnancy, GU disease, systemic disease, cancer
Dysfunctional Uterine Bleeding
first eval of DUB
- bleeding hx
- PE
- lab test - CBC, hCG, TSH
- cervical cytology - can help screen for invasive cervical lesions
- Endometrial cells in postmenopausal pt - abnormal unless on MHT
further w/u for DUB
-
Pelvic US
- Transvaginal - empty bladder - pelvic organs
- Transabdominal - full bladder - less detail, wider visualization
- Sonohysterography - saline injected in intrauterine cavity - increased sensitivity - Endometrial Bx
- D&C
- Hysteroscopy - Gold standard for eval pathology in uterine cavity
when can observation be the mgmt for DUB?
premenopausal - if serious pathology ruled out and not impacting patient functioning or quality of life
tx for premenopausal DUB
- observation
- hormones - COC, estrogen
- acute hemorrhage - IV estrogen
- refractory - levonorgestrel-releasing IUD, D&C (temporary fix) or endometrial ablation
- Definitive - hysterectomy
causes for postmenopausal DUB
- Exogenous hormones - MCC postmenopausal uterine bleed - Menses usually stop 6-12 months after discontinuing MHT
-
Vaginal Atrophy - MCC lower GU tract postmenopausal bleed
- lubricants, topical or systemic estrogen; avoidance of trauma - Tumors of Reproductive Tract - surgery possible
Hysteroscopic procedures - destroy or resect endometrium → eumenorrhea
Similar outcomes with bleeding and patient satisfaction between first and second generation procedures
Endometrial Ablations
what are the 1st gen Endometrial Ablations
- Endometrial vaporization (Nd-YAG)
- Rollerball electrosurgical desiccation
- Endometrial resection (electrosurgery)
- Direct hysteroscopic guidance
- Advanced skills and training
- Longer operating times; More complications
what are the 2nd gen endometrial ablations?
- Do not require direct hysteroscopic guidance to perform
- Quicker and less complicated
- Thermal energy
- Cryosurgery
- Radiofrequency electrosurgery
- Microwave
MC sign from endometrial ablations?
- Decreased menstrual flow - 70-80% of patients
- Amenorrhea - 15-35%
endometrial ablations are CI if patients want what?
What happens if the CI happens?
- who desire future fertility
- Patient will still need adequate post-op contraception
- If pregnancy occurs - miscarriage, prematurity, abnormal placentation, perinatal ablation
T/F: patients need to be treated prophylactically with abx for endometrial ablation
F: not needed MC
pts may premedicate for 1-2 mo with tx that cause endometrial atrophy, what are they?
- GnRH agonist, combination oral contraceptives, progestins
- Alternatively may consider curettage before procedure
CIs for endometrial ablations
- Obstetric - Pregnancy, Women wishing to preserve fertility
- Endometrial hyperplasia or genital tract cancer
- Postmenopausal women
- Acute pelvic infection
- Expectation of amenorrhea
- IUD in place
concerns if endometrial ablation is done
not CIs
- Patients at high risk for endometrial cancer
- Large or distorted endometrial cavity
- Prior uterine surgery
- First tool for endometrial ablation
- Uterus is distended with saline
- laser fiber touches endometrium and is dragged across endometrial surface - Creates 5-6mm deep furrows in endometrium
Vaporization (Nd-YAG Laser) - 1st gen
2-4 mm ball or barrel shaped electrode
Shorter operating time, less perforation than other first gen methods
Does not work for intracavitary lesions
Rollerball Ablation - 1st gen
- Less expensive and larger loop diameter than laser ablation
- Resectoscope with electrical current used to excise strips of endometrium
- Higher rates of perforation
Endometrial Resection - 1st gen
- Uncontained saline solution heated and recirculated for 10 minutes
- Low pressure to avoid opening fallopian tubes to peritoneal cavity
- Water seal to avoid leakage into vagina - Allows direct observation of endometrium as it is being destroyed
- Higher burn risk than other 2nd-gen methods
- Can use with anatomically abnormal uterus
Hysteroscopic Thermal Ablation - 2nd gen
- Fan-shaped mesh device contours to shape of endometrial cavity
- Uses suction to improve contact with mesh and remove vapor
- Radiofrequency run through mesh fan to desiccate endometrium - Does not require endometrial preparation
- Has been used in patients with small submucosal leiomyomas and polyps
Radiofrequency Thermal Ablation - 2nd gen
- Silicone device contours to shape of endometrial cavity
- Filled with RF-heated argon gas
- Liquid produced during procedure is also heated, providing hot liquid thermal ablation - Does not require endometrial preparation
- Has not been studied in patients with fibroids
- Higher rates of normal or no menstrual flow after the procedure
Thermal + RF Thermal Ablation - 2nd gen
- Uterus is sealed off with balloons
- Uterine cavity then filled with high-temperature water vapor
- Thermal injury causes scarring to endometrium - Does not require endometrial preparation
- May be used in patients with irregular uterine cavity contour
Water Vapor Thermal Ablation - 2nd gen
- Generates temperatures -100 to -120 C to produce an iceball in the endometrial cavity
- Endometrium undergoes cryonecrosis due to low temperatures
- Less pain than thermal energy procedures
Cryoablation - 2nd gen
what are the 2 endometrial ablation that are no longer in the US?
- Thermal Balloon Ablation
- Microwave Ablation
Aberrant growth of endometrium outside uterine cavity
Most common GYN diagnosis responsible for hospitalization in women 15-44
Endometriosis
Endometriosis MC in who?
- 53% of adolescents with severe pelvic pain warranting surgical evaluation
- 25-35% of infertile women
- 6-10% of women in reproductive age group
possible causes of endometriosis
- Retrograde menstruation
- Genetic predisposition
- Altered immunity → inhibited ability to recognize abnormal endometrial implants
common implant sites of endometriosis
- ovary, uterine cul-de-sac, pelvic ligaments, uterus, fallopian tubes, large intestine
- Other sites - small bowel, bladder, ureters, vagina, cervix, scars, umbilicus
- Distant sites - rare - lung, brain, kidney
RF for endometriosis
- (+) Family history
- Early menarche
- Nulliparity
- Long duration of flow
- Heavy menstrual bleeding
- Shorter menstrual cycles
negative risk factors of endometriosis
- Regular exercise
- Late menarche
- Higher parity
- Longer duration of lactation
s/s of endomentriosis
- dysmenorrhea (79%), pelvic pain (69%) dyspareunia (45%), infertility (26%)
- Severity does not correlate with extent of lesions
- May be asx or only present with infertility!
- constant pelvic pain or sacral backache
- Often worse just before menses, may persist through menses
- May be accompanied by pelvic pressure
other sx of endometriosis based on the sites?
- Urinary - hematuria, irritative voiding
- Bowel - bloody stool, diarrhea, constipation, cramping
- Menstrual - in addition to dysmenorrhea, premenstrual spotting is possible
- tender nodules in posterior vaginal fornix or uterosacral ligaments, and pain with uterine motion
- Uterus may be fixed and retroverted (cul-de-sac adhesions)
- Tender adnexal masses may be felt
- Endometrial implants may be found in healed wounds, in the vaginal fornix, or on the cervix
- MC no findings on PE
dx?
endometriosis
imaging for endometriosis
limited use
- TVUS - modality of choice to detect for rectum or rectovaginal septum
- MRI - may help diagnose equivocal cases
definitive dx for endometriosis and findings?
surgery (laparoscopy) with bx
- Early lesions - small, red, petechial
- Larger - cystic, dark brown, dark blue or black appearance
- Surrounding peritoneum - thickened and scarred - “powder burn”
- On ovary- enlarge to several centimeters - “chocolate cysts”
tx for min-mild sx of endometriosis
- Expectant management
- Analgesics - NSAIDs
- Hormonal Tx - combination or progestin-only contraceptives - dec dysmenorrhea and may slow progression
tx for Moderate to severe symptoms (unresponsive to mild/mod tx) of endometriosis
- Hormonal Tx - GnRH agonists or antagonists, danazol, aromatase inhibitors
- Neuropathic Pain - gabapentin, pregabalin, TCAs
-
Surgical - attempt to excise or destroy endometriotic implants
- Can be done at time of diagnostic laparoscopy
- Post-op pregnancy rates - depend on severity: 75% (mild), 50-60% (moderate), 30-40% (severe)
testosterone derivative; acts like progestin
Inhibits gonadotropin release and enzymes that produce estrogen
what drug?
what SE?
- Danazol
- oily skin, acne, deepened voice, weight gain, edema, dyslipidemia
inhibit enzymes that make estrogens
Can be used as adjuvant treatment to agents such as GnRH agonists
what med?
Aromatase Inhibitors - Anastrozole or letrozole
SE of GnRH agonists & GnRH antagonists
lower BMD, vasomotor symptoms, vaginal dryness, mood changes
Infection of upper genital tract
Any combination of - endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
Pelvic Inflammatory Disease
cause of PID?
pathogens
- Often polymicrobial
- Associated with gonorrhea and chlamydia
- May be caused by anaerobes, H. flu, G- rods, streptococci
what pts are at highest risk for PID?
young, nulliparous, sexually active women with multiple partners
PID is the leading cause for ?
how to prevent?
- infertility, ectopic pregnancy
- Use of barrier contraception
lower abdominal pain (insidious or acute)
- May begin during or just after menses
- May be worse with coitus, jarring movement
- bilateral; rarely >2 wks duration
- RUQ pain - associated perihepatitis (Fitz-Hugh-Curtis syndrome)
- Other sx - abnml menses, cervical/vaginal discharge, irritative voiding, F, chills, N/V
cervical motion tenderness (“Chandelier sign”)
> 38.3 C (101 F)
BL lower quadrant abd tenderness
inflammation of Skene or Bartholin glands
PID
w/u for PID
- Pregnancy test - negative
- Vaginal - WBC in vaginal fluid; + G/C nucleic acid probe
- CBC - leukocytosis and left shift
- Inflammatory markers - ESR, CRP may be elevated
- Imaging - TVUS
- Laparoscopy
TVUS findings that suggest PID?
- Thickened, fluid-filled fallopian tubes
- Free pelvic fluid
- Tubo-ovarian complex
- Tubal hyperemia
dx PID and treat empirically in sexually active young women and at-risk women if:
- Pelvic or lower abdominal pain with no other cause identified
- One or more - cervical motion tenderness, uterine tenderness, adnexal tenderness
tx for PID
Empiric, broad-spectrum abx for gonorrhea/chlamydia - ceftriaxone + doxy + metronidazole
when to admit PID?
- Complicated - Severe illness, N/V, or high F; Pregnancy; Pelvic abscess (including tubo-ovarian abscess)
- Unable to exclude surgical emergency
- Failure to respond to, tolerate, or comply with outpt oral tx
- Presentation varies from asx adnexal mass to acute abdomen
- pelvic and abd pain, fever, N/V
- severe abdominal tenderness and guarding
- Pressure can cause rupture of abscess and peritonitis - acute abdomen, septic shock
Tubo-Ovarian Abscess
classic pt for Tubo-Ovarian Abscess
young, low-parity, hx of pelvic infection
imaging of choice for tubo-ovarian abscess
- US - Complex, multiloculated adnexal mass
- CT will also diagnose
complications of tubo-ovarian abscess?
- Unruptured - rupture (15%), sepsis (10-20%); Long-term - reinfection, bowel obstruction, infertility, ectopic pregnancy
- Ruptured - septic shock, intra-abdominal abscess, septic emboli
tx for tubo-ovarian abscess
- Unruptured - similar to inpt PID but duration usually 4-6 weeks; surgical drainage if large or no improvement w/ abx
- Ruptured - life-threatening emergency; TAH and BSO w/ fluids and abx
- TOA in postmenopausal pt - high risk of concurrent malignancy
types of pelvic organ prolapse
- Cystocele - anterior vaginal wall defect (bladder); anterior vaginal prolapse
- Uterine prolapse - descent of the uterus
- Vaginal vault prolapse - post-hysterectomy
- Enterocele - bowel in prolapsed segment of vaginal wall
- Rectocele - posterior vaginal wall defect (rectum); posterior vaginal prolapse
staging of pelvic organ prolapse
- Staged based on most severe portion of the prolapse when straining
- Pelvic Organ Prolapse Quantification (POP-Q) - most precise and objective
-
Baden-Walker Halfway System - scores each organ prolapse individually
- 0 - Normal
- 1 - halfway to hymen
- 2 - to hymen
- 3 - halfway past hymen
- 4 - Maximum possible descent for site
s/s of pelvic organ prolapse
- Vaginal - fullness, pressure, heaviness, and/or discomfort
- “Something falling out” or “Sitting on a ball”
- Soft, reducible mass bulging into vagina or through introitus - inc w/ strain/coughing
- Coital laxity - Pain - back pain, vaginal pain, and/or pelvic pain
- Urinary - stress incontinence, frequency, hesitancy, incomplete bladder emptying; May need to “splint” bladder to void
- Defecatory - incomplete emptying, need to strain; May need to “splint” vagina or perineum to defecate
RF for pelvic organ prolapse
- OB/GYN - incr parity, h/o pelvic surgery, Postmenopausal
- Age
- Obesity or physical debilitation
- Chronic coughing (lung disease) or straining (constipation)
- Neurologic decline
Imaging for pelvic organ prolapse is usually only done if ?
other underlying process suspected or equivocal case
Physical exam techniques to help dx pelvic organ prolapse
- Inspect vulva and perineum - note prolapse at rest
- Stress test (cough test) for urinary incontinence
- Assess strength - vaginal support with strain, anal sphincter tone, pelvic floor strength
- If no prolapse seen with supine pt, examine in standing position
conservative tx options for pelvic organ prolapse
- Pessary - intravaginal device
- Pelvic floor exercises (Kegel Exercises), topical estrogens
mgmt of pessary for pelvic organ prolapse?
- Must be fitted by provider - can cause pressure necrosis and ulceration
- Re-examine 1-2w after pessary placement, 4w after, then q 3-6m or q 2-3m if pt cannot remove and clean device
surgical tx for pelvic organ prolapse
- Multiple methods for repair of fibromuscular vaginal wall
- May involve use of synthetic mesh - Can put at risk for vaginal erosions, dyspareunia, pelvic pain
- Advise pts - risk for recurrence even after surgical repair
Uterine enlargement due to ectopic endometrium deep within the myometrium
Adenomyosis
cause of Adenomyosis?
pregnancy, surgery, dec hormones may weaken myometrium - Allows endometrium to invade
RF for adenomyosis
- Parity - nearly 90% of cases are in parous women
- Age - nearly 80% develop in 40s and 50s
- Menorrhagia, dysmenorrhea
- global uterine enlargement
- Rarely greater than that of a 12 week pregnancy
- Smooth uterine contour
- Generalized softening of uterus
- Minimal hemorrhage during menses
Adenomyosis
More areas of invasion = more symptoms
w/u for adenomyosis?
findings?
TVUS
- Myometrium - focal thickening, heterogeneous texture, cysts
- Endometrium - projections into myometrium, ill-defined echo
difference between adenomyosis vs leiomyomas on imaging?
adenomyosis has poorly defined margins, elliptical shape, lack of calcifications
tx options for adenomyosis
symptom relief
- NSAIDs - pain
- COCs, progestin-only contraceptives - pain and bleeding
- Endometrial ablation/resection - help somewhat; Will not treat deep lesions
- Definitive - hysterectomy
adenomyosis sx often subside after what?
menopause
MC benign neoplasm of female genital tract; Benign smooth muscle tumors
AKA “myomas,” “fibroids,” “fibroid tumors”
Leiomyomas
3 types of Leiomyomas
- Submucous - directly beneath endometrial lining
- Subserous - directly beneath serosal lining
- Intramural - completely within myometrium
what two things can leiomyomas do that can become a problem?
- Can become pedunculated and undergo torsion
- Can become parasitic
- Most are asx
- MC - abnormal uterine bleeding, pelvic pressure/pain
- Pain - if torsion, infarction, degeneration occurs - Local compression of other pelvic organs
- Infertility, miscarriage, pregnancy complications
- uterus may be enlarged, may have irregular contour
Leiomyomas
w/u for Leiomyomas
- May see iron-def anemia; Rare - polycythemia d/t myoma EPO production
- US - confirm presence, and monitor growth
- MRI - intramural vs submucous
- Hysterography/Hysteroscopy - confirm cervical or submucous
tx for leiomyomas
-
Asx - observation; annual exam
- No intervention needed unless significant pressure on pelvic organs, severe bleeding/anemia, torsion of pedunculated myoma, or rapid growth - Medical tx - NSAIDs, hormonal therapy (contraceptives, GnRH agonists)
- Surgical - myomectomy, hysterectomy, uterine artery embolization; May treat preop w/ hormone tx to reduce myoma size
leiomyomas will regress spontaneously after what?
menopause
MC GYN malignancy
Endometrial Cancer
Endometrial Cancer MC in who?
- White - 2.4% lifetime risk; Black - 1.3% lifetime risk; 8% better survival for white women
- Peak onset - 70s
- 20-25% occur in premenopausal women
- 20-30 yrs possible
MCC of endometrial cancer
pathogenesis/physiology
MC endometrial hyperplasia
- Estrogens - stimulate endometrium
- Progesterones - antiproliferative
- Long-term estrogen exposure → hyperplasia → cancer
MCC of endogenous overproduction of estrogen
obesity
causes of Abnormally high levels of estrogen in/from?
- obesity
- MetS
- PCOS
- Exogenous unopposed estrogen therapy
- Chronic anovulation
- Granulosa cell tumors of ovary
- Tamoxifen (SERM) - 2-3x increased risk
other RF for endometrial cancer?
- GYN hx - early menarche, late menopause, low parity
- History of breast cancer
- Western society - high animal fat in diet
- Older age - 75-80% are in postmenopausal women
- FHx - Hereditary Nonpolyposis Colorectal Cancer (HPNCC)
- Comorbidities including DM, HTN, gallbladder disease
what 2 factors reduce risk of endometrial cancer?
- COC - min 1 yr lasts for 10-20 yrs; Progestin - chemoprotective biologic effect; Progesterone IUDs may also be protective
- smoking - less estrogen, wt reduction, earlier menopause, latered hormonal metabolism, current and past smokers
MC sx of endometrial hyperplasia?
abmml uterine bleeding
difference between simple vs complex hyperplasia without atypia
- Simple: 1% progress to endometrial cancer w/o tx; 80% spontaneously regress w/o tx
- Complex: 3-5% progress to endometrial cancer w/o tx; 85% regress with progestin therapy
Endometrial glands lined with enlarged cells
Considered premalignant
Progress to cancer - 10% of simple atypical, 30% of complex atypical
Endometrial Hyperplasia with Atypia
mgmt for Endometrial Hyperplasia with Atypia
- progestin therapy; Higher rate of relapse after progestin tx than non-atypical lesions
- If intolerant of progestin therapy or relapse following - hysterectomy
- 85% of cases
- Younger patients
- More favorable prognosis
- Low grade or well-differentiated
which type of endometrial CA?
type I
- 15% of cases
- Older patients
- Poorer prognosis
- Independent of estrogen
- Associated with endometrial atrophy
which type of endometrial CA?
Type II Endometrial Cancer
classic presentation of endometrial CA?
obese, nulliparous, infertile, hypertensive, DM white woman
Only 25% of pts have a known hx of hyperplasia
spread of endometrial CA?
direct extension, peritoneal implants, lymphatic and/or hematogenous
MC type of cancer in endometrial CA?
adenocarcinoma
which type of endometrial CA is More likely to be in older patients; poorer prognosis
Less associated with hyperestrogenic states
Serous
which type of endometrial CA is High-grade and aggressive
Not associated with hyperestrogenic state
Clear Cell Carcinoma - 1-4%
s/s of endometrial CA
- abnml bleeding - MC, earliest sx, Always work-up a postmenopausal pt with bleeding
- abnml vaginal discharge
- Lower ab cramps and pain - Cervical os stenosis → hematometra; Can develop abscess and sepsis
- PE - unremarkable; age-related changes (atrophic vaginitis); +/- Blood; Early - nml uterus, Late - enlarged and/or fixed uterus, local LN and/or ovarian metastases
w./u for endometrial CA
-
Pelvic US
- Endometrial thickness >4 mm in postmenopausal pt - high suspicion, do not defer bx with consistent even if < 4 mm
- Can be used to monitor asx high-risk pts - Definitive - bx; endometrial biopsy , D&C, hysteroscopy with bx
outpatient, minimal or no anesthesia needed
False negative rate - 10%
which type of bx for endometrial CA
Endometrial biopsy
If symptomatic and negative bx - need D&C
more definitive procedure for diagnosis - larger tissue sample
Done inpatient and under anesthesia
Not curative
which type of bx for endometrial CA
D&C
other testing for endometrial CA
- Pap smear
- CA-125
- CBC
tx for endometrial CA
-
Surgery - Total hysterectomy with BL salpingo-oophorectomy and staging with pelvic and periaortic lymphadenectomy
- Surgery alone may be curative in low-risk, localized disease -
Adjuvant - radiation, progesterone, chemo
- Doxorubicin and cisplatin are 2 most active chemo agents - severe anemia - fluids, blood, uterine tamponade w/ vaginal packing; high-dose radiation if fails.
5-year survival rates of each endometrial CA staging?
- Stage I - 80-90%
- Stage II - 70-80%
- Stage III - 35-55%
- Stage IV - 17-22%
endometrial CA prognosis worsens with what factors?
- increasing age
- higher pathologic grade
- advanced-stage disease
- increasing depth of myometrial invasion
- lymphovascular invasion
