Menstrual and Uterine Disorders - Exam 3 Flashcards
What 3 things do we need to have to have normal menses?
- intact HPO axis
- endometrium responsive to hormonal stimulation
- intact outflow tract form internal to external genitalia
What is considered primary amenorrhea?
By age 13 (if sexual development also impaired)
By age 15 (if normal sexual development)
What are the top 2 main causes of primary amenorrhea?
50%: Abnormal chromosomes that leads to gonadal dysgenesis
20%: Hypothalamic hypogonadism-> disruption of the HPO axis
What are 2 causes of abnormal chromosomes that cause primary amenorrhea?
Ovarian insufficiency due to premature depletion of oocytes
and
Turner syndrome (45,X) is one of the most common causes
What are some causes that can disrupt the HPO axis leading to primary amenorrhea?
excessive exercise, psychological stress, eating disorders
What is considered secondary amenorrhea? What is the MC cause? What is the other highlighted common cause?
Absence of menses for >3 cycles or 6 consecutive months in a previously menstruating pt
pregnancy
PCOS
What is the relationship between primary and secondary amenorrhea causes?
everything that causes secondary amenorrhea can also cause primary amenorrhea!
What are 4 causes of Hypothalamic-Pituitary Dysfunction?
GnRH deficiency
Pituitary dysfunction
surgical destruction
infiltrative disease
**_______ is postpartum pituitary necrosis due to hypovolemia
Sheehan’s syndrome
What are the broad causes of amenorrhea? both primary and secondary
Hypothalamic-Pituitary Dysfunction
ovarian causes
anatomic causes
What are the 3 different options for ovarian failure. Give a brief description of each
Primary - directly due to ovaries
Secondary - due to hypothalamic or pituitary disease
Premature - onset of menopause in women <40 y/o
What is mullerian dysgenesis? What does it lead to?
congenital absence of the uterus
and upper ⅔ of the vagina
amenorrhea due to anatomic causes
What will a pt with mullerian dysgenesis present like?
amenorrhea but may ovulate and have normal sex characteristics
after complete pelvic exam, will notice congenital absence of uterus and upper 2/3 of vagina
What is Asherman’s syndrome? What are they commonly due from? What does it result in?
uterine synechiae (adhesions)
Often due to dilation and curettage
amenorrhea
What is this picture illustrating?
Asherman’s Syndrome
What should be included in the w/u of a pt with primary amenorrhea who HAS secondary sex characteristics?
good PE to verify normal vaginal and uterine structures
then check karyotype
check outflow from cervix to vaginal introitus
pregnancy test
primary amenorrhea with secondary sex characteristics, are their ovaries producing estrogen?
yes, ovaries are producing estrogen
What should be included in the w/u of a pt with primary amenorrhea who DOES NOT HAVE secondary sex characteristics?
good PE to check anatomy
prolactin and TSH
LH and FSH
primary amenorrhea without sex characteristics, their LH and FSH are low, what are the possible causes? What should you order next?
hypothalamic/pituitary disease, stress, low weight/malnutrition
MRI of the brain
primary amenorrhea without sex characteristics, their LH and FSH are high, what are the possible causes? What should you order next?
ovarian failure
check karyotype
In primary amenorrhea without sex characteristics, are the ovaries producing estrogen?
NO! ovaries are not producing estrogen
What should be included in the w/o of a pt with secondary amenorrhea?
good PE +/- imaging
PREGNANCY TEST
TSH and prolactin
progesterone challenge test
estrogen and progesterone challenge test
FSH and LH
secondary amenorrhea, and TSH is abnormal = ______. abnormal prolactin = ______
abnormal TSH → thyroid disease
abnormal prolactin → pituitary imaging
What is the progesterone challenge test? What are the 2 options of results? When would you use this test?
give pt oral progesterone for a few days and see if bleeding occurs
bleeding occurs: endometrium is intact but progesterone is lacking
anovulation: no production of progesterone by CL
working up a pt for secondary amenorrhea
If the pt does an estrogen and progesterone challenge test and no bleeding happens, what does this suggest? If bleeding occurs?
unresponsive endometrium or blockage of outflow
If bleeding occurs, suspect hypogonadism
In secondary amenorrhea and the FSH and LH is high, what does that suggest? Low?
If high → primary/premature ovarian failure
If low → secondary ovarian failure
What are some complications of amenorrhea?
infertility
Lack of normal physical sexual development
Osteoporosis and fractures
Endometrial hyperplasia and carcinoma
Why is endometrial hyperplasia and carcinoma a complication of amenorrhea?
because having unopposed estrogen increases cancer risk
What is the tx for amenorrhea if the pt wants to become pregnant?
may attempt ovulation induction using Letrozole (Femara) or clomiphene (Clomid)
What is the tx for amenorrhea if the pt does NOT want to become pregnant?
may use estrogen/ progesterone
think OCP
Consider looking at this again for the w/u of secondary amenorrhea
do it! its very helpful
Define dysmenorrhea. What are the 3 causes?
Painful menstruation that inhibits normal activity and requires medication
primary
secondary
membranous
______ dysmenorrhea is due to no organic, demonstrable cause
primary
______ dysmenorrhea is due to the presence of another disorder that could cause s/s
secondary
think endometriosis, adenomyosis, PID, cervical stenosis,
fibroids, endometrial polyps
_____ dysmenorrhea is due to passage of a cast of the endometrium through an undilated cervix. How common is it?
membranous
rare
What is the pathogenesis of dysmenorrhea? What do abnormal uterine contractions lead to? What 2 additional factors are involved?
Associated with prostaglandin activity during ovulatory cycle
decreased blood flow to uterus → uterine hypoxia
leukotriences and psych factors
What is the hallmark characteristic of dysmenorrhea? What is the quality?
PAIN
intermittent intense cramps or dull, continuous ache
What is the associated timing of dysmenorrhea? Does it usually begin at menarche or later in life? Is the pain usually present with a few or all of the periods?
begins at menses onset or up to 1-2 days prior and subsides over 12-72 hours after menses begins
later in life
Recurs with most or all menstrual cycles!
What is first line tx for dysmenorrhea? When does the pt need to take them? ______ can be taken as second line or adjunct
NSAIDs - reduce prostaglandins and continuous heat to abdomen
more effective if taken at the first sign of symptoms
acetaminophen
_______ is used if no relief from NSAIDs/Acetominophen. How does it work?
Hormonal Contraceptives (OCP or IUDs)
Believed to help by stopping ovulation or altering endometrium
During what phase does PMS and PMDD occur in? What hormone is it associated with?
luteal phase of menstrual cycle
NOT associated with any pathologic hormone levels
How common are PMS and PMDD? What age range has the highest incidence?
Up to 75% of women experience
late 20s-early 30s
When does PMS cross over into PMDD? What type of symptoms are the most predominant?
PMDD: when there is a clear functional impairment (either at work or in relationships)
usually psych/behavioral symptoms
What are the non-pharm managment strategies of PMS/PMDD?
avoid caffeine, alcohol, tobacco, chocolate, sodium
choose small frequent meals high in complex carbs
exercise, stress management, CBT
What are the 2 supplements that have mixed evidence to help with PMS/PMDD?
chasteberry
myo-inositol
What are the medication management options for PMS/PMDD? What are each used for?
NSAIDs, Spironolactone, Bromocriptine
NSAIDs - headache, breast or abdominopelvic pain
Spironolactone - cyclic edema
Bromocriptine (dopamine agonist) - breast pain
**What medication class if first line for SEVERE PMS/PMDD? How can they be taken?
SSRIs - first-line
daily OR 14 days prior to menses onset through the end of the cycle
What is second line tx options for severe PMS/PMDD? May consider limited use of ______
Hormonal contraception - second-line
Yaz, Yasmin, Beyaz
alprazolam
Why are Yaz, Yasmin, Beyaz preferred hormonal contraception options in severe PMS/PMDD?
Often use contraceptives with drospirenone
can be added on
What is the refractory PMS/PMDD tx? What is the definitive tx?
refractory: GnRH agonists
definitive: bilateral oophorectomy +/- hysterectomy
Dysfunctional uterine bleeding encompasses both _______ and ________
Encompasses both abnormal menstrual bleeding and bleeding due to underlying causes or diseases
If you do a cervical cytology in a postmenopasal pt with dysfunctional uterine bleeding and find endometrial cells, what does this mean?
endometrial cells postmenopause is abnormal! unless on menopausal hormone therapy
Consider looking at this chart again before the test?
What are 4 additional tests that you could be ordered on a pt with DUB?
Pelvic Ultrasound
endometrial bx
dilation and curettage
hysteroscopy
What is a Sonohysterography?
saline injected in intrauterine cavity - increased sensitivity of the pelvic US
Which type of pelvic US has a wider visualization? Which one does the bladder have to be empty vs full?
Transabdominal has a wider view than transvaginal
Transvaginal - empty bladder
Transabdominal - full bladder
**What is the gold standard of further evaluation of DUB? What does the procedure entail?
Hysteroscopy
Camera through cervix with biopsy; direct visualization (higher accuracy)
What things need to be rule out before deciding on tx for DUB? What are the tx options?
need to rule out pregnancy and cancer
oral contraceptives, antifibrinolytics, levonorgestrel-releasing IUDs, intramuscular progestin injection
What are the 5 treatment options for premenopausal DUB?
observation
hormone therapy
IV estrogen if acute hemorrhage
IUD, D&C, endometrial ablation
hysterectomy
When is observation a treatment option for premenopausal DUB?
if serious pathology ruled out and not impacting patient functioning or quality of life
How is hormone therapy initiated for premenopausal DUB?
often started at high doses, then decreased in a few days for maintenance
When is IV estrogen used as a treatment for premenopausal DUB?
in acute hemorrhages
What is the tx for refractory DUB in a premenopausal pt? What is the definitive tx for premenopausal DUB?
levonorgestrel-releasing IUD
D&C (temporary fix)
endometrial ablation
hysterectomy
What are causes of postmenopausal DUB?
endometrial atrophy
exogenous hormones
vaginal atrophy
tumors of reproductive tract
T/F: It is okay for postmenopausal women to bleed sometimes.
FALSE!! if postmenopausal, any bleeding is worth further investigation
______ is the MC cause of postmenopausal uterine bleeding
endometrial atrophy
_______ is the MC cause of lower GU tract postmenopausal bleed
vaginal atrophy
if you suspect tumors of the reproductive tract, what should you do next?
Endometrial sampling and endocervical curettage should be done at a minimum; may require D&C or hysteroscopy
definitive therapy is take out the tumor/structure
what generation of endometrial ablation is considered superior?
2nd gen is superior
What is the highlighted first generation endometrial ablation technique?
rollerball electrosurgical desiccation
approximately 3% of ablation
What is the highlighted second generation endometrial ablation technique?
radiofrequency electrosurgery
______ happens as a result in 70-80% of endometrial ablation patients. When are endometrial ablations CI?
Decreased menstrual flow
Contraindicated if patient desires future fertility
Will the pt still need to use contraception after a endometrial ablation? If the pt becomes pregnant, what is she at a higher risk for?
Patient will still need adequate post-op contraception
isk of miscarriage, prematurity, abnormal placentation, perinatal ablation
______ are used 1-2 months before the planned endometrial ablation. Why? What is the alternative to premediation?
GnRH agonist, combination oral contraceptives, progestins
causes endometrial atrophy and will reduce thickness
Alternatively may consider curettage before procedure
What are the CI to endometrial ablations?
pregnancy/wishing to have future baby
Endometrial hyperplasia or genital tract
cancer
Postmenopausal women
Acute pelvic infection
Expectation of amenorrhea
IUD in place
________ is the first tool for endometrial ablation. What generation?
Vaporization (Nd-YAG Laser)
1st generation
Which first generation endometrial ablation technique does NOT work on intracavitary lesions?
rollerball ablation
Which first generation endometrial ablation technique has high rates of peroration?
endometrial resection
Describe what is happening in a hysteroscopic thermal ablation. What generation? Has a higher _____ risk than other 2nd gens.
Uncontained saline solution heated and recirculated for 10 minutes
2nd generation
higher burn risk
**Which 2 endometrial ablation technique can you use with an anatomically abnormal uterus?
**hysteroscopic thermal ablation
Water Vapor Thermal Ablation
aka fibroids and double uterus
Which 3 endometrial ablation technique does NOT require endometrial preperation?
radiofrequency thermal ablation: Fan-shaped mesh device contours to shape of endometrial cavity
thermal and RF thermal ablation (Minerva)
Water Vapor Thermal Ablation (Mara)
Which endometrial ablation technique has higher rates of normal or no menstrual flow after the procedure?
Thermal + RF Thermal Ablation (Minerva)
What is the MC gyn diagnosis responsible for hospitalization in women 15-44?
endometriosis
endometriosis effects _____ of women in reproductive age group. _____ of infertile women and _____ of adolescents with severe pelvic pain warranting surgical evaluation
6-10% of women in reproductive age group
25-35% of infertile women
53% of adolescents with severe pelvic pain warranting surgical evaluation
What is the suspected pathogenesis of endometriosis?
retrograde menstruation
Where are some common implantation sites of endometriosis?
ovary, uterine cul-de-sac, pelvic ligaments, uterus, fallopian tubes, large intestine
What are the risk factors for endometriosis?
(+) Family history
Early menarche
Nulliparity
Long duration of flow
Heavy menstrual bleeding
Shorter menstrual cycles
aka having more periods
What are negative risk factors for endometriosis?
Regular exercise
Late menarche
Higher parity
Longer duration of lactation
What are the classic symptoms of endometriosis? Do symptoms correlate with the extent of lesions?
dysmenorrhea (79%)
pelvic pain (69%)
dyspareunia (45%)
infertility (26%)
can also be asymptomatic!!
NO!! can have super severe symptoms with hardly any lesions and vice versa
If the pt is asymptomatic with endometriosis, how are they likely to present?
first sign will usually be infertility
**What is the classic PE finding for endometriosis?
“tender nodules in posterior vaginal fornix or uterosacral ligaments, and pain with uterine motion”
What imaging is used frequently when diagnosing endometriosis? ______ is the modality of choice
there is LIMITED use for imaging when dx endometriosis
transvaginal US
What is the definitive dx tool for endometriosis?
usually laparoscopy surgery with bx
What do early endometriosis lesions look like?
small, red, petechial
What do larger endometriosis lesions look like?
cystic, dark brown, dark blue or black appearance
If an endometrial lesion is found on the surrounding peritoneum, how would you describe it? How would you describe it on the ovary?
thickened and scarred - “powder burn”
appear as “chocolate cysts”- can be several centimeters
What type of lesion?
chocolate cysts
What type of lesion?
powder burn/classic gunmetal
What type of lesion?
red/purple raspberry spot
What is the tx for minimal to mild symptoms of endometriosis?
expectant management
NSAIDs
hormonal tx: COC or progestin-only
What is the though process behind giving hormonal tx in minimal/mild endometriosis?
Decrease dysmenorrhea and may slow progression
What is the tx for mod/severe endometriosis?
GnRH agonists or antagonists, danazol,
aromatase inhibitors
gabapentin, pregabalin, TCAs
surgical tx to remove/excise endometriotic implants
______ is used in the tx of mod/severe endometriosis and is a testosterone derivative and acts like progestin
Danazol
_____ MOA inhibits gonadotropin release and enzymes that produce estrogen
Danazol
What are the SE of Danazol? What is the outcome?
oily skin, acne, deepened voice, weight gain, edema, dyslipidemia
Pain relief in up to 90% of patients
What are the 2 aromatase inhibitors that are used in mod/severe endometriosis as adjuvant treatments? What is the MOA?
Anastrozole or letrozole
inhibit enzymes that make estrogens
Leuprolide (monthly IM), Goserelin (monthly SC), Nafarellin (daily intranasal). What drug class? What are the SEs? How long can you use it for?
GnRH agonists - suppress gonadotropin secretion
SE - lower BMD, vasomotor symptoms, vaginal dryness, mood changes
Duration - Use limited to 6 months due to hypoestrogenic state
**_____ is the most studied drug for mod/severe endometriosis and is FDA approved. What drug class? How long can you use it for?
Elagolix (Orilissa)
GnRH antagonists
Use limited to 6 months (high dose) or 24 months (low dose)
What is pelvic inflammatory disease? What pathogen? What 2 disease is it associated with?
Infection of upper genital tract
Often polymicrobial
gonorrhea and chlamydia
What pt population is at the highest risk of PID?
young, nulliparous, sexually active women with multiple partners
______ is a leading cause of infertility and ectopic pregnancy
PID
What is the cardinal symptom of PID?
lower abdominal pain, usually bilateral and rarely lasts longer than 2 weeks
What is Fitz-Hugh-Curtis syndrome?
a rare complication of pelvic inflammatory disease (PID), an infection of the female reproductive organs. It is characterized by inflammation of the liver capsule (perihepatitis) and surrounding tissues.
RUQ pain
What is the classic PE sign of PID? What is their oral temperature? What other structures are likely to be inflammed?
cervical motion tenderness (“Chandelier sign”)
Oral temp > 38.3 C (101 F)
May see inflammation of Skene or Bartholin glands
What labs should you order in PID? What imaging?
pregnancy test: to r/o ectopic pregnancy
vaginal fluid: WBC in vaginal fluid
CBC: may show leukocytosis and left shift
ESR/CRP may be elevated
transvaginal US should be ordered
What are the CDC guidelines to treat PID empirically?
young sexually active women who have pelvic/lower abdonimal pain without any identifiable cause
AND
one or more of the following: cervical motion tenderness, uterine tenderness, adnexal tenderness
outpt treatment is acceptable in mild/moderate cases of PID, When should you admit?
Severe illness, N/V, or high fever
pregnancy
Pelvic abscess (including tubo-ovarian abscess)
Unable to exclude surgical emergency
Failure to respond to, tolerate, or comply with outpt oral tx
What is the outpt PID abx tx regimen? for how long?
ceftriaxone IM
doxycycline PO
metronidazole PO
14 days
need all 3!
What is the inpt tx for PID? for how long?
ceftriaxone 1 g IV q 24 hrs AND
doxycycline 100 mg IV or PO BID AND
metronidazole 500 mg IV or PO BID
Can change to PO agents 24-48 hours after s/s improve
total treatment for 14 days
How will a tubo-ovarian abscess present?
May report pelvic and abdominal pain, fever, N/V
Often have severe abdominal tenderness and guarding
Pressure can cause rupture of abscess and peritonitis
If a tubo-ovarian abscess ruptures, what is the pt at risk for?
acute abdomen and septic shock
What is the classic pt with a tubo-ovarian abscess? What is the imaging method of choice?
young, low-parity, hx of pelvic infection
US
CT will also dx
What is the tx for an unruptured tubo-ovarian abscess? How long?
hospitalize!!
same abx as PID:
ceftriaxone 1 g IV q 24 hrs AND
doxycycline 100 mg IV or PO BID AND
metronidazole 500 mg IV or PO BID
4-6 weeks
+/- surgical drainage if large or if not improving with antibiotics alone
What is the tx for an ruptured tubo-ovarian abscess?
life-threatening emergency!!
Surgical intervention - often use open laparotomy
Drainage and washout of abscess
Consider TAH and BSO
Aggressive fluid resuscitation and antibiotics
If you see a tubo-ovarian abscess in a postmenopausal women, what should you think?
high risk of concurrent malignancy
What is a cystocele? What is another name for it?
anterior vaginal wall defect (bladder)
Also termed anterior vaginal prolapse
What is a vaginal vault prolapse?
a condition where the top part of the vagina, known as the vaginal vault, drops down into the vaginal canal due to weakened pelvic floor muscles, often occurring after a hysterectomy, causing a feeling of bulging or pressure in the pelvic area
What is an enterocele? Rectocele?
bowel in prolapsed segment of vaginal wall
posterior vaginal wall defect (rectum) or posterior vaginal prolapse
What are the two pelvic organ prolapse staging options? Which one is most precise and objective?
Pelvic Organ Prolapse Quantification (POP-Q) - most precise and objective
Baden-Walker Halfway System- scores each organ prolapse individually
Draw the scale of Baden-Walker Halfway system
How will a pt with pelvic organ prolapse describe their symptoms?
fullness, pressure, heaviness, and/or discomfort
“Something falling out” or “Sitting on a ball”
may have pain but most patients describe it as pressure
What are some urinary s/s associated with pelvic organ prolapse? What may the pt need to do when voiding?
stress incontinence, frequency, hesitancy, incomplete bladder emptying
May need to “splint” bladder to void
What are some defecatory s/s of pelvic organ prolapse?
incomplete emptying, need to strain
May need to “splint” vagina or perineum to defecate
What are risk factors for pelvic organ prolapse?
Increasing parity
History of pelvic surgery
Postmenopausal status
Age
Obesity or physical debilitation
Chronic coughing (lung disease) or straining (constipation)
Neurologic decline
When is imaging done in pelvic organ prolapse?
Imaging usually only done if other underlying process suspected or equivocal case
aka imaging is not really done!! can be easily dx on PE
What is the conservative tx for pelvic organ prolapse? What is associated follow up?
Pessary - intravaginal device, pelvic floor exercises and topical estrogens
must be fitted by the provider and re-examine 1-2 weeks after pessary placement, 4 weeks after, then every 3-6 months or every 2-3 months if patient cannot remove and clean device
What is the more invasive tx option for pelvic organ prolapse?
surgical tx
may or may use synthetic mesh
What is adenomyosis? What factors can weaken myometrium?
Uterine enlargement due to ectopic endometrium deep within the myometrium
pregnancy, surgery, decreased hormones weaken myometrium and allow endometrium to invade
What am I?
adenomyosis
What are the risk factors for adenomyosis?
parity
age: most are in their 40s and 50s
What symptoms will pts with adenomyosis exhibit? What percentage of pts will exhibit s/s?
Menorrhagia (excessive or prolonged menstrual bleeding) and dysmenorrhea
in approximately 1/3 of patients
In adenomyosis, will the number of implants correlate with the severity of s/s ?
YES!!
More areas of invasion = more symptoms
What will the PE of a pt with adenomyosis look like?
global uterine enlargement
Rarely greater than that of a 12 week pregnancy (pubic symphysis)
smooth uterine contour with softening
minimal hemorrhage during menses
What is the preferred imaging in adenomyosis? What will the myometrium look like? endometrium?
transvaginal US
Myometrium - focal thickening, heterogeneous texture, cysts
Endometrium - projections into myometrium, ill-defined echo
How does an adenomyosis compare to a leiomyoma on imaging?
adenomyosis will be poorly defined margins, elliptical shape, lack of calcifications
irregular shaped
What is the treatment for adenomyosis? What is the definitive treatment?
trying to relieve symptoms
IUD -most effective 1st line
oral contraceptives: progestine only
NSAIDs
GnRH agonists/antagonists- 2nd line
hysterectomy- definitive tx
**______ is the most effective first line tx for adenomyosis. What kind of OCP are preferred?
IUD
progestin-only!
**_____ are the MC benign neoplasm of female genital tract. What are another name for them? What do they consist of?
Leiomyomas
“myomas,” “fibroids,” “fibroid tumors”
Benign smooth muscle tumors
Where are 3 places that you can find leiomyomas in the genital tract?
Submucous - directly beneath endometrial lining
Subserous - directly beneath serosal lining
Intramural - completely within myometrium
can also be pedunculated
What are the s/s of leiomyomas? How will they present?
most are asymptomatic!!!
abnormal uterine bleeding, pelvic pressure/pain, may have local compression of other pelvic organs
What will the uterine exam reveal of a pt with leiomyomas?
uterus may be enlarged, may have irregular contour
in general, labs of leiomyomas are typically _______. But may see ______. _______ is rare but possible
labs typically not helpful
may see iron-deficiency anemia
polycythemia due to myoma EPO production- rare but possible
What is the first line testing in leiomyomas?
US! to confirm presence and monitor growth
_____ confirm cervical or submucous leiomyomas
Hysterography/Hysteroscopy
What is the tx for asymptomatic leiomyomas?
observation; annual exam
What is the tx for symptomatic leiomyomas?
NSAIDs, hormonal therapy (contraceptives, GnRH agonists)
myomectomy, hysterectomy, uterine artery embolization: may tx preoperatively with hormones to help reduce the myoma size
What is the prognosis for leiomyomas after menopause?
Usually will regress spontaneously
**______ is the MC gyn malignancy. Is it MC in white or black pts? What is the peak onset age?
endometrial cancer
MC in white women
70s but may occur in 20s and 30s
endometrial cancer most commonly arises from _______. _____ are antiproliferative
endometrial hyperplasia from unopposed estrogen
progesterones are antiproliferative
What is the pathogenesis of endometrial cancer?
Abnormally high levels of estrogen
Give 7 reasons of abnormally high levels of estrogens that can lead to endometrial cancer?
obesity
Metabolic syndrome
PCOS
Exogenous unopposed estrogen therapy
Chronic anovulation
Granulosa cell tumors of ovary
Tamoxifen (SERM
**_____ is the MC cause of ENDOgenous overproduction of estrogen
obesity
What are 2 ways to decrease your risk for endometrial cancer?
combination oral contraceptive use for at least 1 year/progestin/progesterone IUDs
smoking
Combination oral contraceptive use for at least 1 year -reduction lasts for ______
10-20 years
Why does smoking help to decrease risk of endometrial cancer?
reduces levels of circulating estrogens, associated with weight reduction, earlier menopause and altered hormonal metabolism
How is endometrial hyperplasia classified? What is the MC symptom?
Classified as simple or complex, +/- atypia
abnormal uterine bleeding
What is the prognosis of simple hyperplasia without atypia?
1% progress to endometrial cancer without treatment
80% spontaneously regress without treatment
What is the prognosis of complex hyperplasia without atypia?
3-5% progress to endometrial cancer without treatment
85% regress with progestin therapy
What is considered endometrial hyperplasia with atypia?
Endometrial glands lined with enlarged cells that are considered PREMALIGNANT
What percentage of simple atypical endometrial hyperplasia with atypia progress to cancer? Complex atypical?
10% of simple atypical
30% of complex atypical
What is the tx for endometrial hyperplasia with atypia?
progestin therapy! and most will regress
What is the tx for endometrial hyperplasia with atypia that is intolerant of progestin therapy or relapse occurs?
hysterectomy!
Describe Type I endometrial cancer in terms of percentages, age, prognosis and differentiation
Describe type II endometrial cancer in terms of percentage, age and prognosis
15% of cases
Older patients
Poorer prognosis
aka they are getting cancer because they are old
Which endometrial cancer is independent of estrogen? Which is associated with endometrial atrophy?
type II
type II
What percentage of endometrial cancer pts have a known hx of hyperplasia?
** What is the classic endometrial cancer pt?
25% have hx of hyperplasia
obese, nulliparous, infertile, hypertensive, diabetic, white
What are some ways endometrial cancer spread? **What is the major one?
direct extension
lymphatic
transtubal spread (seeding into the peritoneum)
aka it invades things it touches
What is the MC type of endometrial cancer? What are 2 additional types of endometrial cancer?
adenocarcinoma
serous and clear cell carcinoma
____ type of endometrial cancer is more likely to be in older patients; poorer prognosis and less associated with hyperestrogenic states. How common is it?
Serous - 10%
_____ type of endometrial cancer is high-grade and aggressive and NOT associated with hyperestrogenic state. How common is it?
clear cell carcinoma
1-4%
What are the 3 s/s of endometrial cancer? ** What is the most important one?
abnormal bleeding** most important
abnormal vaginal discharge
lower abdominal cramps and pain
**a postmenopausal pt with ______ is an automatic work-up! What is the next test you should order?
**Always work-up a postmenopausal patient with bleeding!
then pelvic US!
What can cervical os stenosis lead to? How will it present?
blood and detritus build-up (hematometra)
develop abscess and sepsis
pt will complain of lower abdominal cramping and pain
What will the PE show in endometrial cancer? give both early and late uterus
PE is usually unremarkable
Early - uterus usually will be normal
Late - enlarged and/or fixed uterus, metastasis to pelvic lymph nodes and/or adenex
What is first line imaging for endometrial cancer? **What finding would make you very suspicious for endometrial cancer? What should you do next?
pelvic US
Endometrium >4 mm thick in postmenopausal pt
bx of endometrial tissue
doing a endometrial bx even if it is less than 4mm
What is the false negative rate of an endometrial biopsy? What should you do next if the bx is negative and symptomatic?
False negative rate - 10%
If symptomatic and negative bx - need D&C
Why is D&C a more definitive procedure for diagnosing endometrial cancer?
larger tissue sample
is performed in the OR and under anesthesia
What are other tests that help to identify endometrial cancer?
pap smear: small % of asymptomatic pts
CA-125: elevated in 20% of clinical stage 1 disease
CBC: may show anemia
What is the tx for endometrial cancer?
sx! Total hysterectomy with bilateral salpingo-oophorectomy and staging with pelvic and periaortic lymphadenectomy
+/- radiation, progesterone therapy, and/or chemo
What is the tx for endometrial cancer with severe anemia after prolonged bleeding?
High-dose progestins and/or IV estrogen can help control bleeding acutely
Tranexamic acid (antifibrinolytic) - can help reduce bleeding
Stabilize with fluids, IV iron, RBC transfusions as indicated
Uterine tamponade with vaginal packing if needed
sx to correct cancer, may embolize the uterine artery for pts who cannot receive surgery in the near future
What is the 5 year survival rate for endometrial cancer depending on the stage? Give all 4 stages
Stage I - 80-90%
Stage II - 70-80%
Stage III - 35-55%
Stage IV - 17-22%
What factors make the prognosis worse in endometrial cancer?
increasing age
higher pathologic grade
advanced-stage disease
increasing depth of myometrial invasion
lymphovascular invasion
