Uterine Disorders

Question 1

Endometriosis

Answer 1

• Definition:
  
  • presence of endometrial tissue (glands & stroma) outside the uterus
• Pathophys:
  
  • the ectopic endometrial tissue responds to cyclical hormonal changes
• Risks:
  
  • hx of c-section or fibroid removal, family hx, prolonged estrogen exposure (nulliparity, late 1st pregnancy, early menarche)
• S/sxs:
  
  • Classic Presentation: **Progressive dysmenorrhea and deep pelvic pain, deep dyspareunia**
  • Consider endometriosis in patients with dysmenorrhea not responsive to COCs and NSAIDs
• Pe:
  
  • usually normal
    
    • but may have a fixed, tender adnexal mass
• Dx:
  
  • Clinical Dx: dx of exclusion
  • Pelvic US:
    
    • r/o other causes, may show ovarian endometriomas as cysts containing “homogeneous” echoes consistent with old blood or free fluid in pelvis
  • Laparoscopy with biopsy = definitive diagnosis, raised patches of thickened discolored scarred implants of tissue
• Tx:
• -Ovulation suppression: combined OCPs (1st line) &NSAIDs (600-800mg TID for first few days, need to start BEFORE the pain begins)
  
  • → continuous therapy, without taking 7 days of inactive pills that induce withdrawal bleeding, can prevent secondary dysmenorrhea
    
    • (cause medical amenorrhea)
• Surgery: conservative laparoscopy with ablation of ectopic endometrial tissue if fertility desired; total abdominal hysterectomy & salpingo-oophorectomy if no desire for fertility
• **LNP IUDs do NOT help b/c they are not systemic **

Question 2

Leiomyoma (Fibroid)

Answer 2

• definition:
  
  • benign uterine smooth muscle tumors that derive from the muscle cells of the myometrium
• Types: intramural, submucosal, subserosal, parasitic
• Risks:
  
  • increasing age (> 35yo), African-Americans, nulliparity, obesity, family hx
• Pathophys:
  
  • growth is estrogen dependent
• Most common reason for hysterectomy → due to symptoms
• S/sxs:
  
  • mostly asymptomatic
  • heavy period → most common reported symptom: worsen at 40-50 yo & resolves with menopause
  • Abd fullness, increased pelvic pressure: with or without urinary or bowel symptoms
  • Pelvic or lower abdominal pain with sex
• PE:
  
  • irregular large uterus (normal is 6-10cm in length, an upside down pear is normal)
  • Firm, nontender, asymmetric mobile mass(es) in the abd or pelvis on bimanual exam
• Dx:
  
  • bimanual exam as clinical impression
  • transvaginal US: focal heterogenic hypoechoic mass(es) with shadowing
  • saline infused pelvic US or hysterectomy for submucosal fibroids
  • MRI for extremely large fibroids
• Tx:
  
  • Observation: most do not need tx
  • -Hysterectomy = definitive
  • -Myomectomy → preserves fertility
  • Medical Tx: to decrease bleeding and pain
    
    • → Progestin and/or prostaglandin synthetase inhibitors
    • → norethindrone 5-10 mg PO daily (not a contraceptive dose!!)
    • → progestin only LARC; LNG IUD, nexplanon, depo IM
• surgical tx:
  
  • myomectomy/hysterectomy
    
    • →GnRH agonists to debulk fibroid 40-60% prior to uterine sparing surgery
• Uterine Artery Embolization:
  
  • causes acute infarct of targeted fibroid

*

Question 3

Adenomyosis

Answer 3

• Definition:
  
  • islands of endometrial tissue within the myometrium (muscular layer of the uterine wall)
• Risks:
  
  • age 30-50, endometriosis, fibroids
• S/sxs:
  
  • menorrhagia, dysmenorrhea, chronic pelvic pain, infertility
• PE:
  
  • symmetrically enlarged “globular” boggy uterus
• Dx:
  
  • transvagina US: heterogenous cystic structure
  • Pelvic MRI
• tx:
  
  • Conservative: analgesics (NSAIDs), progestins, aromatase inhibitors
  • -Hormonal contraceptives: COCs or progesterone therapy (Depo, nexplanon, LNG (levonorgestrel) IUD→ IUD = great option )
  • -Definitive: total abd hysterectomy

Question 4

Uterine Prolapse

Answer 4

• Definition:
  
  • uterine herniation into the vagina
• Risks:
  
  • multiple vaginal births, obesity, heavy lifting
• S/sxs:
  
  • Vaginal fullness, heaviness, or “falling out” sensation worse with prolonged standing & relieved with lying down
  • low back pain, abd pain, urinary frequency or urgency
  • stress incontinence
• PE:
  
  • Bulging mass esp with increased intraabdominal pressure
• Dx:
  
  • Grading:
    
    • 0: no descent
    • 1: descent into upper ⅔ of vagina
    • 2: cervix approaches introitus
    • 3: cervix outside introitus
    • 4: entire uterus outside of vagina
• Tx:
  
  • Kegel exercises, behavioral modification, weight control
  • Estring–localized ERT (estrogen replacement therapy) replaced q 90 days, vaginal ring, acts as a support structure and has estrogen
  • Pessaries: elevate & support the uterus
  • Estrogen: improves atrophy
  • Surgery: hysterectomy is definitive

Question 5

Uterine Hyperplasia & Cancer

Answer 5

• Epidemiology: 2-3% of women develop uterine cancer
  
  • 97% of uterine cancers arise from glands of endometrium -→ endometrial carcinoma
  • 3% arise from myometrium or stromal components -→ sarcoma
• s/sxs:
  
  • abnormal uterine bleeding → HALLMARK SXS
  • must evaluate in:
    
    • women > 45 yo
    • women < 45 yo with risk factors:
      
      • fmhx of breast, gyn or colon CA, obesity, prior endometrial hyperplasia, chronic anovulation, tamoxifen or ERT use
  • Dx:
  • transvaginal u/s first with endometrial stripe measurement: symptomatic with endometrial stripe > 5mm = have to do an endometrial biopsy
  • Asymptomatic with endometrial stripe > 11mm = have to do an endometrial biopsy
• Tx:
  
  • Goal: reduce risk of malignant transformation and control presenting symptoms
  • Meds:
    
    • Oral progesterone; 1 tablet PO x 10 days → to help them shed
    • -Long acting progesterone: Depo, nexplanon, LNG D
    • -Women on SERM (Tamoxifen/Raloxifene) for breast cancer treatment, therapy should be discontinued
• Surgical:
  
  • dilation & curettage

Question 6

Endometrial Carcinoma: Dx & Tx

Answer 6

• Dx:
  
  • endometrial biopsy
• Tx:
  
  • total hysterectomy with salpingo-oophorectomy and cancer staging
  • Post surgical estrogen replacement: may be used for menopausal symptoms
  • These people are candidates for ERT based on prognostic indicators and pts must be willing to assume the risk

Question 7

Uterine Sarcoma

Answer 7

• Presentation:
  
  • progressive uterine enlargement after menopause
  • Low dose HRT does not increase risk of sarcoma
• s/sxs:
  
  • post-menopausal bleeding
  • pelvic pain with uterine enlargment
  • increased unusual vaginal discharge
• Dx:
  
  • Total hysterectomy (yes for the diagnosis, I know)
• Tx:
  
  • Post-surgical tx:
    
    • radiation & chemo decreases recurrence rate but doesnt change much in terms of survival
  • Prognosis:
    
    • 5 year survival = 29%-76%