uterine disorders Flashcards by Erica Guevara

What is endometriosis?

The presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature

usually located in the pelvis

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endometriosis is a risk factor for…

epithelial ovarian cancer

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Risk factors for endometriosis?

Nulliparity
Prolonged exposure to endogenous estrogen
Heavy menstrual bleeding
Obstruction of menstrual outflow
DES exposure in utero
Height greater than 68 inches
Lower BMI
High consumption of unsaturated fat

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Presentation of endometriosis?

Premenstrual pelvic pain

PAIN SUBSIDES AFTER MENSES

Infertility

Dysmenorrhea

Dyspareunia

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What will you see on PE in pt with Endometriosis?

Tenderness / nodules at posterior cul-de-sac

Fixed or retroverted uterus (2ary to adhesions)

Endometriomas cause adnexal masses or tenderness

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What diagnostic studies could you order to eval for endometriosis?

CA-125 > may be elevated

Imaging

*Laparoscopy
-lesions vary
-ovaries can demonstrate chocolate cysts
-may be therapeutic
-

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Endometriosis tx for those with mild disease?

sxs management

NSAIDS +/- OCPs

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Tx for mod-severe endometriosis?

want to interrupt stimulation of endometrial tissues

OCPs > continuous cycle fashion
Progestins (PO, IM or IUD)
GnRH > suppression of estrogen and progesterone by down regulation of pituitary

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What tx options for endometriosis do you have if nothing else works?

Danazol (androgen)

Aromatase inhibitors

Laparoscopic excision

Hysterectomy with bilateral salpingo-oophorectomy

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Where do uterine fibroids arise from?

smooth muscle cells within the uterine wall

Fibroids are made up of collagen, smooth muscle, and elastin surrounded by a pseudocapsule

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Uterine fibroids are more common in which pts?

2-3x more common in black women

Seen in 50% of population by the 5th decade

Seen earlier and grow faster

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How are uterine fibroids classified?

by anatomic location within the myometrium

Submucosal: Lie just beneath the endometrium

Subserosal: Lie just at the serosal surface of the uterus

Intramural: Lie within the uterine wall

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Presentation for uterine fibroids?

Abnormal uterine bleeding

pain

pelvic pressure

infertility (esp. submucosal)

SAB

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PE findings in pt with uterine fibroids?

On bimanual exam:
Enlargement
Irregular shape
Masses

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Dx studies to eval for uterine fibroids?

Transvaginal US

Saline-infused sonohysertogram

Hysteroscopy

MRI- for surg planning

H&H- may become anemic

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What drives tx for uterine fibroids?

sxs

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medical options for uterine fibroids?

COCs/progestin
GnRH analogs
Steroid therapies (androgens)
Tranexamic acid

Surgical options for uterine fibroids?

Hysteroscopic resection
Endometrial ablation
Laparoscopic myomectomy
Abdominal myomectomy
Laparoscopic radiofrequency ablation

How do GnRH analogs tx uterine fibroids?

will decrease fibroid size.

Improves anemia prior to surgery

Decreases blood loss during surgery

Allows minimally invasive approach

not approved >6 mo

____are indicated for pts with prolonged heavy menses with no submucosal fibroids

Steroidal Therapies

OCP
IUD
NuvaRing

Lysteda

Benefit for myomectomy for uterine fibroids? disadvantage?

Preserves fertility/uterus

high rate of recurrence, need c-section

Complications of laparoscopic myomectomy?

hemorrhage, re-operation, adhesions, vascular and visceral injuries

After hyperoscopic resection when can pts return to normal activity? Sexual activity?

1-2 days

1 month

Describe endometrial ablation

Minimally invasive,
Preserves uterus,
Treatment of menorrhagia

no future childbearing, must continue a contraceptive

Which pts are candidates for UAE?

Patient does not desire future childbearing Numerous and large fibroids are contraindications

What is adenomyosis?

Growth of endometrial glands and stroma into uterine myometrium

Clinical presentation of adenomyosis?

Menorrhagia Dysmenorrhea Pelvic pain History of previous uterine surgery

PE findings in pt with adenomyosis?

Bimanual exam: diffuse uterine enlargement Globular Size doesn’t usually exceed > 12w gestation

Definitive dx of adenomyosis?

histologic examination after hysterectomy

Medical tx for dysmenorrhea/menorrhagia assoc. with adenomyosis?

Oral contraceptive pills Mirena® IUD NuvaRing®

Surgical options for adenomyosis?

Hysterectomy =Definitive treatment UAE -44% recurrence Endometrial ablation -high failure rate

Risk factors for endometrial hyperplasia?

OBESITY ``` Early menarche (<12yo) Late menopause (>52yo) Infertility, nulliparous ``` others: tx for tamoxifen for breast CA, DM, PCOS, hx breast CA, hx radiation therapy for pelvic CA, fam hx of lynch syndrome

Classifications of endometrial hyperplasia?

Hyperplasia without atypia (non-neoplastic) Atypical hyperplasia (endometrial intraepithelial neoplasia)

presentation for endometrial hyperplasia

Asymptomatic Post-menopausal bleeding! Menorrhagia Intermenstrual bleeding, decreased menstrual interval, oligomenorrhea/amenorrhea

Work up for endometrial hyperplasia?

pelvic exam pelvic US > asses endometrial thickening Endometrial bx D&C, hysteroscopy

tx for endometrial hyperplasia without atypia?

Mirena IUD Provera 10mg QD for 3 – 6mos Reassess with EMB to ensure resolution

Tx for endometrial hyperplasia -atypical hyperplasia?

Hysterectomy is treatment of choice! -Completed childbearing Progesterone therapy - Megestrol acetate (Megace) 40 – 80mg BID - Mirena IUD - if child bearing not complete

What is the MC pelvic genital CA?

endometrial CA

What are the 2 types of endometrial CA?

Presentation for endometrial CA?

abn vaginal bleeding abd cramping, back pain, weight loss, dyspareunia screening recommended in women with Lynch syndrome

Work up for endometrial CA?

``` CBC transvag US Endometrial biopsy D &C Pap smear CA-125 MRI/CT ```

Tx for endometrial CA?

Hysterectomy with bilateral salpingo-oophorectomy with pelvic and periaortic lymphadenectomy Radiation/Chemo