uterine disorders Flashcards
What is endometriosis?
The presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature
usually located in the pelvis
endometriosis is a risk factor for…
epithelial ovarian cancer
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
Presentation of endometriosis?
Premenstrual pelvic pain
PAIN SUBSIDES AFTER MENSES
Infertility
Dysmenorrhea
Dyspareunia
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
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
-
Endometriosis tx for those with mild disease?
sxs management
NSAIDS +/- OCPs
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
What tx options for endometriosis do you have if nothing else works?
Danazol (androgen)
Aromatase inhibitors
Laparoscopic excision
Hysterectomy with bilateral salpingo-oophorectomy
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
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
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
Presentation for uterine fibroids?
Abnormal uterine bleeding
pain
pelvic pressure
infertility (esp. submucosal)
SAB
PE findings in pt with uterine fibroids?
On bimanual exam:
Enlargement
Irregular shape
Masses
Dx studies to eval for uterine fibroids?
Transvaginal US
Saline-infused sonohysertogram
Hysteroscopy
MRI- for surg planning
H&H- may become anemic
What drives tx for uterine fibroids?
sxs
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?
60
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
