uterine disorders Flashcards
What is endometriosis
presence of endometrial glands and stroms outside the endometrial cavity and uterine musculature (MC pelvis) causing inflammation
Endometriosis is a risk factor for
epithelial ovarian cancer
can also cause infertility
What is the suspected etiology of endometriosis
Retrograde menstruation (endometrial tissue goes retrograde through fallopian tubes and peritoneum -Deficient cell immunity, heredity
RF for endometriosis are
nulliparity heavy menstrual bleeding prolonged exposure to estrogen DES exposure in utero >68 inches in height low BMI high unsaturated fat consumption
How do women with endometriosis present
premenstrual pelvic pain (lesions stimulated by estrogen/progesterone) Pelvic pain SUBSIDES after menses infertility (30-40%) Dysmenorrhea Dyspareunia Rectal pain w/ bowel movements
what is the difference between vulvodynia and dyspareunia
Dys: pain with deep penetration
Vulvo: pain with insertion
PE findings indicating endometriosis incllude
ttp/nodules in posterior coldesac
fixed or retroverted uterus 2/2 adhesions
adnexal mass ttp
How do you diagnose endometriosis
Need laparoscopy for solid Dx
Imaging and CA-125 can help support
On laparoscopy, what will endometriosis show
erythematous, petechial lesions on peritoneum
thick, scarred surrounding peritoneum
lesions/endometriomas (chocolate cysts) on ovaries
adhesions
MC site of endometriosis is
The ovaries
How do you treat mild endometriosis
expectant management
NSAIDS +/- OCP (can skip menses all together by stringing packs)
How do you treat mod-severe endometriosis
OCP (string)- can atrophy endometrium Progestins (PO, IM, IUD)- prevent endometrial growth GnRH agonists (Depot Lupron) suppress estrogen/progesterone
Other endometriosis treatments are
Danazol
Aromatase inhibitors
Laparoscopic excision
Hysterectomy w/ b/l salpingo-oopherectomy
Endometriosis treatment considerations include
clinical presentation Sx severity extent and location fo dz reproductive plans age med ADE surgical compliance rates cost
Good effects of OCP in endometriosis are
40-50% pregnancy rate after d/c
decrease risk of ovarian cancer
What are uterine fibroids
proliferation of smooth muscle cells in uterine wall
made up of collagen, smooth muscle, and elastin, surrounded by pseudocapsule
What group of women typically gets uterine fibroids
20-25% in women of child-bearing age
50% of populaiton have them by age 50
Seen earlier and grow faster
2-3x MC in black women
What is the implicated etiology of uterine fibroids
- Estrogen; myomas have higher concentration of estrogen receptors= increased production of extracellular matrix
- Progesterone increases mitotic activity, suppresses apoptosis
How can you classify uterine fibroids
Submucosal: just beneath endometrium (more inwards)
Subserosal: serosal surface (more outwards)
Intramural: w/in uterine wall
Which uterine fibroids are associated with infertility
Submucosal- impinge uterine cavity
also increase surface area of endometrium and also cause menorrhagia
What are symptoms of uterine fibroids
Abn uterine bleeding pain (contractions, dyspareunia) pelvic pressure (mass effect) infertility (submucosal) spontaneous abortion
On bimanual exam of uterine fibroids you may find
uterine enlargement
irregular shape
mass (NOT fluctuant)
How do you diagnose uterine fibroids
#1: Transvaginal US saline infused sonohysterogram hysteroscopy MRI H&H
Is there one specific way to Tx uterine fibroids
no standard of cure, let Sx drive Tx
Medical Tx options for uterine fibroids are
#1: Steroidal (OCP, Mirena, ortho-evra, nuvaring) COC, progestin GnRH analog (Depot Lupron) Tranexamic acid (Lysteda)
Surgical options for treating uterine fibroids are
Hysteroscopic resection
Endometrial ablation
Laparoscopic myomectomy
Laparoscopic radiofrequency ablation
Other Tx for uterine fibroids are
uterine artery embolization
MRU
How does Depot Lupron treat uterine fibroids
decreases fibroid size (bc they are associated w/ estrogen)
also helps improve anemia before, and decrease blood loss during surgery
DO NOT USE >6 months
Who can use steroidal therapies to Tx uterine fibroids
prolonged, heavy menses
NO submucosal fibroids
Who can take Lysteda and how does it work
prolonged, heavy menses W/O submucosal fibroids
PO anti-fibrinolytic for menorrhagia (decrease blood loss, little evidence on fibroid effects)
USE ONLY during menses, two 650mg tab BID (total 1300)
What surgical option for uterine fibroid removal is good for preserving Fertility and the uterus
-Myomectomy- on intramural, subserosal, and pedunculated fibroids (20-50% recurrence)
but, delay pregnancy 3-6 mo to avoid uterine rupture and c-section
-Hysteroscopy- submucosal fubroids. has risk of fluid overload and hyponatremia
Wat is a laparoscopic myomectomy
robot assistance myomectomy depending on number and size of fibroids
Complications: hemorrhage, re-op, adhesions
What uterine fibroid patients are candidates for abdominal/mini-laparotomy myomectomy
those with CI to laparoscopy (cardiopulmonary dsease)
if fibroid size doesn’t allow laparoscopic
Hx of pelvic or abdominal radiation
Severe hip dz
How do you perform a hysteroscopy
give a non-iodine solution to distend (1.5% glycine or 3% sorbitol)
use a heated loop to resect the fibroid
can be done outpt, can return to normal activity in 1-2 days, sex in 1 month
What is endometrial ablation
min invasive method to preserve uterus, takes 2 min.
done outpt. at any time in menstrual cycle (general anesthesia or cervical block)
Admin CO2 for distention
Tx for menorrhagia w/o major uterine distortions (best if <9cm)
If you have had an endometrial ablation, can you have kids?
You should NOT bear children, but use contraceptives because if you do get pregnant it can implant into the muscle wall (placenta accreta)
Con’s to endometrial ablation include
must first remove polyps and submucosal fibroids (does not distort the uterus)
doesn’t address fibroid Sx
50% experience amenorrhea
What is uterine artery embolization
arteriogram to ID blood supply to fibroid
cath goes into uterine artery and embolizing agent flows in
Preserves the uterus NOT fertility!
What pts are candidates for uterine artery embolization
If they do not want kids
Who is a uterine artery embolization contraindicate in
pts with many and large fibroids
ADE of uterine artery embolization are
post-embolization syndrome (overnight hospital stay)
NON-purulent vag discharge
uterine infection
10-15% recurrence
embolization can reach ovaries (premie ovarian failure)
uterine necrosis, sepsis, bacteremia, death
What is adenomyosis
growth of endometrial glands and stroma into MYOmetrium
What are suspected etiologies of adenomyoma
ovarian hormones
invagination of endometrium (it weakens with degeneration)
Parity (C-section)
How does adenomyoma present
menorrhagia
dysmenorrhea
pelvic pain
Hx of previous uterine surgery (c-section, myomectomy)
On adenomyoma bimanual exam, you are likely to see
diffuse uterine enlargement, symmetric (globular), not larger than 12 wk gestation
Definitive Dx of adenomyosis is based on
histology after hysterectomy
imaging only AIDS Dx (US, MRI)
Medical Tx options for adenomyoma are
OCP, Mirena, Nuvaring
-improve dysmenorrhea and menorrhagia
Durgical Tx options for adenomyoma are
Definitive Tx: hysterectomy
Uterine artery embolization
endometrial ablation (high fail rate), painful
RF for endometrial hyperplasia are
OBESITY!!!!!!!! high fat= high estrogen early menarche, late menopause (estrogen exposure) infertility nulliparous Hx of Tamoxifen Tx (breast cancer) unopposed estrogen Tx diabetes PCOS PMHx breast or ovarian cancer, or radiation for pelvic CA FHx lynch syndrome
Current WHO classification for endometrial hyperplasia is
hyperplasia without atypia (non-neoplastic)
atypical hyperplasia
What is the pathophys behind endometrial hyperplasia
estrogen stimulates endometrial proliferation
progesterone is anti-proliferative (shedding)
unoposed estrogen= hyperplasia and atypia
How does endometrial hyperplasia typically present
asymptomatic! post-menopausal bleeding menorrhagia intermenstrual bleeding prolonged menses (>7d) decreased menstrual interval (<21 days) oligomenorrhea, amenorrhea
What PE is important to do for endometrial hyperplasia
pelvic exam pelvic US (thick endometrium) endometrial biopsy D&C hysteroscopy
what endometrial thickness is a good sign
<4mm, malignancy is NOT likely
How do you treat endometrial hyperplasia W/O atypia
Mirena (progestin)
Depo-Provera
-reassess with EMB to ensure resolution
How do you treat atypical endometrial hyperplasia
1: hysterectomy (if done having kids)- bc 50% have cancer
-Progesterone therapy- megestrol acetate, Mirena
(reassess q3 mos until resolved)
What is the MC pelvic genital cancer
endometrial cancer
4th MC female cancer
Typical onset: 50-69
White>Black
RF for endometrial cancer are (hint: same as hyperplasia)
Obesity early menarche, late menopause infertility nulliparous Tamoxifen Tx Dm, PCOS PMHx breast or ovarian cancer, radiation FHx lynch syndrome unopposed estrogen therapy
What is the pathophys behind endometrial cancer
estrogen is implicated
usually evolves from hyperplasia
-Exogenous estrogen, anovulatory cycles, altered estrogen metabolism
What are the types of endometrial cancer
I: arise from unopposed estrogen. good prognosis. well differentiated
II: arise independent of estrogen, seen w/ endometrial atrophy. poorly differentiated. poor prognosis
What are the classifications of endometrial cancer
- Adenocarcinoma (MC)
- adenocarcinoma w/ squamous differentiation
- Serous carcinoma (not estrogen associated)- bad prognosis
- Clear cell carcinoma (not estrogen associated)- high grade, deep invasion
Endometrial cancer staging is based on
FIGO (international federation of gyno and obs)
How does endometrial cancer present
***abnormal vaginal bleeding (menorrhagia, intermenstrual, PMB) abd cramping back pain weight loss dyspareunia
When is endometrial cancer screening recommended
in women with Lynch syndrome (HNPCC)
How do you diagnose endometrial cancer
CBC Transvaginal US Endometrial biopsy D&C pap smear CA-125 (high w/ extra-uterine spread) MRI/CT
How do you treat endometrial cancer
Hysterectomy w/ b/l salpingo-oopherectomy
radiation (if surgery CI, pr advanced pelvic dz)
Chemo (not common, good for advanced dz)
