Uterine disorders Flashcards
What is endometriosis?
Endometrial glands & stroma outside endometrial cavity & uterine musculature
What is the cause of endometriosis?
Unknown, but maybe:
- Retrograde menstruation
- Deficient cellular immunity
- Hereditary
What are RFs of endometriosis?
- Nulliparity
- Prolonged exposure to endogenous estrogen
- Heavy menstrual bleeding
- Obstruction of outflow
- DES exposure in utero
- Height > 68 in
- Low BMI
- High consumption of unsaturated fat
What is the clinical presentation of endometriosis?
- Premenstrual pelvic pain (SUBSIDES AFTER MENSES)
- Infertility
- Dysmenorrhea
- Dyspareunia
What does endometriosis look like on PE?
- Tenderness/nodules at posterior cul-de-sac
- Fixed or retroverted uterus
- Endometriomas –> adnexal masses or tenderness
How do you dx endometriosis?
CA-125
Imaging
Laparoscopy
What is seen on laparoscopy in endometriosis?
- Erythematous, petechial lesions on peritoneum
- Peritoneum thickened/scarred
- Endometriomas on ovaries
- Adhesions
How do you treat mild endometriosis?
Expectant management w/ NSAIDs +/- OCPs
What meds help to interrupt stimulation of endometrial tissue?
OCPs
Progestins
GnRH agonists
What are more drastic tx options for endometriosis?
Danazol
Aromatase inhibitors
Laparoscopic excision
Hysterectomy w/ B/L salpingo-oophorectomy
Where do uterine fibroids arise?
From SM cells within te uterine wall
What are uterine fibroids made of?
Collagen, SM, & elastin surrounded by pseudocapsule
What population experiences uterine fibroids?
20% childbearing age
MC in black women
What causes uterine fibroids?
Unknown
- Estrogen is implicated in growth
- Progesterone increases mitotic activity & possibly suppresses apoptosis within the tumor
How are uterine fibroids classified? (3)
By anatomic location within myometrium
- Submucosal: beneath endometrium
- Subserosal: at serosal surface
- Intramural: within uterine wall
What is the clinical presentation of uterine fibroids?
Sx present in 35-50%
Sx occur due to location & size
- Abnormal uterine bleeding
- Pain
- Pelvic pressure
- Infertility
- Spontaneous abortion
What uterine abnormalities are seen on the bimanual exam w/ respect to uterine fibroids?
Enlargement
Irregular shape
Masses
What labs & imaging are used to dx uterine fibroids?
Transvaginal u/s
Saline-infused sonohysterogram
Hysteroscopy
MRI
H&H
How do you treat uterine fibroids?
No standard of care. Sx drive tx of choice
Medical & surgical options available. See slide 27
What are 3 medical options for uterine fibroid tx?
- Depot Lupron
- Steroidal therapy
- Lysteda
What are surgical options for tx of uterine fibroids?
- Myomectomy (Laparoscopic or abdominal/mini-laparotomy)
- Hysteroscopy
- Endometrial ablation
- Uterine artery embolization
Describe Depot Lupron
GnRH agonist
Decreases fibroid size
Decreases blood loss during surgery & improves anemia prior to surgery
Don’t use over 6mos
Steroidal therapies & Lysteda are indicated for patients w/…
prolonged, heavy menses w/ no submucosal fibroids
Describe Lysteda
Oral antifibrinolytic
50% decrease in menorrhagia
Use only during menstrual cycle
What is the benefit of a myomectomy or hysteroscopy?
Both PRESERVE FERTILITY/UTERUS
What is the disadvantage of a myomectomy?
Delays pregnancy 3-6mos
What are complications of a laparoscopic myomectomy (robot assisted)?
Hemorrhage
Re-operation
Adhesions
Vascular/visceral injury
What procedure is used for patients w/ contraindications to laparoscopy?
Abdominal or mini-laparotomy myomectomy
What are contraindications to laparoscopy?
Large fibroid size
Prior pelvic or abd radiation
Severe hip disease
What type of fibroids are removed during myomectomy vs hysteroscopy?
Myomectomy = intramural, subserosal, & pedunculated
Hysteroscopy = submucosal only
What are 2 risks of hysteroscopy?
Fluid overload
Hyponatremia
What are hysteroscopy post op instructions ?
Return to normal activities 1-2 days later
Sex after one month
What are disadvantages of endometrial ablation?
No future childbearing
MUST CONTINUE CONTRACEPTIVE
Amenorrheic rate = 50%
What are benefits to endometrial ablation?
Outpatient or in-office w/ general or paracervical block
Small amt of CO2
Takes less than 2 mins & pt can go home in 1-2 hrs
Can be performed at anytime during cycle
Describe uterine artery embolization (UAE)
Preserves uterus, but not fertility
Catheter placed into uterine artery & infused w/ embolizing agent
Who are candidates for UAE?
Those who don’t want kids
What is a contraindication to UAE?
Numerous or large fibroids
What are side effects & complications of UAE?
- Postembolization syndrome
- Non-purulent vaginal discharge
- Endometriosis & uterine infection
- Recurrence
- Embolization agent found in other tissues
- Uterine necrosis, sepsis, bacteremia, death
What is adenomyosis?
Growth of endometrial glands & stroma into uterine myometrium
What causes adenomyosis?
Unknown
- Ovarian hormones
- Invagination of endometrium
- Parity
What is the clinical presentation of adenomyosis?
Menorrhagia
Dysmenorrhea
Pelvic pain
Hx of uterine surgery
What does adenomyosis look like on PE?
Diffuse uterine enlargment on bimanual exam
What does the definitive diagnosis require in adenomyosis?
Histologic exam after hysterectomy
What imaging is used to aid in the dx of adenomyosis?
U/S
MRI
What are medical options for treating adenomyosis? What do they do?
OCPs, Mirena, NuvaRing
Improve dysmenorrhea/menorrhagia
What are surgical options for adenomyosis?
Hysterectomy (definitive tx)
UAE
Endometrial ablation
What are RFs for endometrial hyperplasia?
Early menarch Late menopause Infertility, nulliparous OBESITY!!!! DM, PCOS Tamoxifen Estrogen replacement Hx of ovarian CA Prior pelvic radiation Fam hx of lynch syndrome
How does WHO classify endometrial hyperplasia?
Hyperplasia w/out atypia
Atypical hyperplasia
What is the pathophys of endometrial hyperplasia?
Unopposed estrogen –> endometrial hyperplasia & atypia
What is the clinical presentation of endometrial hyperplasia?
Asx Post-menopausal bleeding Menorrhagia Intermenstrual bleeding Prolonged menses Decreased menstrual interval Oligomenorrhea/amenorrhea
What does endometrial hyperplasia look like on u/s?
> 4mm of endometrial thickness
Besides u/s, what are other dx tests of endometrial hyperplasia?
Pelvic exam
Endometrial biopsy
D&C, hysteroscopy
How do you treat hyperplasia w/out atypia?
Mirena
Provera
Reassess w/ EMB
How do you treat atypical hyperplasia?
Hysterectomy = tx of choice
Progesterone therapy
What is the MC pelvic genital CA?
Endometrial CA
What population is most affected by endometrial CA?
50-69 yo
White women
What are RFs of endometrial CA?
Same RFs as endometrial hyperplasia!
OBESITY = #1
Describe type I vs type II endometrial CA
Type I: arise due to unopposed endo/exogenous estrogen, better prognosis
Type II: seen w/ endometrial atrophy, poor prognosis
What is the MC type of endometrial CA?
Adenocarcinoma
What 2 types of endometrial CA are NOT associated w/ hyperestrogenic state?
Serous carcinoma
Clear cell carcinoma
What is the clinical presentation of endometrial CA?
Abnormal vag bleeding Abd cramping Back pain Wt loss Dyspareunia
Who should you screen for endometrial CA?
Women w/ lynch syndrome
How do you dx endometrial CA?
- CBC
- Transvag u/s
- Endometrial biopsy
- D&C
- Pap
- CA-125 (elevated extrauterine spread)
- MRI/CT
How do you treat endometrial CA?
Hysterectomy w/ B/L salpingo-oophorectomy w/ pelvic & periaortic lymphadenectomy
Chemo & radiation
