Uterine disorders Flashcards

1
Q

What is endometriosis?

A

Endometrial glands & stroma outside endometrial cavity & uterine musculature

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2
Q

What is the cause of endometriosis?

A

Unknown, but maybe:

  • Retrograde menstruation
  • Deficient cellular immunity
  • Hereditary
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3
Q

What are RFs of endometriosis?

A
  • 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
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4
Q

What is the clinical presentation of endometriosis?

A
  • Premenstrual pelvic pain (SUBSIDES AFTER MENSES)
  • Infertility
  • Dysmenorrhea
  • Dyspareunia
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5
Q

What does endometriosis look like on PE?

A
  • Tenderness/nodules at posterior cul-de-sac
  • Fixed or retroverted uterus
  • Endometriomas –> adnexal masses or tenderness
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6
Q

How do you dx endometriosis?

A

CA-125
Imaging
Laparoscopy

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7
Q

What is seen on laparoscopy in endometriosis?

A
  • Erythematous, petechial lesions on peritoneum
  • Peritoneum thickened/scarred
  • Endometriomas on ovaries
  • Adhesions
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8
Q

How do you treat mild endometriosis?

A

Expectant management w/ NSAIDs +/- OCPs

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9
Q

What meds help to interrupt stimulation of endometrial tissue?

A

OCPs
Progestins
GnRH agonists

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10
Q

What are more drastic tx options for endometriosis?

A

Danazol
Aromatase inhibitors
Laparoscopic excision
Hysterectomy w/ B/L salpingo-oophorectomy

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11
Q

Where do uterine fibroids arise?

A

From SM cells within te uterine wall

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12
Q

What are uterine fibroids made of?

A

Collagen, SM, & elastin surrounded by pseudocapsule

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13
Q

What population experiences uterine fibroids?

A

20% childbearing age

MC in black women

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14
Q

What causes uterine fibroids?

A

Unknown

  • Estrogen is implicated in growth
  • Progesterone increases mitotic activity & possibly suppresses apoptosis within the tumor
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15
Q

How are uterine fibroids classified? (3)

A

By anatomic location within myometrium

  • Submucosal: beneath endometrium
  • Subserosal: at serosal surface
  • Intramural: within uterine wall
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16
Q

What is the clinical presentation of uterine fibroids?

A

Sx present in 35-50%
Sx occur due to location & size

  • Abnormal uterine bleeding
  • Pain
  • Pelvic pressure
  • Infertility
  • Spontaneous abortion
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17
Q

What uterine abnormalities are seen on the bimanual exam w/ respect to uterine fibroids?

A

Enlargement
Irregular shape
Masses

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18
Q

What labs & imaging are used to dx uterine fibroids?

A

Transvaginal u/s

Saline-infused sonohysterogram

Hysteroscopy

MRI

H&H

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19
Q

How do you treat uterine fibroids?

A

No standard of care. Sx drive tx of choice

Medical & surgical options available. See slide 27

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20
Q

What are 3 medical options for uterine fibroid tx?

A
  • Depot Lupron
  • Steroidal therapy
  • Lysteda
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21
Q

What are surgical options for tx of uterine fibroids?

A
  • Myomectomy (Laparoscopic or abdominal/mini-laparotomy)
  • Hysteroscopy
  • Endometrial ablation
  • Uterine artery embolization
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22
Q

Describe Depot Lupron

A

GnRH agonist

Decreases fibroid size

Decreases blood loss during surgery & improves anemia prior to surgery

Don’t use over 6mos

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23
Q

Steroidal therapies & Lysteda are indicated for patients w/…

A

prolonged, heavy menses w/ no submucosal fibroids

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24
Q

Describe Lysteda

A

Oral antifibrinolytic

50% decrease in menorrhagia

Use only during menstrual cycle

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25
Q

What is the benefit of a myomectomy or hysteroscopy?

A

Both PRESERVE FERTILITY/UTERUS

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26
Q

What is the disadvantage of a myomectomy?

A

Delays pregnancy 3-6mos

27
Q

What are complications of a laparoscopic myomectomy (robot assisted)?

A

Hemorrhage

Re-operation

Adhesions

Vascular/visceral injury

28
Q

What procedure is used for patients w/ contraindications to laparoscopy?

A

Abdominal or mini-laparotomy myomectomy

29
Q

What are contraindications to laparoscopy?

A

Large fibroid size

Prior pelvic or abd radiation

Severe hip disease

30
Q

What type of fibroids are removed during myomectomy vs hysteroscopy?

A

Myomectomy = intramural, subserosal, & pedunculated

Hysteroscopy = submucosal only

31
Q

What are 2 risks of hysteroscopy?

A

Fluid overload

Hyponatremia

32
Q

What are hysteroscopy post op instructions ?

A

Return to normal activities 1-2 days later

Sex after one month

33
Q

What are disadvantages of endometrial ablation?

A

No future childbearing
MUST CONTINUE CONTRACEPTIVE

Amenorrheic rate = 50%

34
Q

What are benefits to endometrial ablation?

A

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

35
Q

Describe uterine artery embolization (UAE)

A

Preserves uterus, but not fertility

Catheter placed into uterine artery & infused w/ embolizing agent

36
Q

Who are candidates for UAE?

A

Those who don’t want kids

37
Q

What is a contraindication to UAE?

A

Numerous or large fibroids

38
Q

What are side effects & complications of UAE?

A
  • Postembolization syndrome
  • Non-purulent vaginal discharge
  • Endometriosis & uterine infection
  • Recurrence
  • Embolization agent found in other tissues
  • Uterine necrosis, sepsis, bacteremia, death
39
Q

What is adenomyosis?

A

Growth of endometrial glands & stroma into uterine myometrium

40
Q

What causes adenomyosis?

A

Unknown

  • Ovarian hormones
  • Invagination of endometrium
  • Parity
41
Q

What is the clinical presentation of adenomyosis?

A

Menorrhagia
Dysmenorrhea
Pelvic pain
Hx of uterine surgery

42
Q

What does adenomyosis look like on PE?

A

Diffuse uterine enlargment on bimanual exam

43
Q

What does the definitive diagnosis require in adenomyosis?

A

Histologic exam after hysterectomy

44
Q

What imaging is used to aid in the dx of adenomyosis?

A

U/S

MRI

45
Q

What are medical options for treating adenomyosis? What do they do?

A

OCPs, Mirena, NuvaRing

Improve dysmenorrhea/menorrhagia

46
Q

What are surgical options for adenomyosis?

A

Hysterectomy (definitive tx)
UAE
Endometrial ablation

47
Q

What are RFs for endometrial hyperplasia?

A
Early menarch
Late menopause
Infertility, nulliparous
OBESITY!!!!
DM, PCOS
Tamoxifen 
Estrogen replacement
Hx of ovarian CA
Prior pelvic radiation 
Fam hx of lynch syndrome
48
Q

How does WHO classify endometrial hyperplasia?

A

Hyperplasia w/out atypia

Atypical hyperplasia

49
Q

What is the pathophys of endometrial hyperplasia?

A

Unopposed estrogen –> endometrial hyperplasia & atypia

50
Q

What is the clinical presentation of endometrial hyperplasia?

A
Asx
Post-menopausal bleeding
Menorrhagia
Intermenstrual bleeding 
Prolonged menses
Decreased menstrual interval 
Oligomenorrhea/amenorrhea
51
Q

What does endometrial hyperplasia look like on u/s?

A

> 4mm of endometrial thickness

52
Q

Besides u/s, what are other dx tests of endometrial hyperplasia?

A

Pelvic exam
Endometrial biopsy
D&C, hysteroscopy

53
Q

How do you treat hyperplasia w/out atypia?

A

Mirena
Provera
Reassess w/ EMB

54
Q

How do you treat atypical hyperplasia?

A

Hysterectomy = tx of choice

Progesterone therapy

55
Q

What is the MC pelvic genital CA?

A

Endometrial CA

56
Q

What population is most affected by endometrial CA?

A

50-69 yo

White women

57
Q

What are RFs of endometrial CA?

A

Same RFs as endometrial hyperplasia!

OBESITY = #1

58
Q

Describe type I vs type II endometrial CA

A

Type I: arise due to unopposed endo/exogenous estrogen, better prognosis

Type II: seen w/ endometrial atrophy, poor prognosis

59
Q

What is the MC type of endometrial CA?

A

Adenocarcinoma

60
Q

What 2 types of endometrial CA are NOT associated w/ hyperestrogenic state?

A

Serous carcinoma

Clear cell carcinoma

61
Q

What is the clinical presentation of endometrial CA?

A
Abnormal vag bleeding
Abd cramping
Back pain 
Wt loss
Dyspareunia
62
Q

Who should you screen for endometrial CA?

A

Women w/ lynch syndrome

63
Q

How do you dx endometrial CA?

A
  • CBC
  • Transvag u/s
  • Endometrial biopsy
  • D&C
  • Pap
  • CA-125 (elevated extrauterine spread)
  • MRI/CT
64
Q

How do you treat endometrial CA?

A

Hysterectomy w/ B/L salpingo-oophorectomy w/ pelvic & periaortic lymphadenectomy

Chemo & radiation