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GK F3E5 > Uterine Disorders > Flashcards

Uterine Disorders Flashcards

1
Q

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

Causes an inflammatory response

Usually located in the pelvis

Which condition?

A

endometriosis

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2
Q

_______ is a RF for epithelial ovarian CA.

A

Endometriosis is a RF for epithelial ovarian CA.

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3
Q

endometriosis pathophys

A

Retrograde menstruation

Retrograde flow of endometrial tissue through fallopian tubes and peritoneum

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4
Q

žNulliparity

žProlonged exposure to endogenous estrogen

žHeavy menstrual bleeding

žObstruction of menstrual outflow

žDES exposure in utero

žHeight greater than 68 inches

žLower BMI

žHigh consumption of unsaturated fat

RF of what condition?

A

endometriosis

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5
Q

žPremenstrual pelvic pain: Lesion growth stimulated by estrogen and progesterone. Lesions grow and are secretory but expansion is inhibited by surrounding fibrosis —> pressure and inflammation leads to pain

**PAIN SUBSIDES AFTER MENSES**

žInfertility

Dysmenorrhea

Dyspareunia

Clinical px of what dz

A

endometriosis

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6
Q

what will be present on physical exam of endometriosis (3)

A

žTenderness / nodules at posterior cul-de-sac

žžFixed or retroverted uterus (secondary to adhesions)

žžEndometriomas cause adnexal masses or tenderness

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7
Q

endometriosis dx

A

CA-125

žImaging

žLaparoscopy:

  • Erythematous, petechial lesions on peritoneal surface
  • Surrounding peritoneum thickened and scarred
  • MC site of dz: Ovaries can demonstrate lesions or endometriomas (“chocolate cysts”)

​ Adhesions

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8
Q

what is this showing

A

“chocolate cysts” on laporoscopy

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9
Q

what must you consider when thinking about how to tx endometriosis

A

Clinical presentation

Symptom severity

Extent and location of disease

Reproductive plans

Age

Medication side effects

Surgical complication rates

Cost

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10
Q

mild endometriosis tx

A

Expectant management

NSAIDS +/- OCPs

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11
Q

mod-severe endometriosis tx

A

main goal interrupt stimulation of endometrial tissue

Combo OCP’s

Progestins (PO, IM or IUD)

Gonadotropic-releasing hormone agonists (GnRH): Depot Lupro

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12
Q

What do the combination OCP’s do?

A

Continuous cycle fashion

Causes atrophy of endometrial tissue

40-50% pregnancy rate after discontinuation

↓ risk of ovarian cancer

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13
Q

What do the GnRH agonists do?

A

Suppression of estrogen and progesterone by down-regulation of pituitary gland

6 - 12 month therapy –> add Norethindrone acetate to prevent bone loss

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14
Q

Other endometriosis txq

A

žDanazol (androgen)

žAromatase inhibitors

žLaparoscopic excision

žHysterectomy with bilateral salpingo-oophorectomy

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15
Q

žArise from smooth muscle cells within the uterine wall

ž Made up of collagen, smooth muscle, and elastin surrounded by a pseudocapsule

What dz?

A

uterine fibroid

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16
Q

uterine fibroids are 2-3x MC in which demographic & gender?

A

black women

seen earlier and grow faster

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17
Q

žNo evidence suggests estrogen causes myomas

žžEstrogen is implicated in growth

Myomas contain higher concentration of estrogen receptors than what is observed in the surrounding myometrium

May cause enlargement by increased production of extracellular matrix

žžProgesterone increases mitotic activity and possibly suppresses apoptosis within the tumor

Which dz pathophys?

A

uterine fibroids

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18
Q

uterine fibroids classification:

submucosal

subserosal

intramural

A

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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19
Q

What are these?

A

uterine fibroids

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20
Q

Abnormal uterine bleeding: increased surface area of endometrium leading to menorrhagia (+/- Fe anemia)

Pain: Degeneration, myometrial contractions, dyspareunia

Pelvic Pressure: Mass effect, compression of surrounding organs

Infertility: Submucosal fibroids impingement of intrauterine cavity

Spontaneous abortion

Clinical px of what?

A

uterine fibroids

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21
Q

physical exam of uterine fibroids

A

Bimanual exam reveals uterine abnormalities: Enlargement, Irregular shape, Masses

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22
Q

labs/imaging for uterine fibroids

A

žTransvaginal US

žSaline-infused sonohysertogram

žHysteroscopy

žMRI

žH&H

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23
Q

T/F: žThere is no standard of care for fibroid treatment in the United States.

A

True

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24
Q

Medical tx options for uterine fibroids (4)

A

COCs/progestin

GnRH analogs

Steroid therapies (androgens)

Tranexamic acid

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25
Q

surgical tx options for uterine fibroids (5)

A

Hysteroscopic resection

Endometrial ablation

Laparoscopic myomectomy

Abdominal myomectomy

Laparoscopic radiofrequency ablation

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26
Q

Other tx options for uterine fibroids

A

Uterine artery embolization

Magnetic resonance-guided focused ultrasonography (MRgFUS)

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27
Q

How will Depot Lupron (GnRH agonist) help tx uterine fibroids?

A

Decreases fibroid size

Improves anemia prior to surgery

Decreases blood loss during surgery

Allows minimally invasive approach

May play primary role in treatment near menopause

_Not approved for use over 6 months**_

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28
Q

steroidal therapies indicated for which patients?

A

Indicated for patients with prolonged, heavy menses with no submucosal fibroids:

Oral contraceptive pills

¢Mirena® IUD

¢Ortho Evra ®

¢NuvaRing ®

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29
Q

when is Lysteda indicated for tx?

A

Indicated for patients with prolonged, heavy menses with no submucosal fibroids

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30
Q

Which medication is an oral antifibrinolytic for menorrhagia and is used only durng the menstrual cycle?

A

Lysteda (tranexamic acid)

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31
Q

What is the main functionof the myomectomy

A

preserves fertility/uterus

32
Q

Performed on intramural, subserosal and pedunculated fibroids

Perform when Pressure symptoms present

Which procedure?

A

Uterine fibroids

33
Q

Imp information to rmr regarding myomectomy

A

Delay pregnancy 3-6 mos: C-section 2o to uterine rupture

34
Q

complications of laparoscopic myomectomy

A

hemorrhage

re-operation

adhesions

vascular and visceral injuries

35
Q

žAbdominal or Mini-laparotomy Myomectomy: Candidates

A

Perform on patients with contraindications to laparoscopy

Cardiopulmonary disease

Fibroid size does not permit laparoscopic approach

Prior pelvic or abdominal radiation therapy

Severe hip disease precluding dorsolithotomy position

36
Q

Hysteroscopy indications

A

Preserves fertility/ uterus

Only performed on submucosal fibroids

Type 0 or 1 associated with menorrhagia

37
Q

risks with hysteroscopy

A

fluid overload

hyponatremia

38
Q

What pt education will you provide your pt who just finished their hysteroscopy?

A

return to normal daily activities 1-2 days later

return to sexual activity 1 mo post-op

conception and pregnancy outcomes vary depending on the size, location & # of fibroids

39
Q

Main points about Endometrial Ablation

A

cavity should be <9cm to prevent recurrence of menses

pt must continueu a contracepive

40
Q

Main pros of endometrial ablation

A

no fluid overload

procedure takes <2 min & pt goes home in 1-2 hrs

can be performed at anytime during the menstrual cycle

41
Q

Endometrial ablation CONS

A

no distortion of the uterine cavity is allowed so polyps & submucosal fibroids must be removed first

50% chance of experiencing amenorrhea

childbearing is rare after the procedure & repro outcomes are poor since endometrial lining is destroyed: placenta accreta

42
Q

Main points about Uterine Artery Embolization (UAE)

A

preserves uterus; not fertility

identifies blood supply to fibroid

catheter is placed into uterine artery

embolizing agent infused until blood flow ceases

43
Q

Candidates for UAE

A

pt does not desire future childbearing

numerous and large fibroids

44
Q

SE’s and complications of UAE

A

PES: post embolization syndrome

non-purulent vaginal discharge

endometritis and uterine infection

embolization agent found in ovaries: premature ovarian failure

uterine necrosis, sepsis, bacteremia & death

45
Q

Growth of endometrial glands and stroma into uterine myometrium

Pathophys of what dz?

A

adenomyosis

46
Q

Ovarian hormones implicated in process

Invagination of endometrium: Myometrium weakens with degeneration

Associated with parity: C-Section

Causes of what dz?

A

Adenomyosis

47
Q

žMenorrhagia

žDysmenorrhea

žPelvic pain

žHistory of previous uterine surgery: C – section, Prior myomectomy

Clinical px of what condition?

A

adenomyosis

48
Q

What will you see on PE of adenomyosis?

A
  • žreveals diffuse uterine enlargement:
    • Globular
    • Size doesn’t usually exceed > 12w gestation
49
Q

What is the definitive dx of adenomyosis?

A

žrequires histologic examination after hysterectomy

50
Q

T/F: žImaging can aid in diagnosis but there is no standardized criteria for adenomyosis

A

TRUE

51
Q

adenomyosis medical tx options

A

Oral contraceptive pills

Mirena® IUD

NuvaRing®

52
Q

surgical tx options for adenomyosis

A

Hysterectomy: Definitive treatment

Uterine artery embolization

53
Q

definitive tx for adenomyosis

A

hysterectomy

54
Q

main risk factor for endometrial hyperplasia

A

OBESITY

55
Q

Other RFs for endometrial hyperplasia

A

Early menarche (<12yo)

Late menopause (>52yo)

Infertility, nulliparous

Treatment with Tamoxifen for breast cancer

Unopposed estrogen replacement therapy

DM

PCOS

CA hx

Fam hx of Lynch Syndrome (HNPCC)

56
Q

WHat two categories does WHO separate endometrial hyperplasia into?

A
  1. Hyperplasia without atypia (non-neoplastic)
  2. Atypical hyperplasia (endometrial intraepithelial neoplasia)
57
Q

žEstrogen stimulates proliferation of endometrium

žProgesterone has anti-proliferative effects causing shedding of the endometrial lining

žUnopposed estrogen leads to endometrial hyperplasia and atypia

Pathophys of what condition?

A

endometrial hyperplasia

58
Q

žAsymptomatic

žPost-menopausal bleeding

žMenorrhagia

žIntermenstrual bleeding

žProlonged menses (> 7d)

žDecreased menstrual interval (< 21d)

Sx of what condition?

A

endometrial hyperplasia

59
Q

What do you perform on the PE of endometrial hyperplasia?

A

pelvic exam/US

Assess endometrial thickness: < 4mm, malignancy is unlikely

žEndometrial biopsy

žD&C, hysteroscopy

60
Q

endometrial hyperplasia w/o atypia tx

A

Mirena IUD

Provera 10mg QD for 3 – 6mos

Reassess with EMB (endometrial biopsy) to ensure resolution

61
Q

endometrial hyperplasia w/ atypia tx

A

Hysterectomy is treatment of choice

Progesterone therapy: Megestrol acetate (Megace) 40 – 80mg BID, Mirena IUD

62
Q

What do you want to make sure with the pt before doing a hysterectomy for atypical hyperplasia?

A

she has completed childbearing and does not plan to have anymore children

63
Q

follow up regimen with progesterone therapy for atypical hyperplasia

A

reasses q 3 mos until resolution

64
Q

What is the MC pelvic genital CA?

A

endometrial CA

65
Q

Main RF for endometrial CA

A

OBESITY

66
Q

Estrogen is implicated as causative factor

Exogenous estrogens VS. alterations in estrogen metabolism

Anovulatory cycles

Progression from endometrial hyperplasia

Pathophys of what condition?

A

endomterial hyperplasia

67
Q

Types of Endometrial CA

A

Type I

Type II

68
Q

Type I endometrial CA

A

Arise due to unopposed endogenous or exogenous estrogen

Favorable prognosis due to well-differentiated tumors

69
Q

Type II Endometrial CA

A

Arise independently of estrogen and seen with endometrial atrophy

Poorly differentiated with poor prognosis

70
Q

What is the MC type of endometrial CA?

A

adenocarcinoma

71
Q

Which types of endometrial CA is NOT associated with hyperestrogenic state?

A

Serous carcinoma

clear cell carcinoma

72
Q

Abnormal vaginal bleeding

Abdominal cramping

Back pain

Weight loss

Dyspareunia

Screening recommended in women with Lynch Syndrome (aka HNPCC)

Clinical px of which dz?

A

endometrial cancer

73
Q

Dx of endometrial CA

A

žCBC

žTransvaginal ultrasound (TVU)

žEndometrial Biopsy (EMB)

žD&C

žPap smear

žCA-125: Elevated with extrauterine spread

žMRI/CT

74
Q

tx of endometrial CA

A

žHysterectomy with bilateral salpingo-oophorectomy with pelvic and periaortic lymphadenectomy

žRadiation: Used in patients with contraindications to surgery, Advanced pelvic disease prior to TAH

žChemotherapy: Used infrequently, Patients with advanced disease

75
Q
A

GK F3E5 (19 decks)

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