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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
surgical tx options for uterine fibroids (5)
**Hysteroscopic** resection **Endometrial ablation** **Laparoscopic** myomectomy **Abdominal** myomectomy Laparoscopic **radiofrequency ablation**
26
Other tx options for uterine fibroids
Uterine **artery embolization** Magnetic resonance-guided focused ultrasonography **(MRgFUS)**
27
How will Depot Lupron (GnRH agonist) help tx uterine fibroids?
**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\*\***_
28
steroidal therapies indicated for which patients?
Indicated for patients with **prolonged, heavy menses with no submucosal fibroids:** Oral contraceptive pills ¢Mirena® IUD ¢Ortho Evra ® ¢NuvaRing ®
29
when is Lysteda indicated for tx?
Indicated for patients with **prolonged, heavy menses with no submucosal fibroids**
30
Which medication is an **oral antifibrinolytic for menorrhagia** and is used **only durng the menstrual cycle**?
Lysteda (tranexamic acid)
31
What is the main functionof the myomectomy
preserves fertility/uterus
32
Performed on **intramural, subserosal and pedunculated fibroids** Perform when **Pressure symptoms present** Which procedure?
Uterine fibroids
33
Imp information to rmr regarding myomectomy
Delay pregnancy 3-6 mos: C-section 2o to uterine rupture
34
complications of laparoscopic myomectomy
**hemorrhage** re-operation **adhesions** **vascular and visceral injuries**
35
žAbdominal or Mini-laparotomy Myomectomy: Candidates
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
Hysteroscopy indications
**Preserves fertility/ uterus** Only performed on **submucosal fibroid**s **Type 0 or 1** associated with **menorrhagia**
37
risks with hysteroscopy
fluid overload hyponatremia
38
What pt education will you provide your pt who just finished their **hysteroscopy?**
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
Main points about **Endometrial Ablation**
cavity should be **\<9cm to prevent recurrence of menses** pt must continueu a contracepive
40
Main pros of endometrial ablation
no fluid overload procedure takes \<2 min & pt goes home in 1-2 hrs can be performed at anytime during the menstrual cycle
41
Endometrial ablation CONS
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
Main points about Uterine Artery Embolization (UAE)
**preserves uterus; not fertility** identifies **blood supply to fibroid** catheter is placed into uterine artery **embolizing agent infused** until blood flow ceases
43
Candidates for UAE
pt does not desire future childbearing numerous and large fibroids
44
SE's and complications of UAE
**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
Growth of endometrial glands and stroma into **uterine myometrium** Pathophys of what dz?
adenomyosis
46
**Ovarian hormones** implicated in process **Invagination of endometrium**: Myometrium weakens with degeneration Associated with **parity**: **C-Section** Causes of what dz?
Adenomyosis
47
**žMenorrhagia** **žDysmenorrhea** **žPelvic pain** žHistory of **previous uterine surgery**: C – section, Prior myomectomy Clinical px of what condition?
adenomyosis
48
What will you see on PE of adenomyosis?
* žreveals **diffuse uterine enlargement:** * **Globular** * Size doesn’t usually exceed \> 12w gestation
49
What is the definitive dx of adenomyosis?
žrequires **histologic examination** after hysterectomy
50
**T/F:** žImaging can aid in diagnosis but there is no standardized criteria for adenomyosis
TRUE
51
adenomyosis medical tx options
Oral contraceptive pills Mirena® IUD NuvaRing®
52
surgical tx options for adenomyosis
**Hysterectomy:** Definitive treatment **Uterine artery embolization**
53
definitive tx for adenomyosis
hysterectomy
54
main risk factor for endometrial hyperplasia
**OBESITY**
55
Other RFs for endometrial hyperplasia
**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
WHat two categories does WHO separate endometrial hyperplasia into?
1. Hyperplasia **without atypia (non-neoplastic)** 2. **Atypical hyperplasia** (endometrial intraepithelial neoplasia)
57
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?
endometrial hyperplasia
58
žAsymptomatic **žPost-menopausal bleeding** žMenorrhagia **žIntermenstrual bleeding** **žProlonged menses (\> 7d)** **žDecreased menstrual interval (\< 21d)** Sx of what condition?
endometrial hyperplasia
59
What do you perform on the PE of endometrial hyperplasia?
pelvic exam/US Assess **endometrial thickness**: **_\< 4mm, malignancy is unlikely_** **žEndometrial biopsy** **žD&C, hysteroscopy**
60
**endometrial hyperplasia w/o atypia** tx
**Mirena IUD** **Provera** 10mg QD for 3 – 6mos **Reassess with EMB** (endometrial biopsy) to ensure resolution
61
**endometrial hyperplasia w/ atypia** tx
Hysterectomy is **treatment of choice** Progesterone therapy: **Megestrol acetate** (Megace) 40 – 80mg BID, **Mirena IUD**
62
What do you want to make sure with the pt before doing a hysterectomy for atypical hyperplasia?
she has completed childbearing and does not plan to have anymore children
63
follow up regimen with progesterone therapy for atypical hyperplasia
reasses q 3 mos until resolution
64
What is the MC pelvic genital CA?
endometrial CA
65
Main RF for endometrial CA
**_OBESITY_**
66
**Estrogen** is implicated as **causative factor** **Exogenous estrogens** VS. alterations in estrogen metabolism **Anovulatory cycles** Progression from **endometrial hyperplasia** Pathophys of what condition?
endomterial hyperplasia
67
Types of Endometrial CA
Type I Type II
68
Type I endometrial CA
Arise due to **unopposed endogenous or exogenous estrogen** **Favorable prognosis** due to **well-differentiated tumors**
69
Type II Endometrial CA
**Arise independently of estrogen** and seen with **endometrial atrophy** ## Footnote **Poorly differentiated with poor prognosis**
70
What is the MC type of endometrial CA?
adenocarcinoma
71
Which types of endometrial CA is NOT associated with hyperestrogenic state?
Serous carcinoma clear cell carcinoma
72
**Abnormal vaginal bleeding** Abdominal cramping **Back pain** Weight loss Dyspareunia **Screening recommended in women with Lynch Syndrome (aka HNPCC)** Clinical px of which dz?
endometrial cancer
73
Dx of endometrial CA
žCBC žTransvaginal ultrasound (TVU) žEndometrial Biopsy (EMB) žD&C žPap smear **žCA-125: Elevated with extrauterine spread** žMRI/CT
74
tx of endometrial CA
ž**Hysterectomy 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

GK F3E5 (19 decks)

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