Uterine Disorders Flashcards
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?
endometriosis
_______ is a RF for epithelial ovarian CA.
Endometriosis is a RF for epithelial ovarian CA.
endometriosis pathophys
Retrograde menstruation
Retrograde flow of endometrial tissue through fallopian tubes and peritoneum
Nulliparity
Prolonged exposure to endogenous estrogen
Heavy menstrual bleeding
Obstruction of menstrual outflow
DES exposure in utero
Height greater than 68 inches
Lower BMI
High consumption of unsaturated fat
RF of what condition?
endometriosis
Premenstrual 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**
Infertility
Dysmenorrhea
Dyspareunia
Clinical px of what dz
endometriosis
what will be present on physical exam of endometriosis (3)
Tenderness / nodules at posterior cul-de-sac
Fixed or retroverted uterus (secondary to adhesions)
Endometriomas cause adnexal masses or tenderness
endometriosis dx
CA-125
Imaging
Laparoscopy:
- Erythematous, petechial lesions on peritoneal surface
- Surrounding peritoneum thickened and scarred
- MC site of dz: Ovaries can demonstrate lesions or endometriomas (“chocolate cysts”)
Adhesions
what is this showing
“chocolate cysts” on laporoscopy
what must you consider when thinking about how to tx endometriosis
Clinical presentation
Symptom severity
Extent and location of disease
Reproductive plans
Age
Medication side effects
Surgical complication rates
Cost
mild endometriosis tx
Expectant management
NSAIDS +/- OCPs
mod-severe endometriosis tx
main goal interrupt stimulation of endometrial tissue
Combo OCP’s
Progestins (PO, IM or IUD)
Gonadotropic-releasing hormone agonists (GnRH): Depot Lupro
What do the combination OCP’s do?
Continuous cycle fashion
Causes atrophy of endometrial tissue
40-50% pregnancy rate after discontinuation
↓ risk of ovarian cancer
What do the GnRH agonists do?
Suppression of estrogen and progesterone by down-regulation of pituitary gland
6 - 12 month therapy –> add Norethindrone acetate to prevent bone loss
Other endometriosis txq
Danazol (androgen)
Aromatase inhibitors
Laparoscopic excision
Hysterectomy with bilateral salpingo-oophorectomy
Arise from smooth muscle cells within the uterine wall
Made up of collagen, smooth muscle, and elastin surrounded by a pseudocapsule
What dz?
uterine fibroid
uterine fibroids are 2-3x MC in which demographic & gender?
black women
seen earlier and grow faster
No evidence suggests estrogen causes myomas
Estrogen 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
Progesterone increases mitotic activity and possibly suppresses apoptosis within the tumor
Which dz pathophys?
uterine fibroids
uterine fibroids classification:
submucosal
subserosal
intramural
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
What are these?
uterine fibroids
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?
uterine fibroids
physical exam of uterine fibroids
Bimanual exam reveals uterine abnormalities: Enlargement, Irregular shape, Masses
labs/imaging for uterine fibroids
Transvaginal US
Saline-infused sonohysertogram
Hysteroscopy
MRI
H&H
T/F: There is no standard of care for fibroid treatment in the United States.
True
Medical tx options for uterine fibroids (4)
COCs/progestin
GnRH analogs
Steroid therapies (androgens)
Tranexamic acid
surgical tx options for uterine fibroids (5)
Hysteroscopic resection
Endometrial ablation
Laparoscopic myomectomy
Abdominal myomectomy
Laparoscopic radiofrequency ablation
Other tx options for uterine fibroids
Uterine artery embolization
Magnetic resonance-guided focused ultrasonography (MRgFUS)
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**_
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 ®
when is Lysteda indicated for tx?
Indicated for patients with prolonged, heavy menses with no submucosal fibroids
Which medication is an oral antifibrinolytic for menorrhagia and is used only durng the menstrual cycle?
Lysteda (tranexamic acid)
What is the main functionof the myomectomy
preserves fertility/uterus
Performed on intramural, subserosal and pedunculated fibroids
Perform when Pressure symptoms present
Which procedure?
Uterine fibroids
Imp information to rmr regarding myomectomy
Delay pregnancy 3-6 mos: C-section 2o to uterine rupture
complications of laparoscopic myomectomy
hemorrhage
re-operation
adhesions
vascular and visceral injuries
Abdominal 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
Hysteroscopy indications
Preserves fertility/ uterus
Only performed on submucosal fibroids
Type 0 or 1 associated with menorrhagia
risks with hysteroscopy
fluid overload
hyponatremia
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
Main points about Endometrial Ablation
cavity should be <9cm to prevent recurrence of menses
pt must continueu a contracepive
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
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
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
Candidates for UAE
pt does not desire future childbearing
numerous and large fibroids
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
Growth of endometrial glands and stroma into uterine myometrium
Pathophys of what dz?
adenomyosis
Ovarian hormones implicated in process
Invagination of endometrium: Myometrium weakens with degeneration
Associated with parity: C-Section
Causes of what dz?
Adenomyosis
Menorrhagia
Dysmenorrhea
Pelvic pain
History of previous uterine surgery: C – section, Prior myomectomy
Clinical px of what condition?
adenomyosis
What will you see on PE of adenomyosis?
- reveals diffuse uterine enlargement:
- Globular
- Size doesn’t usually exceed > 12w gestation
What is the definitive dx of adenomyosis?
requires histologic examination after hysterectomy
T/F: Imaging can aid in diagnosis but there is no standardized criteria for adenomyosis
TRUE
adenomyosis medical tx options
Oral contraceptive pills
Mirena® IUD
NuvaRing®
surgical tx options for adenomyosis
Hysterectomy: Definitive treatment
Uterine artery embolization
definitive tx for adenomyosis
hysterectomy
main risk factor for endometrial hyperplasia
OBESITY
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)
WHat two categories does WHO separate endometrial hyperplasia into?
- Hyperplasia without atypia (non-neoplastic)
- Atypical hyperplasia (endometrial intraepithelial neoplasia)
Estrogen stimulates proliferation of endometrium
Progesterone has anti-proliferative effects causing shedding of the endometrial lining
Unopposed estrogen leads to endometrial hyperplasia and atypia
Pathophys of what condition?
endometrial hyperplasia
Asymptomatic
Post-menopausal bleeding
Menorrhagia
Intermenstrual bleeding
Prolonged menses (> 7d)
Decreased menstrual interval (< 21d)
Sx of what condition?
endometrial hyperplasia
What do you perform on the PE of endometrial hyperplasia?
pelvic exam/US
Assess endometrial thickness: < 4mm, malignancy is unlikely
Endometrial biopsy
D&C, hysteroscopy
endometrial hyperplasia w/o atypia tx
Mirena IUD
Provera 10mg QD for 3 – 6mos
Reassess with EMB (endometrial biopsy) to ensure resolution
endometrial hyperplasia w/ atypia tx
Hysterectomy is treatment of choice
Progesterone therapy: Megestrol acetate (Megace) 40 – 80mg BID, Mirena IUD
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
follow up regimen with progesterone therapy for atypical hyperplasia
reasses q 3 mos until resolution
What is the MC pelvic genital CA?
endometrial CA
Main RF for endometrial CA
OBESITY
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
Types of Endometrial CA
Type I
Type II
Type I endometrial CA
Arise due to unopposed endogenous or exogenous estrogen
Favorable prognosis due to well-differentiated tumors
Type II Endometrial CA
Arise independently of estrogen and seen with endometrial atrophy
Poorly differentiated with poor prognosis
What is the MC type of endometrial CA?
adenocarcinoma
Which types of endometrial CA is NOT associated with hyperestrogenic state?
Serous carcinoma
clear cell carcinoma
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
Dx of endometrial CA
CBC
Transvaginal ultrasound (TVU)
Endometrial Biopsy (EMB)
D&C
Pap smear
CA-125: Elevated with extrauterine spread
MRI/CT
tx of endometrial CA
Hysterectomy with bilateral salpingo-oophorectomy with pelvic and periaortic lymphadenectomy
Radiation: Used in patients with contraindications to surgery, Advanced pelvic disease prior to TAH
Chemotherapy: Used infrequently, Patients with advanced disease
