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SG F3 E5 > uterine disorders > Flashcards

uterine disorders Flashcards

1
Q

What is endometriosis

A

presence of endometrial glands and stroms outside the endometrial cavity and uterine musculature (MC pelvis) causing inflammation

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2
Q

Endometriosis is a risk factor for

A

epithelial ovarian cancer

can also cause infertility

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3
Q

What is the suspected etiology of endometriosis

A 
Retrograde menstruation (endometrial tissue goes retrograde through fallopian tubes and peritoneum 
-Deficient cell immunity, heredity
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4
Q

RF for endometriosis are

A 
nulliparity 
heavy menstrual bleeding 
prolonged exposure to estrogen 
DES exposure in utero
>68 inches in height 
low BMI 
high unsaturated fat consumption
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5
Q

How do women with endometriosis present

A 
premenstrual pelvic pain (lesions stimulated by estrogen/progesterone) 
Pelvic pain SUBSIDES after menses 
infertility (30-40%) 
Dysmenorrhea 
Dyspareunia 
Rectal pain w/ bowel movements
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6
Q

what is the difference between vulvodynia and dyspareunia

A

Dys: pain with deep penetration
Vulvo: pain with insertion

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7
Q

PE findings indicating endometriosis incllude

A

ttp/nodules in posterior coldesac
fixed or retroverted uterus 2/2 adhesions
adnexal mass ttp

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8
Q

How do you diagnose endometriosis

A

Need laparoscopy for solid Dx

Imaging and CA-125 can help support

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9
Q

On laparoscopy, what will endometriosis show

A

erythematous, petechial lesions on peritoneum
thick, scarred surrounding peritoneum
lesions/endometriomas (chocolate cysts) on ovaries
adhesions

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10
Q

MC site of endometriosis is

A

The ovaries

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11
Q

How do you treat mild endometriosis

A

expectant management

NSAIDS +/- OCP (can skip menses all together by stringing packs)

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12
Q

How do you treat mod-severe endometriosis

A 
OCP (string)- can atrophy endometrium
Progestins (PO, IM, IUD)- prevent endometrial growth 
GnRH agonists (Depot Lupron) suppress estrogen/progesterone
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13
Q

Other endometriosis treatments are

A

Danazol
Aromatase inhibitors
Laparoscopic excision
Hysterectomy w/ b/l salpingo-oopherectomy

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14
Q

Endometriosis treatment considerations include

A 
clinical presentation 
Sx severity 
extent and location fo dz 
reproductive plans 
age
med ADE 
surgical compliance rates 
cost
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15
Q

Good effects of OCP in endometriosis are

A

40-50% pregnancy rate after d/c

decrease risk of ovarian cancer

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16
Q

What are uterine fibroids

A

proliferation of smooth muscle cells in uterine wall

made up of collagen, smooth muscle, and elastin, surrounded by pseudocapsule

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17
Q

What group of women typically gets uterine fibroids

A

20-25% in women of child-bearing age
50% of populaiton have them by age 50
Seen earlier and grow faster
2-3x MC in black women

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18
Q

What is the implicated etiology of uterine fibroids

A
  • Estrogen; myomas have higher concentration of estrogen receptors= increased production of extracellular matrix
  • Progesterone increases mitotic activity, suppresses apoptosis
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19
Q

How can you classify uterine fibroids

A

Submucosal: just beneath endometrium (more inwards)
Subserosal: serosal surface (more outwards)
Intramural: w/in uterine wall

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20
Q

Which uterine fibroids are associated with infertility

A

Submucosal- impinge uterine cavity

also increase surface area of endometrium and also cause menorrhagia

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21
Q

What are symptoms of uterine fibroids

A 
Abn uterine bleeding 
pain (contractions, dyspareunia) 
pelvic pressure (mass effect) 
infertility (submucosal) 
spontaneous abortion
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22
Q

On bimanual exam of uterine fibroids you may find

A

uterine enlargement
irregular shape
mass (NOT fluctuant)

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23
Q

How do you diagnose uterine fibroids

A 
#1: Transvaginal US 
saline infused sonohysterogram 
hysteroscopy 
MRI 
H&H
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24
Q

Is there one specific way to Tx uterine fibroids

A

no standard of cure, let Sx drive Tx

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25
Q

Medical Tx options for uterine fibroids are

A 
#1: Steroidal (OCP, Mirena, ortho-evra, nuvaring) 
COC, progestin
GnRH analog (Depot Lupron) 
Tranexamic acid (Lysteda)
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26
Q

Surgical options for treating uterine fibroids are

A

Hysteroscopic resection
Endometrial ablation
Laparoscopic myomectomy
Laparoscopic radiofrequency ablation

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27
Q

Other Tx for uterine fibroids are

A

uterine artery embolization

MRU

28
Q

How does Depot Lupron treat uterine fibroids

A

decreases fibroid size (bc they are associated w/ estrogen)
also helps improve anemia before, and decrease blood loss during surgery
DO NOT USE >6 months

29
Q

Who can use steroidal therapies to Tx uterine fibroids

A

prolonged, heavy menses

NO submucosal fibroids

30
Q

Who can take Lysteda and how does it work

A

prolonged, heavy menses W/O submucosal fibroids
PO anti-fibrinolytic for menorrhagia (decrease blood loss, little evidence on fibroid effects)
USE ONLY during menses, two 650mg tab BID (total 1300)

31
Q

What surgical option for uterine fibroid removal is good for preserving Fertility and the uterus

A

-Myomectomy- on intramural, subserosal, and pedunculated fibroids (20-50% recurrence)
but, delay pregnancy 3-6 mo to avoid uterine rupture and c-section
-Hysteroscopy- submucosal fubroids. has risk of fluid overload and hyponatremia

32
Q

Wat is a laparoscopic myomectomy

A

robot assistance myomectomy depending on number and size of fibroids
Complications: hemorrhage, re-op, adhesions

33
Q

What uterine fibroid patients are candidates for abdominal/mini-laparotomy myomectomy

A

those with CI to laparoscopy (cardiopulmonary dsease)
if fibroid size doesn’t allow laparoscopic
Hx of pelvic or abdominal radiation
Severe hip dz

34
Q

How do you perform a hysteroscopy

A

give a non-iodine solution to distend (1.5% glycine or 3% sorbitol)
use a heated loop to resect the fibroid
can be done outpt, can return to normal activity in 1-2 days, sex in 1 month

35
Q

What is endometrial ablation

A

min invasive method to preserve uterus, takes 2 min.
done outpt. at any time in menstrual cycle (general anesthesia or cervical block)
Admin CO2 for distention
Tx for menorrhagia w/o major uterine distortions (best if <9cm)

36
Q

If you have had an endometrial ablation, can you have kids?

A

You should NOT bear children, but use contraceptives because if you do get pregnant it can implant into the muscle wall (placenta accreta)

37
Q

Con’s to endometrial ablation include

A

must first remove polyps and submucosal fibroids (does not distort the uterus)
doesn’t address fibroid Sx
50% experience amenorrhea

38
Q

What is uterine artery embolization

A

arteriogram to ID blood supply to fibroid
cath goes into uterine artery and embolizing agent flows in
Preserves the uterus NOT fertility!

39
Q

What pts are candidates for uterine artery embolization

A

If they do not want kids

40
Q

Who is a uterine artery embolization contraindicate in

A

pts with many and large fibroids

41
Q

ADE of uterine artery embolization are

A

post-embolization syndrome (overnight hospital stay)
NON-purulent vag discharge
uterine infection
10-15% recurrence
embolization can reach ovaries (premie ovarian failure)
uterine necrosis, sepsis, bacteremia, death

42
Q

What is adenomyosis

A

growth of endometrial glands and stroma into MYOmetrium

43
Q

What are suspected etiologies of adenomyoma

A

ovarian hormones
invagination of endometrium (it weakens with degeneration)
Parity (C-section)

44
Q

How does adenomyoma present

A

menorrhagia
dysmenorrhea
pelvic pain
Hx of previous uterine surgery (c-section, myomectomy)

45
Q

On adenomyoma bimanual exam, you are likely to see

A

diffuse uterine enlargement, symmetric (globular), not larger than 12 wk gestation

46
Q

Definitive Dx of adenomyosis is based on

A

histology after hysterectomy

imaging only AIDS Dx (US, MRI)

47
Q

Medical Tx options for adenomyoma are

A

OCP, Mirena, Nuvaring

-improve dysmenorrhea and menorrhagia

48
Q

Durgical Tx options for adenomyoma are

A

Definitive Tx: hysterectomy
Uterine artery embolization
endometrial ablation (high fail rate), painful

49
Q

RF for endometrial hyperplasia are

A 
OBESITY!!!!!!!! high fat= high estrogen
early menarche, late menopause (estrogen exposure)
infertility 
nulliparous 
Hx of Tamoxifen Tx (breast cancer) 
unopposed estrogen Tx 
diabetes 
PCOS 
PMHx breast or ovarian cancer, or radiation for pelvic CA
FHx lynch syndrome
50
Q

Current WHO classification for endometrial hyperplasia is

A

hyperplasia without atypia (non-neoplastic)

atypical hyperplasia

51
Q

What is the pathophys behind endometrial hyperplasia

A

estrogen stimulates endometrial proliferation
progesterone is anti-proliferative (shedding)
unoposed estrogen= hyperplasia and atypia

52
Q

How does endometrial hyperplasia typically present

A 
asymptomatic! 
post-menopausal bleeding
menorrhagia 
intermenstrual bleeding 
prolonged menses (>7d) 
decreased menstrual interval (<21 days) 
oligomenorrhea, amenorrhea
53
Q

What PE is important to do for endometrial hyperplasia

A 
pelvic exam 
pelvic US (thick endometrium) 
endometrial biopsy 
D&amp;C
hysteroscopy
54
Q

what endometrial thickness is a good sign

A

<4mm, malignancy is NOT likely

55
Q

How do you treat endometrial hyperplasia W/O atypia

A

Mirena (progestin)
Depo-Provera
-reassess with EMB to ensure resolution

56
Q

How do you treat atypical endometrial hyperplasia

A

1: hysterectomy (if done having kids)- bc 50% have cancer

-Progesterone therapy- megestrol acetate, Mirena
(reassess q3 mos until resolved)

57
Q

What is the MC pelvic genital cancer

A

endometrial cancer
4th MC female cancer
Typical onset: 50-69
White>Black

58
Q

RF for endometrial cancer are (hint: same as hyperplasia)

A 
Obesity 
early menarche, late menopause 
infertility 
nulliparous 
Tamoxifen Tx 
Dm, PCOS 
PMHx breast or ovarian cancer, radiation 
FHx lynch syndrome 
unopposed estrogen therapy
59
Q

What is the pathophys behind endometrial cancer

A

estrogen is implicated
usually evolves from hyperplasia
-Exogenous estrogen, anovulatory cycles, altered estrogen metabolism

60
Q

What are the types of endometrial cancer

A

I: arise from unopposed estrogen. good prognosis. well differentiated
II: arise independent of estrogen, seen w/ endometrial atrophy. poorly differentiated. poor prognosis

61
Q

What are the classifications of endometrial cancer

A
  • Adenocarcinoma (MC)
  • adenocarcinoma w/ squamous differentiation
  • Serous carcinoma (not estrogen associated)- bad prognosis
  • Clear cell carcinoma (not estrogen associated)- high grade, deep invasion
62
Q

Endometrial cancer staging is based on

A

FIGO (international federation of gyno and obs)

63
Q

How does endometrial cancer present

A 
***abnormal vaginal bleeding (menorrhagia, intermenstrual, PMB) 
abd cramping 
back pain 
weight loss 
dyspareunia
64
Q

When is endometrial cancer screening recommended

A

in women with Lynch syndrome (HNPCC)

65
Q

How do you diagnose endometrial cancer

A 
CBC 
Transvaginal US 
Endometrial biopsy 
D&amp;C 
pap smear 
CA-125 (high w/ extra-uterine spread) 
MRI/CT
66
Q

How do you treat endometrial cancer

A

Hysterectomy w/ b/l salpingo-oopherectomy
radiation (if surgery CI, pr advanced pelvic dz)
Chemo (not common, good for advanced dz)

SG F3 E5 (23 decks)

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