Uterine Disorders Flashcards
Irregular uterine bleeding in the absence of identifiable pelvic pathology, medical disease or pregnancy?
Abnormal Uterine Bleeding (AUB).
Condition of EXTRAUTERINE presence of endometrial tissue (glands/stroma) influenced by hormonal changes and respond to similarly to uterine cells?
Endometriosis.
The most common benign tumor of the uterus due to overgrowth of smooth muscle and connective tissue?
Leiomyoma – aka “FIBROID.”
Epidemiology for Abnormal uterine bleeding?
- Adolescence (< 20) = 20%.
- -Immature hypothalamus results in failure of HPO Axis to respond to +Feedback of estrogen. - Reproductive age (20-40) = 30%.
- -PCOS, Premature Ovarian Failure. - Menopause (40-50+) = 50%
- -due to impending ovarian failure.
Epidemiology for Endometriosis
- 3-10% of reproductive age.
- Typical pt – 30’s, nulliparous and infertile.
- 7% of pt.’s with 1st degree relative.
Epidemiology for Leiomyoma
- Usually Asymptomatic.
- Approx. 50% of AAs and 30% of Caucasians.
- Rare before puberty and shrink after menopause.
- Estrogen dependent and may grow during HRT and pregnancy.
What is another name for Leiomyoma?
Fibroids.
Clinical presentation of Abnormal Uterine Bleeding?
- Unpredictable; excessively heavy or light, prolonged, frequent or random bleeding; despite normal pelvic exam.
- Anovulatory – adrenal enzyme defects, hyperprolactinemia, thyroid disease or other metabolic disorder.
Clinical presentation of Leiomyoma?
- Usually Asymptomatic, but can cause Sx.
- Heavy menstrual bleeding.
- Menstrual periods > 1 week.
- Pelvic pressure or pain.
- Frequent urination.
- Difficulty emptying the bladder.
- Constipation.
- Backache or leg pains.
Diagnostics for Abnormal Uterine Bleeding?
- Pelvic U/S:
- -Endometrial hyperplasia/cancer.
- -Endometrial Polyps.
- -Uterine Fibroids. - Procedures:
- -Hysterosalpingography.
- -Hysteroscopy +/- D and C.
- -Sonohysterography.
Diagnostics for Endometriosis?
- LAPAROSCOPY.
- Histology.
- LABS:
- -CBC w/Diff to diff. pelvic infx from endometriosis.
- -UA and Urine Culture to diff. UTI.
- -Cervical Gram stain and cultures to diff. STIs. - Imaging (pelvic or adnexal mass’).
- -U/S: transvaginal or endorectal.
- -MRI.
Diagnostics for Leiomyoma?
- Pelvic Exam:
- -Enlarged, irregular uterus w/one or more smooth, spherical, firm masses. - Pelvic U/S.
- CBC, Pregnancy Test.
- Endometrial Bx if >35 y/o w/abnormal bleeding.
Describe the management of Abnormal Uterine Bleeding?
- OCPs.
- Estrogen-only.
- Progestin-only.
- Desmopressin.
Describe the management of Asymptomatic Leiomyoma?
OBSERVATION.
Risk factors for Endometriosis?
- Nulliparity.
- Infertility.
- Reproductive age.
- 1st degree relative w/endometriosis.
- Regular menstrual cycles <27 days.
- Prolonged menses of >8 days.
Name the common sites for endometriosis?
- OVARIES is the most common site.
- Posterior cul-de-sac (Pouch of Douglas).
- Broad ligaments.
- Uterosacral ligament.
- Rectosigmoid colon.
- Bladder.
- Distal Ureter.
What is the retrograde menstruation theory in regards to the pathogenesis of Endometriosis?
Retrograde flow of menstrual product via fallopian tubes – implants on pelvic and abdominal structures.
What is the Mullerian metaplasia theory in regards to the pathogenesis of Endometriosis?
Metaplastic transformation of peritoneal mesothelium into endometrium under influence of an unidentified stimuli.
What is the pathogenesis of hematogenous or lymphatic spread in regards to Endometriosis?
Endometrial tissue taken up into lymphatics draining the uterus and transported to various pelvic sites where it grows topically – pelvic sites in 20% of pt’s.
How many pt’s with Endometriosis are asymptomatic?
1/3.
What is the TRIAD of pain associated with Endometriosis?
- Dysmenorrhea.
- Dyspareunia.
- Dyschezia.
Name other S/Sx of Endometriosis besides the triad of pain?
- Heavy or irregular bleeding.
- Pelvic pain.
- Lower abd or back pain.
- Bloating, N/V.
- Inguinal pain.
- Pain on micturition (dysuria) and/or urinary frequency.
- Pain during exercise.
- Triad of pain.
What is Dyschezia?
Excessive straining with stools; involved cycles of diarrhea and constipation.
Physical exam findings associated with Endometriosis?
- Tender, fixed adnexal (area where uterus occupies) mass – CHARACTERISTIC.
- Small, exquisitely tender nodule in CUL-DE-SAC or Uterosacral ligaments.
- Hugh, NONTENDER, CYSTIC abd. mass.
- Small, tender MULBERRY-like spot on posterior vaginal fornix.
- Asymptomatic.
What is the primary diagnostic modality for Endometriosis?
Laparoscopy – sensitivity of 97%, specificity of only 77%.
Goal of medical mgmt of Endometriosis?
Amenorrhea.
What does treatment of Endometriosis depend on?
On the certainty of diagnosis, severity of Sx, extent of disease, desired future fertility, pt. age, threat to GI or GU Tract or both.
Medical management (2 options) for Endometriosis?
- 1st line: NSAIDs, OCPs, progestins.
- 2nd line: GnRH agonist (temporary medical castration), higher-dose progestins, Danazol.
What are the benefits of OCPs in Endometriosis?
Inhibition of ovulation; reduces dysmenorrhea.
Benefit of Progestin-only therapy in Endometriosis?
Suppresses estrogenic stimulation of ectopic endometrial tissue; reduces dysmenorrhea.
What is the most definitive medical management option for Endometriosis?
GnRH Agonists.
- Utilized when refractory to other meds.
- Prevents estrogen production from ovary (medical castration).
*AE: hot flashes, sweating, vaginal dryness/vaginitis, HA, decr. libido, depression, emotional liability, bone loss.
Danazol MOA and MC adverse effect?
- “Anti-estrogen” that suppressed growth of ectopic endometrial tissue.
- MC AE: Acne.
What is the definitive treatment for Endometriosis?
A total hysterectomy w/bilateral salpingo-oophorectomy, destruction of all peritoneal implants and dissection of adhesions.
Invasive endometriotic lesions/cysts on the extrauterine sites? What may it cause?
Endometrioma that may cause extensive pelvic adhesions.
What is characteristic of endometrioma and what are they?
“Chocolate Cysts.”
-Chocolate-colored, bloody fluid sometimes with a black/tarry consistency.
What is considered normal menstrual blood loss and what is considered excessive?
- Approx. 30 cc; 80% total loss in the 1st 2 days.
2. Greater than 80 cc.
Define normal menses?
Interval 28 +/- 7 days, blood loss < 80cc.
Define Menorrhagia?
Excessive bleeding at the time of the menstrual period or prolonged bleeding.
Define Metrorrhagia?
Bleeding occurring irregularly between menstrual cycles, usually not excessive.
Define Menometrorrhagia?
Prolongation of the menstrual flow, typically excessive with irregular intermenstrual bleeding.
Define Polymenorrhea?
Menstrual interval < 21 days.
Define Oligomenorrhea?
Menstrual interval > 35 days.
What is Abnormal Uterine bleeding typically caused by?
Ovulatory dysfunction.
*It reflects disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining.
What is the DDx mnemonic of Abnormal/Dysfunctional Uterine Bleeding?
“PALM COEIN.”
- Polyp/pregnancy.
- Adenomyosis.
- Leiomyoma.
- Malignancy/hyperplasia/meds.
- Coagulopathy.
- Ovulatory Dysfunction.
- Iatrogenic.
- Not yet classified.
Etiology of Abnormal/Dysfunctional Uterine Bleeding?
- Estrogen breakthrough bleeding:
- -AUB assoc. w/anovulatory cycles — no corpus luteal formation, thus no production of progesterone — endometrium continues to proliferate (unopposed estrogen).
- -Assoc. bleeding often prolonged and heavy. - Estrogen withdrawal bleeding:
- -Perimenopausal women (length of menstrual cycle shortened with shortened proliferative phase) — ovarian follicles secrete LESS Estradiol, which results in insufficient endometrial proliferation w/irregular menstrual shedding.
- -Bleeding might be light, irregular spotting.
- -Duration of the luteal phase shortens and ovulation stops — results in irregular menstrual shedding. - Progestin-only OCPs.
- Immature HPT Axis (Adolescents):
- -Failure to mount an ovulatory LH surge in response to rising estradiol levels. - Climacteric – anovulation; peri/menopause.
- Bleeding disorders.
What should you suspect if a pt has had AUB since menarche?
PCOS – Polycystic ovarian syndrome.
What is the hallmark finding of AUB?
A NEGATIVE Pelvic Exam.
What do we need to further evaluate during examination of someone who presents with AUB?
- Obesity (BMI).
- Signs of Androgen excess (hirsutism, Acne).
- Thyromegaly (Hypo/Hyperthyroidism).
- Galactorrhea (Hyperprolactinemia).
- Visual field defects (intracranial/pituitary lesion).
- Ecchymosis, purpura (bleeding disorders).
- Signs of anemia or chronic blood loss.
What will most endometrial biopsy specimens show?
Proliferative or Dyssynchronous endometrium.
What is the invasive mgmt of Endometriosis?
- Hysteroscopy +/- D and C.
- Endometrial Ablation.
- Hysterectomy.
Patient education of Endometriosis?
- Most bleeding stops with appropriate hormonal treatment.
- Adolescent females often establish a predictable ovulatory pattern over time.
- Keep a good menstrual calendar to document daily bleeding patterns.
- -Severity of blood loss, impact on ADLs.
Common locations for Leiomyoma?
- Intramural or inside muscular uterine wall.
- Subserosal or grows outside of uterine wall.
- Submucosal or bulge into the uterine cavity and can cause uterine bleeding.
Describe the management of Symptomatic Leiomyoma?
- Progestin releasing IUD:
- -Can relieve heavy bleeding. - Danazol, GnRH analogs (Lupron, Zolodex) or OCPs.
- -GnRH treat Fibroids by blocking the production of estrogen and progesterone.
- -Temporary menopausal like state; menstruation stops, fibroids shrink, and anemia can improve.
* *Typically, used for 3-6 months, can cause bone loss.
Surgical mgmt of Leomyoma?
- TAH (Total Abdominal Hysterectomy), Myomectomy.
- Uterine Artery Embolization.
- -Small embolic particles injected into the arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die. - Hysterectomy Myomectomy:
- -If fibroids are mucosal.
- -Access and remove fibroids using instruments inserted through the vagina and cervix into the uterus.
