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OB/Gyn > Uterine Disorders > Flashcards

Uterine Disorders Flashcards

1
Q

Irregular uterine bleeding in the absence of identifiable pelvic pathology, medical disease or pregnancy?

A

Abnormal Uterine Bleeding (AUB).

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2
Q

Condition of EXTRAUTERINE presence of endometrial tissue (glands/stroma) influenced by hormonal changes and respond to similarly to uterine cells?

A

Endometriosis.

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3
Q

The most common benign tumor of the uterus due to overgrowth of smooth muscle and connective tissue?

A

Leiomyoma – aka “FIBROID.”

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4
Q

Epidemiology for Abnormal uterine bleeding?

A
  1. Adolescence (< 20) = 20%.
    - -Immature hypothalamus results in failure of HPO Axis to respond to +Feedback of estrogen.
  2. Reproductive age (20-40) = 30%.
    - -PCOS, Premature Ovarian Failure.
  3. Menopause (40-50+) = 50%
    - -due to impending ovarian failure.
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5
Q

Epidemiology for Endometriosis

A
  1. 3-10% of reproductive age.
  2. Typical pt – 30’s, nulliparous and infertile.
  3. 7% of pt.’s with 1st degree relative.
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6
Q

Epidemiology for Leiomyoma

A
  1. Usually Asymptomatic.
  2. Approx. 50% of AAs and 30% of Caucasians.
  3. Rare before puberty and shrink after menopause.
  4. Estrogen dependent and may grow during HRT and pregnancy.
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7
Q

What is another name for Leiomyoma?

A

Fibroids.

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8
Q

Clinical presentation of Abnormal Uterine Bleeding?

A
  1. Unpredictable; excessively heavy or light, prolonged, frequent or random bleeding; despite normal pelvic exam.
  2. Anovulatory – adrenal enzyme defects, hyperprolactinemia, thyroid disease or other metabolic disorder.
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9
Q

Clinical presentation of Leiomyoma?

A
  1. Usually Asymptomatic, but can cause Sx.
  2. Heavy menstrual bleeding.
  3. Menstrual periods > 1 week.
  4. Pelvic pressure or pain.
  5. Frequent urination.
  6. Difficulty emptying the bladder.
  7. Constipation.
  8. Backache or leg pains.
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10
Q

Diagnostics for Abnormal Uterine Bleeding?

A
  1. Pelvic U/S:
    - -Endometrial hyperplasia/cancer.
    - -Endometrial Polyps.
    - -Uterine Fibroids.
  2. Procedures:
    - -Hysterosalpingography.
    - -Hysteroscopy +/- D and C.
    - -Sonohysterography.
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11
Q

Diagnostics for Endometriosis?

A
  1. LAPAROSCOPY.
  2. Histology.
  3. 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.
  4. Imaging (pelvic or adnexal mass’).
    - -U/S: transvaginal or endorectal.
    - -MRI.
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12
Q

Diagnostics for Leiomyoma?

A
  1. Pelvic Exam:
    - -Enlarged, irregular uterus w/one or more smooth, spherical, firm masses.
  2. Pelvic U/S.
  3. CBC, Pregnancy Test.
  4. Endometrial Bx if >35 y/o w/abnormal bleeding.
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13
Q

Describe the management of Abnormal Uterine Bleeding?

A
  1. OCPs.
  2. Estrogen-only.
  3. Progestin-only.
  4. Desmopressin.
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14
Q

Describe the management of Asymptomatic Leiomyoma?

A

OBSERVATION.

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15
Q

Risk factors for Endometriosis?

A
  1. Nulliparity.
  2. Infertility.
  3. Reproductive age.
  4. 1st degree relative w/endometriosis.
  5. Regular menstrual cycles <27 days.
  6. Prolonged menses of >8 days.
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16
Q

Name the common sites for endometriosis?

A
  1. OVARIES is the most common site.
  2. Posterior cul-de-sac (Pouch of Douglas).
  3. Broad ligaments.
  4. Uterosacral ligament.
  5. Rectosigmoid colon.
  6. Bladder.
  7. Distal Ureter.
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17
Q

What is the retrograde menstruation theory in regards to the pathogenesis of Endometriosis?

A

Retrograde flow of menstrual product via fallopian tubes – implants on pelvic and abdominal structures.

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18
Q

What is the Mullerian metaplasia theory in regards to the pathogenesis of Endometriosis?

A

Metaplastic transformation of peritoneal mesothelium into endometrium under influence of an unidentified stimuli.

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19
Q

What is the pathogenesis of hematogenous or lymphatic spread in regards to Endometriosis?

A

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.

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20
Q

How many pt’s with Endometriosis are asymptomatic?

A

1/3.

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21
Q

What is the TRIAD of pain associated with Endometriosis?

A
  1. Dysmenorrhea.
  2. Dyspareunia.
  3. Dyschezia.
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22
Q

Name other S/Sx of Endometriosis besides the triad of pain?

A
  1. Heavy or irregular bleeding.
  2. Pelvic pain.
  3. Lower abd or back pain.
  4. Bloating, N/V.
  5. Inguinal pain.
  6. Pain on micturition (dysuria) and/or urinary frequency.
  7. Pain during exercise.
  8. Triad of pain.
23
Q

What is Dyschezia?

A

Excessive straining with stools; involved cycles of diarrhea and constipation.

24
Q

Physical exam findings associated with Endometriosis?

A
  1. Tender, fixed adnexal (area where uterus occupies) mass – CHARACTERISTIC.
  2. Small, exquisitely tender nodule in CUL-DE-SAC or Uterosacral ligaments.
  3. Hugh, NONTENDER, CYSTIC abd. mass.
  4. Small, tender MULBERRY-like spot on posterior vaginal fornix.
  5. Asymptomatic.
25
Q

What is the primary diagnostic modality for Endometriosis?

A

Laparoscopy – sensitivity of 97%, specificity of only 77%.

26
Q

Goal of medical mgmt of Endometriosis?

A

Amenorrhea.

27
Q

What does treatment of Endometriosis depend on?

A

On the certainty of diagnosis, severity of Sx, extent of disease, desired future fertility, pt. age, threat to GI or GU Tract or both.

28
Q

Medical management (2 options) for Endometriosis?

A
  • 1st line: NSAIDs, OCPs, progestins.

- 2nd line: GnRH agonist (temporary medical castration), higher-dose progestins, Danazol.

29
Q

What are the benefits of OCPs in Endometriosis?

A

Inhibition of ovulation; reduces dysmenorrhea.

30
Q

Benefit of Progestin-only therapy in Endometriosis?

A

Suppresses estrogenic stimulation of ectopic endometrial tissue; reduces dysmenorrhea.

31
Q

What is the most definitive medical management option for Endometriosis?

A

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.

32
Q

Danazol MOA and MC adverse effect?

A
  1. “Anti-estrogen” that suppressed growth of ectopic endometrial tissue.
  2. MC AE: Acne.
33
Q

What is the definitive treatment for Endometriosis?

A

A total hysterectomy w/bilateral salpingo-oophorectomy, destruction of all peritoneal implants and dissection of adhesions.

34
Q

Invasive endometriotic lesions/cysts on the extrauterine sites? What may it cause?

A

Endometrioma that may cause extensive pelvic adhesions.

35
Q

What is characteristic of endometrioma and what are they?

A

“Chocolate Cysts.”

-Chocolate-colored, bloody fluid sometimes with a black/tarry consistency.

36
Q

What is considered normal menstrual blood loss and what is considered excessive?

A
  1. Approx. 30 cc; 80% total loss in the 1st 2 days.

2. Greater than 80 cc.

37
Q

Define normal menses?

A

Interval 28 +/- 7 days, blood loss < 80cc.

38
Q

Define Menorrhagia?

A

Excessive bleeding at the time of the menstrual period or prolonged bleeding.

39
Q

Define Metrorrhagia?

A

Bleeding occurring irregularly between menstrual cycles, usually not excessive.

40
Q

Define Menometrorrhagia?

A

Prolongation of the menstrual flow, typically excessive with irregular intermenstrual bleeding.

41
Q

Define Polymenorrhea?

A

Menstrual interval < 21 days.

42
Q

Define Oligomenorrhea?

A

Menstrual interval > 35 days.

43
Q

What is Abnormal Uterine bleeding typically caused by?

A

Ovulatory dysfunction.

*It reflects disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining.

44
Q

What is the DDx mnemonic of Abnormal/Dysfunctional Uterine Bleeding?

A

“PALM COEIN.”

  1. Polyp/pregnancy.
  2. Adenomyosis.
  3. Leiomyoma.
  4. Malignancy/hyperplasia/meds.
  5. Coagulopathy.
  6. Ovulatory Dysfunction.
  7. Iatrogenic.
  8. Not yet classified.
45
Q

Etiology of Abnormal/Dysfunctional Uterine Bleeding?

A
  1. 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.
  2. 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.
  3. Progestin-only OCPs.
  4. Immature HPT Axis (Adolescents):
    - -Failure to mount an ovulatory LH surge in response to rising estradiol levels.
  5. Climacteric – anovulation; peri/menopause.
  6. Bleeding disorders.
46
Q

What should you suspect if a pt has had AUB since menarche?

A

PCOS – Polycystic ovarian syndrome.

47
Q

What is the hallmark finding of AUB?

A

A NEGATIVE Pelvic Exam.

48
Q

What do we need to further evaluate during examination of someone who presents with AUB?

A
  1. Obesity (BMI).
  2. Signs of Androgen excess (hirsutism, Acne).
  3. Thyromegaly (Hypo/Hyperthyroidism).
  4. Galactorrhea (Hyperprolactinemia).
  5. Visual field defects (intracranial/pituitary lesion).
  6. Ecchymosis, purpura (bleeding disorders).
  7. Signs of anemia or chronic blood loss.
49
Q

What will most endometrial biopsy specimens show?

A

Proliferative or Dyssynchronous endometrium.

50
Q

What is the invasive mgmt of Endometriosis?

A
  1. Hysteroscopy +/- D and C.
  2. Endometrial Ablation.
  3. Hysterectomy.
51
Q

Patient education of Endometriosis?

A
  1. Most bleeding stops with appropriate hormonal treatment.
  2. Adolescent females often establish a predictable ovulatory pattern over time.
  3. Keep a good menstrual calendar to document daily bleeding patterns.
    - -Severity of blood loss, impact on ADLs.
52
Q

Common locations for Leiomyoma?

A
  1. Intramural or inside muscular uterine wall.
  2. Subserosal or grows outside of uterine wall.
  3. Submucosal or bulge into the uterine cavity and can cause uterine bleeding.
53
Q

Describe the management of Symptomatic Leiomyoma?

A
  1. Progestin releasing IUD:
    - -Can relieve heavy bleeding.
  2. 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.
54
Q

Surgical mgmt of Leomyoma?

A
  1. TAH (Total Abdominal Hysterectomy), Myomectomy.
  2. 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.
  3. Hysterectomy Myomectomy:
    - -If fibroids are mucosal.
    - -Access and remove fibroids using instruments inserted through the vagina and cervix into the uterus.

OB/Gyn (14 decks)

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