uterus Flashcards
dysfunctional uterine bleeding occurs when and why
shortly after menarche and during perimenopause d/t increased anovulatory cycles
main reason for dysfunctional uterine bleeding
absence of anatomic lesion; problem with the hypothalmic-pituitary-ovarian hormonal axis
other 3 causes of dysfunctional uterine bleeding
PCOS, exogenous obesity, adrenal hyperplasia
clinical feature of dysfunctional uterine bleeding
abnormal bleeding with an unremarkable physical exam in a very young or perimenopausal woman
abnormal bleeding with an unremarkable physical exam in a very young or perimenopausal woman
think dysfunctional uterine bleeding
initial test for abnormal bleeding
B-hCG
postmenopausal bleeding
cancer until proven otherwise; do endometrial bx
reasons for these tests for abnormal bleeding
- CBC
- pap smear
- G/C probe
- TFTs and prolactin
- Platelet count, PT/PTT
- Ultrasound
- CBC: anemia
- pap smear: rule out cervical cancer
- G/C probe: cervitis
- TFTs and prolactin: hypo/hyperthyroidism and hyperprolactinemia
- Platelet count, PT/PTT: Willebrand d/s and factor XI def-primarily in adolescents
- Ultrasound: uterine masses, PCOS, endometrial thickness
DUB: do what trial test
prolactin. If the bleeding stops, then anovulatory cycles are confirmed.
DUB: who to give oral contraceptives to
older women w/out risk factors.
avoid in smokers, HTN, DM, hx of vascular d/s, breast cancer, liver disease, focal headaches
DUB: what to use in younger pts
cyclic progestins
DUB: what is diagnostic and curative
D and C
DUB: tx for refractory cases
endometrial ablation or vaginal hysterectomy
tx for acute heavy bleeding
- 1st line
- 2nd line
- if bleeding is not controlled w/in 12-24 hrs
- high dose estrogen IV stabilizes the endometrial lining and typically stops bleeding w/in 1 hr.
- if estrogen contraindicated, do high dose progestin therapy alone
- if bleeding is not controlled w/in 12-24 hrs: Do a D&C
tx for ovulatory bleeding
- NSAIDs to decrease blood loss
- tranexamic acid 5 days during menses
- if hemodynamically stable, do OCPs, progestin po or inj, or insert a progestin IUD
tx for anovulatory bleeding
- progestins x 10 days to stimulate withdrawal bleeding
- OCD
- progestin IUD
goal for tx for anovulatory bleeding
goal to convert proliferative endometrium to secretory endometrium(to decrease risk of endometrial hyperplasia/cancer)
75% endometrial cancer type and type of women/race too
adenocarcinoma; post menopausal women; white more than black women
worse prognostic factor in endometrial cancer
the older the worse
4th most common malignancy in women in the U.S.
endometrial cancer
what is endometrial cancer not related to
sexual history
protective effect in endometrial cancer
oral contraceptives
unopposed estrogen stimulation, chronic tamoxifen use, nulliparity, infertility, late menopause, DM, HTN, gallbladder d/s,
all risk factors for endometrial cancer
cardinal symptom and 3 other symptoms in endometrial cancer
- 90% will have inappropriate uterine bleeding
- obesity, HTN, DM
testing for postmenopausal bleeding to rule out endometrial cancer
pap smear, endocervical curettage, endometrial biopsy
endometrial biopsy accuracy rate
90-95%
other 2 tests for postmenopausal bleeding to rule out endometrial cancer
fractional D&C, transvaginal ultrasonography
tx of endometrial cancer
1) for basis of tx and staging
2) radiotherapy vs chemo
3) recurrence tx
1) total hyst with bil salpingo-oophorectomy with peritoneal lymphnode and tissue sampling
2) radiotherapy maybe. chemo for advanced stages
3) recurrence treated w/ high dose progestins or anti-estrogens
pap smear for endometrial cancer
negative
metrorrhagia
bleeding which occurs at any time during the menstrual cycle
bleeding which occurs at any time during the menstrual cycle
metrorrhagia
menometrorrhagia
heavy bleeding which occurs at any time during the menstrual cycle
heavy bleeding which occurs at any time during the menstrual cycle
menometrorrhagia
dysmenorrhea
menstrual pain which interferes with ADLs
menstrual pain which interferes with ADLs
dysmenorrhea
oligomenorrhea
menstrual periods which occur at intervals greater than 35 days
endometriosis is usually found where
pelvis or ovary(60%)
endometriosis occurs in who and what age
nulliparous women in late 20s or early 30s
infertility and endometriosis
infertility is common. It is found in 25-34% of infertile women
endometriosis symptoms
dysmenorrhea, deep thrust dyspareunia, dyschezia, spotting, pelvic pain, infertility
dyschezia
difficulty passing bowel movement
dysmenorrhea, deep thrust dyspareunia, dyschezia, spotting, pelvic pain, infertility
endometriosis symptoms
endometriosis signs
tender nodularity of the cul de sac and uterine ligaments and a fixed uterus
tender nodularity of the cul de sac and uterine ligaments and a fixed uterus
endometriosis signs
endometriosis symptoms and degree of disease
they do not correlate
endometriosis testing(2)
ultrasonography and laparoscopy
medical tx of endometriosis
NSAIDs, prostaglandin synthetase inhibitors, combined oral contraceptives or progestins, GnRH agonist, danazol
surgical tx of endometriosis
laparoscopic fulguration(destruction of tissue using high voltage electricity) or total hyst
chocolate cysts
endometriomas
NSAIDs, prostaglandin synthetase inhibitors, combined oral contraceptives or progestins, GnRH agonist, danazol
medical tx of endometriosis
what is adenomyosis
extension of endometrial glands into the uterine musculature
adenomyosis and endometriosis relation
not related
adenomyosis symptoms
severe secondary dysmenorrhea OR most pts asymptomatic
adenomyosis triad
pain, menorrhagia, enlarged-boggy-symmetric uterus
adenomyosis tests
- pelvic U/S to detect it, r/o pregnancy.
- endometrial bx, fractional D&C, hysteroscopy all to rule out endometrial cancer
avoid what tx in adenomyosis
hormonal treatment
tx of adenomyosis
- definitive
- other tx (3)
- hysterectomy definitive
- others: D&C, GnRH agonist, mifepristone
- hysterectomy definitive
- others: D&C, GnRH agonist, mifepristone
tx of adenomyosis
- definitive
- other tx (3)
uterus is irregular and mobile
uterine myomas
if a uterine mass continues to grow after menopause
consider malignancy
fibroids occur at what age, race, FH
occur in 4th decade, blacks, +FH
fibroids
- depend on what
- appear in increased frequency in women who have what (3)
depend on estrogen and appear with increased frequency in women who have endometrial hyperplasia, anovulatory states, and estrogen producing ovarian tumors
women with fibroids…
- have how much of an increase of endometrial cancer
- risk of what is else is increased
- 4 fold
- spontaneous abortion
fibroids locations
- subserous
- intramural
- submucous
- what causes uterine bleeding
fibroids locations
- subserous (deforming external serosa)
- intramural (w/in uterine wall)
- submucous (deforming uterine cavity)
- what causes uterine bleeding- submucous
firm, enlarged irregular uterine mass
fibroids; could also be asymptomatic
menorrhagia, metorrhagia, intermenstrual bleeding, dysmenorrhea
fibroids
common symptom of fibroid
bleeding
fibroid dx tests (5)
pelvic U/S, pelvic MRI, D&C, hysterectomy, and laparoscopy
fibroid symptomatic tx
myomectomy, hysterectomy, or D&C
what can reduce fibroids tumor size (2)
and length of treatment
GnRH agonists and mifepristone; tx limited to 6 months
fibroids tx
- restore fertility
- no desire of fertility
- final step
- GnRH agonists
- uterine arterial embolization or endometrial ablation
- hysterectomy
leuprorelin
- GnRH agonist
- causes a decrease in LH and FSH and thereby a decrease in estrogen
cobblestone uterus on exam
fibroids
fibroids size will increase and decrease with what
increase with pregnancy and decrease after menopause
endometrial cancer relation to vaginal bleeding
vaginal bleeding is present in 80% of women with endometrial cancer
only 5-10% of women with abnormal vaginal bleeding have endometrial cancer
when to perform a biopsy for endometrial cancer in postmenopausal women
any bleeding or spotting
when to perform a biopsy for endometrial cancer in premenopausal women
[after initial workup and in the setting of unopposed estrogen- obesity, DM]
- sustained intermenstrual bleeding
- menorrhagia
- amenorrhea
when to do a transvaginal and endometrial stripe
postmenopausal women. under 4 mm unlikely cancer
uterine prolapse
- increases 50% after what
- race
- menopause
- less common in asian and black women
obesity, asthma, COPD, pelvic tumor, ascities
predisposes pts to prolapse
cystocele
bladder herniating into vagina
rectocele
rectum herniating into vagina
enterocele
small intestine herniating into vagina
uterine prolapse symptoms
- worse with what
- relieved with what
- worse after prolonged standing or late in day
- relieved by lying down
uterine prolapse symptoms (3)
vaginal fullness, lower abdominal aching, low back pain
- vaginal fullness, lower abdominal aching, low back
- worse after prolonged standing or late in day
- relieved by lying down
prolapse symptoms
uterine prolapse grading
0 is no descent; 4 is through the hymen
falling out sensation or feeling of sitting on a ball
moderate uterine prolapse
most uterine prolapses accompanied by what (3)
cystocele, rectocele, or enterocele
non surgical tx for uterine prolapse
wt reduction, smoking cessation, pelvic muscle exercises, vaginal pessary
surgical tx for uterine prolapse
mesh, hyst, sacrocolpopexy, or uterosacral ligament suspension may also be necessary
PID includes what 5 disorders
acute salpingitis, IUD related pelvic cellulitis, tuboovarian abscess, pelvic abscess
PID definition
polymicrobial infection of fallopian tubes and pelvis
2 complications of PID
ectopic and infertility
PID symptoms (4)
purulent vaginal discharge, BILATERAL PELVIC/ABD PAIN, n/v, fevers
pain sign of PID, next sign
cervical motion tenderness; friable cervix
cervical motion tenderness/chandelier sign
PID or cervicitits
purulent vaginal discharge, BILATERAL PELVIC/ABD PAIN, n/v, fevers
PID
2 main organisms with PID
G/C
dx PID
- what to find G/C (2)
- imaging
- invasive
- if no improvement in 48 hrs then order what
- DNA probe and gram stain
- transvaginal ultrasonography to differentiate acute and chronic inflammation or presence of adnexal masses
- culdocentesis- needle to transvaginal space to culture fluid
- laparoscopy to visualize abdominal and pelvic structure
