Uterus Flashcards
Adenomyosis - presentation
- dysmenorrhea
- menorrhagia
- uniformly enlarged, soft, globular uterus
Adenomyosis - treatment
- only hysterectomy is definitive treatment
- GnRH agonists
adenomyosis - definition / age
- invasion of endometrial glands into the myometrium
- women 35-50
adenomyosis - RF
- endometriosis
2. uterine fibrinoids
adenomyosis - diagnosis / physical findings
diagnosis: it is clinical / MRI is the most accurate test. hysteroctomy for definitive diagnosis
examination: large globular and boggy
soft and tender uterus - MC?
adenomyosis
endometriosis - epidimiology
women in reproductive age and is MORE COMMON if a FIRST DEGREE RELATIVE (mother or sister) has
endometriosis - symptoms presentation
cyclic pelvic pain that starts 1 to 2 weeks before menstruation and peaks 1 to days before. The pain end with menstruation.
Abnormal bleeding is common
dysmenorrhea and dyspraeunia are also common
endometriosis - physical exam
tenderness of the recto-vaginal area, tenderness withh movement of the uterus, thickening of the uterosacral ligaments caused by endometrial implants on the recto-vaginal septum, pelvic peritoneum, anterior and posterior cul-de-sac, and uterosacral ligaments
endometriosis - diagnosis (and appearance)
can be made only by direct visualization via laparoscopy. It looks like rusty or dark brown lesions. On the ovary, a cluster of lesions called an endometrioma looks like a chocolate cyst
endometriosis - treatment
- analgesia (NSAID)
- OCPs to iterrupt the menstrual cycle and stop ovaluation (mild symptoms)
- danazole or leuprolide to decrease FSH/LH (moderate to severe pain)
- surgical treatment (severe symptoms or infertility)
Danazole - mechanism of action and SE
androgen derivative that is associated with acne, oily skin, weigh gain, hirsutism
surgery on endometriosis - purpose
attempts to remove all endometrial implants and adhesion, and to restore pelvic anatomy. Patients who have completed their childbearing may undergo total abdominal hysterectomy and bilateral salpingo-oophorectomy
DDX of dysmenorrhea
- 1ry desmenorrhea
- endometriosis
- fibroids
- adenomyosis
- pelvic congestion
tenderness and nodularity in theposterior cul-de-sac
endometriosis
Dysmenorrhea?
pain with menses
Dysmenorrhea - DDX
- Primary
- endometriosis
- Fibroids
- Adenomyosis
- pelvic congestion
- pelvic infection
1ry desmenorrhea - treatment
NSAID
Hormonal contraception
pelvic congestion syndrome
dull and ill-defined pelvic ache –> worsens prior to menstruation or with long periods of sanding and is relieved by mense
- also it is often associate with history of sexual problems
menorrhagia - description
- heavy and prolonged menstrual bleeding (more than 80 ml or more than 7 days)
- Gushing of blood
- clots may be seen
menorrhagia - etiology
- endometrial hyperplasia
- uterine fibroids
- Dysfunction uterine bleeding
- intrauterine device
hypomenorrhea - description
- light menstrual flow
- my only have spotting
hypomenorrhea - etiology
- obstruction (hymen, cervical stenosis)
- oral contraceptive pills
metrorrhagia - description
inter-menstrual bleeding
metrorrhagia - etiology
- endometrial polyps
- endometrial/cervical cancer
- exogenous estrogen administration
menometrorragia - etiology
- endometrial polyps
- endometrial/cervical cancer
- exogenous estrogen administration
oligomenorrhea - description
menstrual cycles smaller than 35 days
oligomenorrhea - etiology
- pregnancy
- menopause
- signif weight loss (anorexia)
- Tumor secreting estrogens
abnromal uterine bleeding - diagnostic test
- CBC (for Hb and Hct)
- PT/PTT to evaluate for coagulation disorders
- Pelvic US (for anatomic abnormalities)
Dysfunctional uterine bleeding - ovaluation (mechanism)
the ovary produces estrogen but no corpus lateum –> no progesteron –> this prevents the usual withdrawal bleeding –> the continuously high estr continues to stimulate growth of the endometrium –> bleeding occurs only once the endometrium outgrows the blood supply
Dysfunctional uterine bleeding - diagnostic tests
- rule out systemic reasons for anovulation, such as hypothyroid and hyperprolactinemia
- endometrial biopsy for women over 35 (for CA)
Dysfunctional uterine bleeding - treatment
- OCP: 1. adolescents and young women who are anovulatory 2. Women over 35 who have normal biopsy
- in acute hemorrhage: Dilation and Curettage is done to stop the bleeding
- IF SEVERE –> endometrial ablation or hysterectomy
Dysfunctional uterine bleeding is severe if
- patients are anemic
- hemorrhage are not controled by OCPs
- patients report that their lifestyle is compromised
evaluation of 2ry amenorrhea
amenorrhea for menses for 3 or more cycles or 6 or more months: HCG?
positive –> pregnancy
negative –> if prior uterine procedure or infection do hysteroscopy, if no, check prolactin, TSH, FSH
Leiomyoma (fibrinoid) - pathophysiological characteristic
Estrogen sensitive –> increased tumor size in pregnancy and decreased with menopause
Leiomyoma (fibrinoid) - presentation
- asymptomatic
- abnormal uterine bleeding
- miscarriage
- iron deficiency anemia (if severe bleeding)
fibroid - the best imaging modality to diagnose
U/S of pelvis
urinary stress incontinence can be a presenting symptom of
fibroids (due to direct pressure on the bladder from an irregularly enlarged uterus)
myomectomy - contraindication for labor
if there is uterine cavity entry
leiomyoma work-up
leiomyoma work-up
anatomic cause of 1ry amneorrhea
imperforate hymen
prolapsing leiomyoma
firm smooth round mass at the cervical os consistent with an aborting submucous myoma –> labor like pain due to mechanical cervical dilation
fibroids - treatment
asymptomatic: observation symptomatic: OCP, surgery
fibroids - clinical features
- heavy prolonged menses
- pressure symptoms
- obstetric complications (impaired fertility, pregnancy loss, preterm labor)
- enlarged, irregular uterus
Endometrial hyperplasia - definition/mechanism/complications
- abnormal endometrial gland proliferation usually caused by excess estrogen stimulation
- high risk for endometrial carcinoma - nuclear atypia is greater risk factor than complex (vs simple)
Endometrial hyperplasia - presentation
postmenopausal vaginal bleeging
Endometrial hyperplasia - risk factors
- anovulatory cycles
- hormone replacement therapy
- polycystic ovarian sydrome
- granulosa cell tumor
endometrial carcinoma - risk factors
- prolonged use of estrogen without progestins
- obesity
- diabetes
- hypertension
- nulliparity
- late menopause
- Lynch syndrome
endometrial biopsy - indications
- 45 or older: abnormal uterine bleeding, postmenopausal bleeding
- younger than 45: abnormal uterine bleeding PLUS: unopposed estrogen (obesity, anovulatio) or failed medical management or Lynch syndrome
- 35 or older: atypical glandular cells on Pap
endometrial hyperplasia / cancer - treatment
hyperplasia: progenstin therapy or hysterectomy
cancer: hysterectomy
