frequent menstruation with bleeding intervals shorter than 21 days
excessive menstrual bleeding (flow >80mL and/or duration >7 days)
irregular menstrution intervals
irregular menstruation intervals with excessive flow and/or duration
menstruation fewer than 9 times per year (average bleeding intervals >35 days
Very light or short-duration menstruation
What is intermenstrual bleeding?
Uterine bleeding in between apparently normal ovulatory menses
What is a uterine fibroid?
What symptoms are associated with uterine fibroids?
Uterine leiomyoma - a benign neoplasm of the uterus
Symptoms depend on exact location of the fibroid(s), but may include:
- Menorrhagia/menometrorrhagia with refractory anemia
- Intermenstrual dysmenorrhea
- Mass symptoms (urinary pressure/urgency, constipation, flank pain, increasing abdominal girth
At what age do uterine fibroids typically present?
Are they hormonally responsive?
Most prevalent during reproductive years. They rarely present during puberty and often regress after onset of menopause
Yes, they are hormonally responsive -> Leiomyomas have increased amounts of both estogen and progesterone receptor mRNA
Name (3) benign neoplasms of the uterus
In what layer of the uterus are endometrial polyps found?
As fleshy outgrowths of the endometrium
As outgrowths of cervical mucosa
As a benign invasion of the endometrium into the myometrium
Anovulation and abnormal uterine bleeding are most common at what ages?
What usually drives formation of these symptoms? What happens structurally to the uterus?
Discuss the relevance of this process to neoplasms of the uterus
Common at the extremes of reproductive age
Often due to chronic exposure of the endometrium to estrogen without cyclic exposure to postovulatory progesterone. This causes the endometrium to become abnormally thickened and structurally incompetent. Asynchronous shedding occurs without progesterone-driven vasoconstriction, often leading to heavy bleeding.
Abnormal cycling predisposes patients to endometrial hyperplasia and endometrial cancer. Increased risk is proportional to the duration of unoppose estrogen exposure.
Name two major types of uterine malignant neoplasms
How is endometrial cancer usually diagnosed?
Endometrial biopsy or endometrial curettage/hysteroscopy specimens
'Spotting' is often related to what?
Maybe it doesn't seem like a big deal -> why is it actually a big deal?
Endometrial atrophy related to hypoestrogenism
Endometrial atrophy with spotting is clinically indistinguishable from the earliest symptoms of endometrial cancer and therefore requires extensive workup and careful evaluation to rule out cancer. This is especially true in peri-/post-menopausal women.
What imaging options are indicated for evaluation of abnormal uterine bleeding and anovulation?
- Pelvic ultrasound
- Pelvic MRI
What medical/hormonal management strategies might be employed to minimize fibroid bleeding issues?
Oral contraceptive pills
GnRH agonists or antagonists
Progesterone receptor modulators
What surgical treatment options exist for endometrial polyps and uterine fibroids?
Endometrial polyps: operative hysteroscopy
Uterine fibroids: myomectomy via abdominal, laparoscopic, or hysteroscopic routes
Other options might include: uterine artery embolization (interventional radiology) or MRI-guided focused ultrasound surgery (this is incredibly cool)
What is endometriosis?
The presence of endometrial glands and stroma ourside the endometrial cavity and uterine musculature, often resulting in adhesions, pain, infertility, and a generalized inflammatory state.
What is a "chocolate cyst"?
An endometrial cyst related to endometriosis
Often occurs due to sloughed endometrium that migrates to the ovary and grows slowly over time due to accumulated blood (hence the brown/chocolate color).
Describe the treatment approach and rationale for each in endometriosis
Why do these treatments make addressing infertility issues especially difficult?
Hormonal suppression (oral contraceptives, GnRH agonists, aromatase inhibitors) to minimize stimulation of endometriosis tissue
NSAIDs to decrease prostaglandin-driven inflammation
- Hormonal suppression therapy also suppresses ovulation
- May result in severe adhesions that are hard to correct surgically
- Higher risk of ectopic pregnancy
Give (4) reasons endometriosis contributes to infertility
- Adhesions distort normal pelvic anatomy
- Ovarian cysts
- Macrophages and cytokines create inflammatory state in the pelvis
- Alters endometrial receptivity (negatively)
What should you never forget to test for in evaluating abnormal bleeding and/or anovulation?