Chapter 37 Management of Diseases of the Uterus and Endometrium

Question 1

levonorgestrel containing intrauterine contraception and oral progestins therapy can be an alternative to hysterectomy to treat

Answer 1

endometrial hyperplasia

Question 2

in advanced cancers, the addition of PACLITAXEL to DOXORUBICIN and CISPLATIN improved the survival compared to just doxorubicin and cisplatin

Answer 2

TRUE

Question 3

in patients <50 with endometrial cancer, 9% were found to carry a germline Lynch syndrome - associated mutation

Answer 3

true

Question 4

_% of caucasians and _% of african american women have leiomyomas

Answer 4

70% caucasians

80% african americans

Question 5

most patients present with increased uterine bleeding, pelvic pressure, and pain or reproductive dysfunction

Answer 5

true

Question 6

submucosal fibroids associated with _ pregnancy rates primarily are the result of decreased implantation

Answer 6

decreased

Question 7

intramural fibroids associated with more __ and slightly lower pregnancy rates

Answer 7

miscarriage

Question 8

leiomyomas during pregnancy increase the risk of malpresentation, cesarean delivery and preterm delivery

Answer 8

true

Question 9

diagnosis: physical finding of an enlarged mobile uterus

Answer 9

true

Question 10

routine radiologic assessment not required ; but..

Answer 10

confirms presence of a leiomyoma versus an adnexal mass

Question 11

TV US has high sensitivity and specificity of detecting leiomyomas in uteri less than __ size

Answer 11

10 weeks in size

Question 12

__ also has high sensitivity and specificity of detecting leiomyomas. it is better at detecting multiple and larger leiomyomas

Answer 12

MRI

Question 13

2 most common symptoms for which women seek treatment for leiomyomas are

Answer 13

abnormal uterine bleeding (usually heavy / prolonged) and

pelvic pressure

Question 14

Medical treatment of leiomyomas:

Answer 14

1. contraceptive steroids (estrogen and progestin or progestin alone) ->short term relief.
2. gonadotropin releasing hormone (GnRH) agonists can decrease volume of leiomyomas by 35% to 65% within 3 months of treatment but will recur within several months after cessatio of treatment; if treatment is continued for more than 6 months, add back therapy should be considered to minimize bone loss and vasomotor symptoms.

Question 15

sequential regimen gives maximal results for GnRH. why?

Answer 15

GnRH agonist first used to achieve down-regulation, then add contraceptive steroids after 1-3 months of therapy. however, addition of progestin results in an increase in uterine volume up to 95% of baseline at 24 mths.

Question 16

Aromatase inhibitors block ovarian and peripheral estrogen production and decrease estradiol after 1 day of treatment;

Answer 16

small studies shown a reduction in leiomyoma size and symptoms.

Question 17

Uterine artery emboliation (UAE) embolization occurs via transcutaneous __ artery approach resulting in leiomyoma devascularization and involution; uterine arteries are embolized using polyvinyl alcohol particles of triascryl gelatin microspheres

Answer 17

femoral artery

Question 18

Endometrial hyperplasia

Answer 18

peaks in early 50s without atypia

early 60s with atypia. diagnosis: heavy, prlonged, frequent (35 yrs.

Question 19

dx of endometrial hyperplasia:

Answer 19

1. endometrial bx. detection rate for endometrial carcinoma 99.6%, and 91% for premenopausal and postmenopausal women. detection for atypical hyperplasia, pipelle most sensitive at 81%
2. Dilation and curettage (D&C
3. Saline infused sonography endometrial sampling.

Question 20

progression to endometrial cancer is 
_%for simple hyperplasia without atypia
_%for complex hyperplasia without atypia
_%for simple hyperplasia with atypia
_%for complex hyperplasia with atypia

Answer 20

1%for simple hyperplasia without atypia
3%for complex hyperplasia without atypia
8%for simple hyperplasia with atypia
29%for complex hyperplasia with atypia

Question 21

Treatment: depends more on presence of atypia and menopausal status; simple or complex hyperplasia does not determine treatment as much as atypia

Answer 21

true

Question 22

__ reverse endometrial hyperplasia by activation of progesterone receptors, which results in stromal decidualization and subsequent thinning of the endometrium; progestins also decrease estrogen and progesterone receptors and activate hydroxylase enzymes to convert estradiol to its less active metabolite estrone

Answer 22

progestins

Question 23

response rate highest in women __ atypia and with therapy of 12-14 days per month

Answer 23

without atypia with therapy 12-14 days/ month. regression has been seen in 80% of treated patients; levonorgestrel containing intrauterine contraception is also effective.

Question 24

in premenopausal patients with atypia: if atypia found on initial endometrial biopsy, further evaluation with a D&C may be indicated given high concurrent risk of carcinoma

Answer 24

true.

Question 25

if maintaining fertility is desired, treatment is:

Answer 25

medroxyprogesterone acetate or megestrol acetate 80mg bid; levonorgestrel containing IUC is also effective option for treating hyperplasia in premenopausal women

Question 26

postmenopausal women without atypia: treatment:

Answer 26

medroxyprogesterone acetate 10mgdaily x 3 months with f/u endometrial bx after cessation of drug therapy

Question 27

postmenopausal women WITH atypia treatment:

Answer 27

if hysterectomy is not an option, continuous oral megestrol acetate 80mg twice daily or levonorgestrel

Question 28

the most common presentation of endometrial cancer is

Answer 28

abnormal uterine bleeding

Question 29

diagnosis of endometrial cancer

Answer 29

endometrial biopsy with pipelle or dilation and curettage in women older than 35 years of age with anovulatory uterine bleeding to r/o endometrial hyperplasia or cancer based on acog guidelines.

Question 30

Leiomyosarcoma 50% of patients with disease limited to the uterus have recurrence within 2 years, 5 year survival rates of

Answer 30

<50%

Question 31

diagnosis of leiomyosarcomas:

Answer 31

after a myomectomy / hysterectomy for fibroids. new / enlarging pelvic mass, abnormal uterine bleeding, and pelvic pain.

Question 32

rapidly growing fibroids is NOT a risk factor for leiomyosarcoma

Answer 32

true

Question 33

27% of hysterectomies performed for rapidly growing fibroids are found to be leiomyosarcomas

Answer 33

true

Question 34

in patients younger than 50 years of age with endometrial cancer, _% found to carry a germline Lynch syndrome associated mutation

Answer 34

9% found to have Lynch syndrome associated mutation.

Question 35

1/2 of women, gyn cancer PRECEDED development of colon cancer by an average of _ years (ovarian cancer) or _ years (endometrial cancer presenting first)

Answer 35

5.5 years for ovarian cancer 11 years for endometrial cancer BEFORE development of ovarian cancer

Question 36

median age for germline Lynch syndrome mutation swas

Answer 36

44 years.

Question 37

women with 1st degree relative with Lynch syndrome associated cancer had 43% chance of having germline Lynch mutation compared with women without an affected 1st degree relative

Answer 37

true