1
Q
Pelvic Organ Prolapse
* What is cystocele?
* What is urethrocele?
* What is rectocele?
* Prolapse of what?
A
- Cystocele – hernia of the bladder wall into the vagina
- Urethrocele – sagging of the urethra following its detachment from the pubic symphysis during childbirth
- Rectocele – herniation of the terminal rectum into the posterior vagina
- Prolapse of the Uterus
2
Q
What are the stages of the uterine prolapse?
A
3
Q
What are the risk factors of any prolapse (7)?
A
- Vaginal birth
- Genetic predisposition
- Aging
- Prior pelvic surgery
- Connective tissue disorders
- Obesity
- Straining from chronic constipation, chronic cough
Lifetime risk of needed surgery is 15-19%
4
Q
Clinical presentation of prolapse
* Senstation of what?
* What type of incontinence?
* Feeling of incomplete what?
* Bowel Movements?
* Difficult or painful what?
A
- Sensation of a bulge or protrusion in the vagina
- Urinary or fecal incontinence
- Feeling of incomplete bladder emptying
- Constipation
- Difficult or painful intercourse
5
Q
Treatment of prolapse:
* What is the primary step? ⭐️
* What are some supportive measures?
* Limit what?
* Incontinence may be improved with what?
A
- Weight reduction in obese patients is primary step and has been shown to reduce stress incontinence ⭐️
- Supportive measures – high-fiber diet, laxatives for constipation
- Limit straining and lifting
- Incontinence may be improved with pelvic floor exercises
6
Q
Pessaries:
* What are they?
* Reduce what?
* Typically used by who?
A
- Vaginal insert designed to support areas of prolapse
- Reduce discomfort of cystocele, rectocele, enterocele
- Typically used in patients who do not want to undergo surgery or for whom the risk of surgery outweighs the possible benefit.
7
Q
Surgical correction of prolapse
* What is most common?
* Combined with what?
* For many years, what was incorporated?
* What may be effective and appropriate for older women?
A
- Vaginal or abdominal hysterectomy most common
- Combined with tacking or suspension of pelvic structures
- For many years, mesh was incorporated into a suspension network-now considered too high risk
- Vaginal excision may be effective and appropriate for older women
8
Q
Vaginal discharge
* What is the normal pH?
* What if the pH above or less than 4.5?
* Measurement of pH is less useful at the extremes of age because why?
A
- The pH of the normal vaginal secretions is 4.0 to 4.5
- A pH above 4.5 in a premenopausal woman with abnormal discharge suggests infections such as bacterial vaginosis or trichomoniasis
- A pH less or 4.5 in a premenopausal woman with abnormal discharge suggests candida
- Measurement of pH is less useful at the extremes of age because the pH of normal vaginal secretions in premenarchal and postmenopausal women is 4.7 or more
9
Q
Normal Vaginal Discharge
* The majority of normal vaginal secretions consist of what?
* What is the color?
* How much is produced per day?
* What is the smell?
A
- The majority of normal vaginal secretions consist of mucus from the cervix
- White to off-white in color
- Normally around 1.5mg of vaginal fluid is produced per day
- Normal discharge is odorless
10
Q
Vulvovaginitis
* What is it?
* What are the common complaints? (3)
A
Spectrum of conditions that cause vaginal or vulvar symptoms
Common complaints:
* Itching
* Burning with urination or sexual activity
* Abnormal discharge
11
Q
Vulvovaginitis
* What are the MCCs? (3)
A
- Bacterial vaginosis
- Vulvovaginal candidiasis
- Trichomoniasis
12
Q
Vulvovaginitis
* What is the clinical evaluation? (5)
A
13
Q
Diagnostic Tests: Vulvovaginitis
* How is the microscopy done?
⭐️
A
- Vaginal discharge is sampled with a cotton-tipped swab, mixed with one to two drops of 0.9 percent normal saline solution on a glass slide and examined under a microscope
- Performed to look for candidal buds or hyphae, motile trichomonads or clue cells
- The addition of 10% potassium hydroxide (KOH) to the wet mount of vaginal discharge destroys cellular elements, thus it is particularly helpful in diagnosing candida vaginitis.
- Smelling (“whiffing”) the slide immediately after applying KOH is useful for detecting the fishy (amine) odor of bacterial vaginosis. Fishy smell only when applied KOH.
14
Q
Vulvovaginal Candidiasis “ Yeast Infection”
* What is it?
* What are risk factors? (5)
* What is the most prominent symptom?
A
- Fungal infection usually caused by Candida albicans
- Risk factors – broad-spectrum antibiotics, pregnancy, diabetes, immune compromise, silk underwear
- Pruritis may be severe, and is most prominent symptom
15
Q
Vulvovaginal Candidiasis
* How is the discharge?
* What is the ph and smell?
* Dx how? What else is available?
A
- Thick, adherent curd like white discharge in vaginal vault
- Not malodorous and pH is normal (<4.5)
- Diagnosed by clinical appearance or KOH prep of slide with microscopy
- PCR testing available
16
Q
What is this?
A
Branched hyphae and budding yeast of Candida albicans (spaghetti & meatballs)
17
Q
What is this?
A
Cervical Candidiasis
18
Q
Treatment: Vulvovaginal Candidiasis
* What are the different choices? (5) ⭐️
A
Typically will respond to a 1-3 day regimen of topical azole⭐️ or one-time dose of oral fluconazole
* In pregnant patient, oral azoles are contraindicated in first trimester
* Clotrimazole, 1% vaginal cream or supp. x7days
* Miconazole, 2% vaginal cream or supp. x7days
* Nystatinis another option but requires prolonged therapy (7 to 14 days). Takes time but it works. Can be used for peds (doesn’t burn).
DO TOPICAL FIRST
19
Q
Treatment: Vulvovaginal Candidiasis
* If complicated or recurrent, what is the treatment?
A
If complicated or recurrent (>4x/year) or in setting of immune compromise, uncontrolled DM or corticosteroid treatment – extend duration to 7-14 days of a topical regimen or 2 doses of oral fluconazole followed by once a week maintenance therapy for 6 months
20
Q
Trichomonas vaginalis
* What is it?
* What is a sxs?
* what is the discharge?
* What is seen on the cervix?
A
- Sexually transmitted flagellated protozoa
- Pruritis
- Frothy clear/white/yellow-green thin malodorous discharge
- Red macular lesions on the cervix in severe cases
21
Q
Trichomonas vaginalis
* Vaginal _
* What is seen with microscopic exam? What is positive?
* What is available?
A
- Vaginal erythema
- Motile organisms with flagella seen by microscopic examination of swab of vaginal area, prepped with saline
- Whiff test may be slightly positive with KOH prep
- Rapid diagnostic tests are available
22
Q
Treatment: trich
* Who should be treated?
* What is the txt? ⭐️
* How long of abstinence?
A
- Highly recommended that both partners be treated simultaneously.
- Metronidazole 500mg PO twice daily for seven days or tinidazole 2 grams PO as a single dose
- Advise 5 days of abstinence upon treatment onset
23
Q
Treatment: Trich
* What is the txt in preg patients?
A
Metronidazole: 2 g orally (single dose) OR
* Extend to 2g PO QD x 7 days in resistant infections
Avoid tinidazole or metrogel
Treatment of asymptomatic patients is not indicated
* In pregnancy, asymptomatic patients do not have to be treated until 37th week gestation
24
Q
BV
* What is it?
* Not what?
* What is a risk factor?
* What is the discharge like?
A
- Polymicrobial disease. Gardnerella most common
- NOT a sexually transmitted infection, only overgrowth of anaerobic bacteria
- Sexual activity is a risk factor
- Malodorous discharge, typical without vaginitis
25
BV
* **What is the whiff test result?**
* **What is a classic finding?**
* What is available ?
* What is not needed?
**+ Whiff test – “fishy” odor present if sample of discharge is alkalinized with 10% potassium hydroxide (KOH)**
**Classic finding – “clue cells” on wet mount with saline**
* Cell coated in bacteria
PCR testing is available and no need to culture
26
# ⭐️
Treatment: BV
* What is the TXT in non pregnant?
* Metronidazole 500mg PO twice daily for seven days is 1st line or
* Clindamycin vaginal cream/Supp. 2%, 5g once daily for seven days or
* Metro-gel (metronidazole gel) 0.75%, 5 g twice daily for 5 days
* Oral Clindamycin or Tinidazole may be used
27
# ⭐️
Treatment BV
* What is the treatment in preg patients?
28
What ate the SE of metronidazole? (4)
* a metallic taste (may be prevented with eating a banana 20min prior to intake of metronidazole)
* nausea
* a disulfiram-like effect with alcohol
* Interaction with warfarin
29
Clindamycin cream can cause what?
may weaken latex condoms
30
Pelvic Inflammatory Disease (PID)
* What is it?
* What are the organisms?
* Acute (typically ascending) infection of the upper genital tract structures in women, involving any or all of the uterus, oviducts, and ovaries
* Polymicrobial; predominant organisms responsible for initiating the infection are gonorrhea and chlamydia
31
Pelvic Inflammatory Disease (PID)
* What are the RFs?(3)
* Previous PID infection
* Multiple sex partners
* Not using condoms
32
Pelvic Inflammatory Disease (PID)
* What is the sign of dx?
cervical motion tenderness (chandelier sign) or uterine or adnexal tenderness in the presence of lower abdominal or pelvic pain
33
Pelvic Inflammatory Disease (PID)
* What is the additional criteria to support a clinical dx?(5)
* Temp > 101 F
* Mucopurulent cervical discharge
* Abundant WBCs on microscopy of vaginal secretions
* Elevated ESR
* Elevated CRP
34
Pelvic Inflammatory Disease (PID)
* Formal dx with what?
* **What are some consequences? (3)**
| ⭐️
Formal diagnosis with culture
Issues:
* Development of tubo-ovarian abscess (surgical/IR involvement)
* Infertility secondary to scarring of fallopian tubes
* **Ectopic pregnancy**
35
What is the txt of PID?
Geared towards primary cause
* Recall drugs for GC/Chlamydia
Hospitalization is usually required
* Transitioning from parenteral to oral therapy started after 24 hours of sustained clinical improvement (clue for discharge to outpatient therapy)
36
What is endometriosis?
Deposition of endometrial tissue – adhesions, mass, ovarian dysfunction
37
Primary dysmenorrhea
* What is it?
Painful menses or menstrual cramps without pelvic pathology involved
38
Primary dysmenorrhea
* Due to what?
* usually starts when?
* Lasts how long?
* Worst when?
* usually begins when?
* Due to excessive prostaglandin (F2a) production and release
* Usually starts 6-12 months after menarche (ovulation established)
* Lasts 48-72 hours
* Worst first 1-2 days of menses
* Usually begins either a few hours before or after bleeding begins
39
Primary Dysmenorrhea
* how do you dx and txt?(4)
Diagnosis: clinical
Treatment: NSAIDs, OCPs, Heat application, exercise
* Make sure they have normal Pap
40
Secondary Dysmenorrhea
* Due to what?
Due to pelvic disease or pathology
* Endometriosis (most common), PID or Fibroids
41
Secondary Dysmenorrhea
* begins when?
* Pain?
* irregular what?
* _
* Begins later in life
* Pain is dull, occurs with ovulation and/or Intercourse and lasts longer than primary dysmenorrhea
* Irregular menses
* Menorrhagia
42
Secondary Dysmenorrhea
* how do you dx and tx them?
* Diagnosis: PE/Labs/Imaging
* Treatment is directed at the underlying cause
43
Endometriosis General info
* What is it?
* manifests as what?
* May cause what?
* Aberrant growth of endometrium outside of the uterus
* Manifests as pain
* May cause infertility
44
Endometriosis General info
* What are the three theories?
* Direct implantation via retrograde menstruation
* Vascular and lymphatic dissemination of endometrial cells
* Coelomic metaplasia – undifferentiated cells in the peritoneal cavity develop into endometrial tissue
45
Endometriosis General info
* What does not correlate?
* Diffuse what?
* Degree of growth does not correlate with degree of pain
* Diffuse distribution of over-growth/implantation
46
Endometriosis
* What are the most common sites?
* Ovaries (most common; bilateral)
* Anterior and posterior cul-de-sac
* Uterosacral ligaments
* Fallopian tubes
* Sigmoid colon
47
Endometriosis
* may manifest as what? (3)
* What is the MC common symptom?
* What are the other sxs?
* May manifest as chronic pelvic pain, dysmenorrhea, painful intercourse
* Pain is the most common symptom associated with endometriosis (75%).
* other sxs: Dymenorrhea, deep dyspareunia-certain angle; cyclical bowel or bladder sxs, subdertility/infertibilty, abnormal menstrual bleeding, chronic fatigue
## Footnote
* Variable and unpredictable
* Endometriosis can be debilitating
48
Endometriosis
* What are the PE findings? (5)
* Palpable tender nodules in the posterior cul-de-sac, uterosacral ligaments, or rectovaginal septum
* Fixed, retroverted uterus
* Thickening of uterosacral ligaments
* Pain with uterine movement/contraction (menses or orgasm)
* Tender, enlarged adnexal masses
49
Differential Diagnosis: Endo
* Must r/o what?
* May invade what?
50
Differential Diagnosis: Endo
* Only definitive dx is what? ⭐️
* What is rarely helpful? Unless what?
* Only definitive diagnosis is direct visualization of the implant confirmed by tissue biopsy via laparoscopy or laparotomy ⭐️
* Imaging studies are rarely helpful -> Unless evaluating a mass
51
Imaging: Endo
* When is imaging typically ordered?
**What is the modality of choice?**
* When is MRI?
* Typically ordered to evaluate a pelvic mass
*** Transvaginal ultrasound is the modality of choice**
* MRI if rectovaginal or bladder endometriosis suspected
52
treatment of endo:
* What is most effective?
* Regimens are designed to inhibit what?
* What is the goal?
* Hormonal therapies are most effective
* Regimens are designed to inhibit ovulation for up to nine months
* Goal is to prevent cyclic stimulation of endometriotic implants and induce atrophy
53
Treatment: endo
* What is first line?
* What are some other options?
* What may provide pain control?
* Estrogen-progestin contraceptives first line (mild symptoms + want to prevent pregnancy), Progestins oral or intrauterine are alternative
* GnRH agonists (moderate to severe), Danazol
* Combining these agents with aromatase inhibitors or GnRH antagonists may provide improved pain control
54
What is the adjunct therapy for endometrosis?
* NSAIDs may help pain in some patients when used as adjunct and are preferred alone only when conception is desired.
55
Hormonal medical therapy-Endo
* Danazol is effective in who?
* Over 80 percent of patients experience what?
* Given how?
* Effective in resolving implants when treating mild or moderate stages of disease
* Over 80 percent of patients experience relief or improvement of pain symptoms within two months of treatment
* Given orally in divided doses ranging from 400 to 800 mg daily, generally for six months
56
What are the SE of danazol?
weight gain, muscle cramps, decreased breast size, acne, hirsutism, oily skin, decreased high density lipoprotein levels, increased liver enzymes, hot flashes, mood changes, and depression
57
Surgical Treatment: Endo
* What is the option for promoting fertility and for whose who do not have desire to have children?
Effective in reducing pain and promoting fertility
* Conservative (retain uterus and ovarian tissue)
* Laparoscopic ablation of endometrial implants reduces pain
* Total hysterectomy in patients with severe/incapacitating pain who do not have desire to have children
* Definitive (removal of the uterus and possibly the ovaries)
## Footnote
symptoms may recur after hysterectomy and oophorectomy
58
Prognosis, referral: Endo
* Prognosis is what?
* Large masses may what?
* Typically does not what?
* Refer to who?
* Prognosis is difficult to predict in regards to pain parameters
* Large masses may rupture, causing an acute abdomen from bleeding
* Typically does not impact life span, though pain may be disabling
* Refer to Gynecology if surgical management necessary
59
# ⭐️
What is Amenorrhea (primary and secondary)?
Amenorrhea – absence of menstruation
* Primary Amenorrhea- no menarche by 15 years old
* Secondary amenorrhea- amenorrhea for 3 or more months with previously regular menstrual cycles
60
# ⭐️
* What is Oligomenorrhea?
* What is menopause?
* Oligomenorrhea: reduction of the frequency of menses: interval being more than 35 days but less than six months
* Menopause- Amenorrhea for 12 months without other apparent cause
61
# ⭐️
What is precocius menstruation?
Precocious menstruation- Menarche before 9 years of age
62
Causes of Amenorrhea
* What are the different alteration of genital outflow tract? (primary and secoundary)
Congenital Mullerian duct abnormality (FSH is normal)
* Mullerian duct abnormality -> absence of uterus/ vagina and/or imperforate hymen
**Gonadal dysgenesis is most common cause of physiologic primary amenorrhea (Turner syndrome)**
**Asherman syndrome is the most common anatomic cause of secondary amenorrhea** (intrauterine adhesions causing outlet/inlet obstruction after D&C)
63
Other Causes of Amenorrhea
* What are some other causes of amenorrhea besides alreration of genital outflow tract? (general-4)
* Menopause
* Pregnancy
* Hypothalamic pituitary dysfunction
* ovarian dysfunction
64
Causes of Amenorrhea: Hypothalamic-pituitary dysfunction
* GnRH decreased ->
* What are causes?
* What can stimulate GN secretion and follicular rupture?
* GnRH decreased ->decreased FSH/LH -> decreased estrogen/progesterone -> disruption of ovulation and menstruation
* Weight loss (low estrogen), obesity, anorexia, illicit substance abuse, thyroid dysfunction
* Clomiphene citrate (Clomid) can stimulate Gn secretion and follicular rupture
65
Causes of Amenorrhea: Ovarian dysfunction
* What happens?
Ovarian follicles/granulosa cells are either ”worn out” or resistant to FSH/LH (perimenopause), leading to low estrogen (menopause)
66
# ⭐️⭐️⭐️
Amenorrhea Tests
* What test?
* What does that convert to?
* Progesterone "challenge test"
* Progesterone converts the proliferative endometrium into a secretory endometrium
67
# ⭐️⭐️⭐️
Amenorrhea Tests:
* What should you administer?
* What happen if withdrawl bleeding occurs?
* Administer either 100mg progesterone injection or 5-14 day course of oral medroxyprogesterone
* If withdrawal bleeding occurs, it is Secondary Amenorrhea (if not, go back to primary causes)
68
69
Amenorrhea Tests
* When should you order an antimullerian hormone level?
If FSH/LH, prolactin and estradiol levels are normal, uterus is present without evidence of any obstructions, there is no aneuploidy, and progesterone test is positive and patient is still not able to conceive, you should order antimullerian hormone (AMH) level.
70
# ⭐️⭐️⭐️
Amenorrhea Tests: AMH
* What does it correlate to?
* When are the levels high and low?
* What can it mean if there is high and low levels?
* AMH level correlates to the ability to produce eggs
* AMH levels are highest in teenagers, lowest in menopause
* High level of AMH may also mean PCOS
* Low level of AMH can also mean premature ovarian failure
71
Defining menstruation
72
Abnormal Uterine Bleeding
* What are the different types? (5)
* Passage of large clots (dime sized clots are common)
* Duration greater than seven days - anemia
* Flow greater than 80 mL/cycle (i.e. more than six full pads or tampons per day)
* Occur more frequently than every 21 days or less frequently than every 45 days
* Intermenstrual bleeding or postcoital spotting
73
Abnormal Uterine Bleeding
* MC caused by what?
* Proliferative endometrium is never converted to?
* Most commonly caused by infrequent ovulation and chronic exposure to estrogen
* Proliferative endometrium is never converted to secretory endometrium (due to absence of progesterone associated with ovulation) and outgrows its blood supply, sloughing irregularly.
74
# [](http://)
Abnormal Uterine Bleeding
* What is polymenorrhea?
* What is menorrhagia?
| *
* Polymenorrhea: frequent bleeding (every 21 days or less)
* Menorrhagia: prolonged or excessive uterine bleeding that occurs at regular intervals (loss of ≥ 80mL; lasts > 7 days)
75
Types of abnormal uterine bleeding
* What is metorrhagia?
* What is menometorrhagia?
| *
* Metrorrhagia: irregular bleeding or bleeding between periods (bleed all the time)
* Menometrorrhagia: frequent bleeding that is excessive in amount and duration (poly and metrorrhagia combined)
76
What are the steps to evaluate abnormal bleeding?
77
Endometrial Ultrasound
* Measure what?
* Varies at different stages of what?
* Measure endometrial thickness (stripe)
* Varies at different stages of cycle but acceptable within 2-16mm in reproductive years
78
Endometrial Ultrasound
* In postmenopausal women (not on tamoxifen), what is normal?
In postmenopausal women (not on tamoxifen), 5mm or less is the upper limit of normal
* Many subcategories such as with or without bleeding (that’s not important)
79
Postmenopausal Uterine Bleeding
* What should be used to always evalute?
* Ultrasound
* Hysteroscopy (less common)
80
Postmenopausal Uterine Bleeding
* What are the causes? (3)
* Atrophic vaginitis or endometrial atrophy- lower estrogen (thinning of the vagina/uterus)
* Cervical or uterine polyp
* Endometrial hyperplasia- especially with HRT
81
Treatment of Abnormal Uterine Bleeding
* Progesteronal agent to convert what?
* Progesteronal agent to convert proliferative endometrium to secretory endometrium (Progesterone challenge for 10 days)
* Oral course of medroxyprogesterone acetate
82
Treatment of Abnormal Uterine Bleeding
* What are the other txts?
83
Menopause
* What is it?
* What happens to the oocytes?
Menopause: cessation of menses
* Oocytes increasingly resistant to FSH-> high serum FSH and low estrogen
84
Menopause
* Perimenopause?
* What is the mean age?
* What is premature ovarian failure?
* Perimenopause: 3-5 years surrounding menopause
* Mean age in the US is 51.5 years
* Premature ovarian failure: prior to age 40
85
86
87
Menopause
* how do you dx?
Diagnosis
* Clinical
* Serum FSH
88
## Footnote
When a woman's FSH blood level is consistently elevated to 30 mIU/mL or higher, and she has not had a menstrual period for a year, it is generally accepted that she has reached menopause
89
Menopause
* What are the alternatives to hormone replacement therapy?
* Diet less than 30% fat and rich in Ca+ (at least 1500mg daily) and Vit. D
* Regular exercise, particularly weight resistance
* Healthy weight
* Avoid smoking
* Limit EtOH
* Soy and isoflavones -> vasomotor sxs
* St. John’s wort -> moderate depression
* Black cohosh -> vasomotor sxs
* SSRIs -> improve sleep and hot flashes
90
Menopause
* What for more severe complications?
Biphosphonates or SERMs (tamoxifen)
91
Menopause
* Unopposed estrogen causes an increased risk of what? Best if what?
* What is the hormone replacement therapy? What are the types
Unopposed estrogen-> increased risk of endometrial CA
* Best if there is no uterus (but not exclusive)
Estrogen plus progesterone
* Continuous estrogen with cyclic progesterone resolves symptoms but results in a monthly w/d bleed
* Daily administration of estrogen plus progestin eliminates the w/d bleed
92
Menopause
* Who are good candidates for SHORT-TERM estrogen therapy?
Most postmenopausal women (with the exception of women with breast cancer or known cardiovascular disease), who have symptoms of vaginal atrophy and/or vasomotor instability are good candidates for SHORT-TERM estrogen therapy
93
Atrophic Vaginitis in Menopause
* Urogential atropy is the result of what? What happens?
Urogenital atrophy — result of decreased estrogen
* Lactobacilli disappear, pH increases (>5) and average secretions decrease
94
Atrophic Vaginitis in Menopause
* What are the symptoms?
Pruritis, vulvar irritation, dysuria (bladder has estrogen receptors too), dyspareunia, spotting, leukorrhea
95
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Atrophic Vaginitis in Menopause
* Almost all postmenopausal women are candidates for what?
* What do you give for mild urogenital atrophy symptoms?
* What do you give for moderate to severe sxs?
Almost all postmenopausal women are candidates for vaginal estrogen (with the exception of women with a history of breast CA)
* Mild urogenital atrophy symptoms -> vaginal moisturizing agents on a regular basis and lubricants during intercourse
* Moderate-to-severe symptoms, or for those in whom moisturizers and lubricants are ineffective -> low-dose vaginal estrogen (Premarin cream, Vagifem tablet)
96
Leiomyoma (Fibroid)
* MC what?
* What is it?
* Not the same as what?
* Most common benign neoplasm of the female genital tract
* Discrete, round, firm tumor composed of smooth muscle and connective tissue
* Not the same as adenomyosis (endometrial tissue growing within the uterine muscle)
97
Leiomyoma (Fibroid)
* Very commen when?
* More common in who?
Very common during reproductive years
* Most common indication for hysterectomy
African American x3>Caucasian
Usually multiple
## Footnote
* Up to 75% of women will have them
* Usually multiple
98
99
Morphology: fibroid
* What type of mass?
* What does it show microscopical?
* Firm, well-circumscribed mass
* Microscopic – interlocking fascicles of smooth muscle cells.
100
Morphology: Fibroid
* Most convenient classification is by anatomic location:
* **Intramural**: centered in the muscular wall of the uterus; most common
* **Subserosal**: just beneath the uterine serosa
* **Submucosal**: in the muscle beneath the endometrium
101
Clinical Presentation: Fibroid
* What are the sxs?(5)
* Menorrhagia
* Pelvic/abdominal pain
* Recurrent miscarriage
* Infertility
* Abnormally contoured enlarged uterus
102
Fibroid treatments:
* What are they responsive to? What happens?
Leiomyomas are hormonally responsive; tend to stop growing or regress after menopause due to estrogen
103
Treatment of fibroids:
* COC's do not do what?
* What cannot be used?
* What is the most effective for size reduction and degree of bleeding?
* COC’s do NOT decrease size of fibroid
* Levonorgestrel-releasing IUD cannot be used with intracavitary or pedunculated fibroid
* GnRH agonists is most effective for size reduction and degree of bleeding
104
GnRH agonists
* What are the SE?
* Primarily used as what?
* cts: hot flashes, sleep disturbance, vaginal dryness, myalgias and arthralgias, and possible impairment of mood and cognition and osteoporosis after long-term (12+ months) use
* Primarily used as preoperative therapy; not appropriate long term therapy
105
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Treatment: Fibroids
* What needs to be done if anemic or menorrhagia? Why?
Annual pelvic exam and CBC if anemic or menorrhagia
* R/o endometrial hyperplasia or cancer if patient is of late reproductive years or post-menopausal with menorrhagia
106
Fibroid: surgical
* What are the three options? (general)
* Myomectomy
* Uterine artery embolization
* Hysterectomy is definitive management
107
Surgical Therapy
* Why myomectomy? What is hte disadvantage?
* For women who have not completed childbearing or otherwise wish to retain their uterus
* The disadvantage os this procedure is the significant risk that more leiomyomas will devlop. Fibroids are usually multiple so that is not very useful
108
Surgical: fibroid
* What is uterine artery embolization based on?
Based on the hypothesis that bilateral reduction of uterine arterial blood flow will result in infarction of fibroids
109
What are the complications of fibroid?
110
Endometrial cancer
* Primarily occurs in who?
* What are the risks?(5)
* Primarily occurs in post-menopausal women
* Obesity, late menopause, altered menstrual cycles are risks
* Tamoxifen and estrogen replacement therapy increase risk
111
Endometrial cancer
* What is the pathology of it?
* Adenocarcinomas in 75-80% of cases
* Mucinous carcinoma, papillary serous carcinoma make up the remaining
112
Endometrial Carcinoma
* What are the risk factors?
Risk Factors for endometrial cancer: chronic increase of estrogen exposure.
* Unopposed estrogen therapy⭐️
* Chronic anovulation – not normal hormonal fluctuation
* Obesity
* HTN
* DM
* Personal or FMH of breast or ovarian CA
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Endometrial Carcinoma
* 90% will have what? What does it look/smell like?
* 90% will have abnormal vaginal discharge
* Leukorrhea (mild, odorless discharge, clear/milky)
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Endometrial Carcinoma
* How do you dx it?
Endometrial bx
D&C
Transvaginal U/S
* Sonohysterogram (transvaginal u/s with fluid for contrast)
Hysteroscopy
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Endometrial Carcinoma
* What is the txt?
* Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the treatment of choice and is used for staging.
* Radiation is used preoperatively to improve resection
