Gynecology - Uterine Leiomyoma(fibroids), endometrial cancer and endometrial hyperplasia

Question 1

What is a uterine leiomyoma?

Answer 1

Benign smooth muscle neoplasm originating from the myometrial cells. Usually clinically insignificant, but very common.

Question 2

What is the most common benign tumor in women?

Answer 2

Uterine leiomyoma

Question 3

What does a uterine leyiomyoma look like?

Answer 3

Gross: Elliptical, pearly white and firm, of a rubbery consistency and covered by a distinct connective tissue.
Histo: Elongated smooth muscle cells aggregated in bundles. Minimal to no mitotic activity. Lack of vascular organization.

Question 4

What are Leiomyomas sensitive to?

Answer 4

Estrogen and Progesterone

Question 5

What is characteristics of leiomyoma considering its environment?

Answer 5

It creates a hyperestrogenic environment. Relative to normal myometrium:

• Leiomyoma cells contain more estrogen receptors
• Leiomyoma cells convert less estradiol to estrone
• Leiomyoma cells contain more aromatase enzyme

Question 6

Risk factors of uterine leiomyoma?

Answer 6

• Women in mid-age
• Black race
• Primary relative hx
• Overweight
• Early menarche
• PCOS
  ! Risk DECREASES with parity, giving birth at an early age, and likely decreases with use of COCs !

Question 7

Symptoms of uterine leiomyoma?

Answer 7

Most are asymptomatic.

• Menorrhagia w/pelvic pressure (most common)
• Dysmenorrhea
• Chronic pelvic comfort
• Acute pain less common, but can happen
• Can cause infertility

Question 8

What happens if there is a sudden pelvic pain in leiomyoma?

Answer 8

Due to degeneration of a leiomyoma

Question 9

Types of degeneration of uterine leyiomyoma?

Answer 9

• Hyaline
• Liquefaction
• Mucoid
• Fatty
• Red (carneous)
• Calcification
• Sarcomatous (malignant)

Question 10

Uterine leiomyoma on physical examination?

Answer 10

Uterine enlargement w/irregular contour. Should be nontender or minimally tender.
Sonography is the imaging modality of choice. Leiomyomas may be hyperechoic or hypoechoic, but they will appear as discrete masses.

Question 11

Medically managing uterine leiomyoma

Answer 11

As most fibroid are minimally symptomatic, they may be managed by pt education and annual surveillance.

Medical therapy:

• NSAIDS for dysmenorrhea/pain
• COCs for pain, menorrhagia
• LNG-IUS (Mirena) for pain, menorrhagia
• GnRH agonists are effective for a variety of fibroid-related sx.

Question 12

Surgically managing

Answer 12

1. Uterine artery embolization
2. Myomectomy (may be performed laporascopically, hysteroscopically, or open) - Particularly used if fertility is the main issue of concern.
3. Hysterectomy.

Question 13

What is the most common cancer of the female genital tract?

Answer 13

Endometrial cancer

Question 14

What is the most common type of endometrial carcinoma?

Answer 14

Adenocarcinomas (75%). These arise from endometrial hyperplasia caused by a hyperestrogenic environment.

Question 15

Risk factors for endometrial carcinoma?

Answer 15

1. Hyperestrogenism
   - High dose menopausal estrogens (10-22x RR)
   - Obesity (2-4x)
   - Nulliparity (2x)
   - Early menarche
   - Late menopause
   - Use of tamoxifen
   - PCOS
2. Medical conditions: type 2 DM, hypertension, gllbladder disease, lynch syndrome
3. White race
4. Higher SES
5. Older age

Question 16

Histologic variants of endometrial cancer, and which is most common?

Answer 16

1. Endometrial adenocarcinoma (75%)
2. Serous carcinoma (5-10%)
3. Clear cell carcinoma (<5%)
4. Mucinous carcinoma
5. Mixed type
6. Undifferentiated (rare)
7. Squamous cell carcinoma (extremely rare)

Question 17

Type 1 endometrial carcinoma?

Answer 17

Endometrial adenocarcinoma (75%)

Question 18

Type 2 endometria carcinoma?

Answer 18

Serous carcinoma + Clear cell carcinoma

Question 19

Se tabell om type 1 og type 2

Answer 19

i endometrial cancer filmen 15.43

Question 20

What is the most common presentation of endometrial carcinoma?

Answer 20

Abnormal uterine bleeding

• Premenopausal: menorrhagia, intermenstrual spotting
• Postmenopausal: any bleeding.

Question 21

What is the imaging test of choice, and what can you see?

Answer 21

Transvaginal sonography.

• In postmenopausal: a thickened endometrial stripe is suspicious for endometrial adenocarcinoma
• In premenopausal: TVS is less useful as the endometrial thickness can vary depending on where she is in her cycle.

Question 22

What should be done after diagnosing endometrial carcinoma?

Answer 22

1. TAH + BSO
2. Peritoneal washing
3. Pelvic and para-aortic lymphadenectomy

• Once removed, the uterus should be opened and assessed for degree of myometrial invasion.
  Also order C-xray + Ca-125

Question 23

Stage I of endometrial cancer is:

Answer 23

Stage I: Tumor confined to corpus uteri

• Stage 1a: < 50% myometrial invasion
• Stage 1b: > 50% myometrial invasion

Question 24

Stage II of endometrial cancer:

Answer 24

Stage II: Tumor invades cervical stroma but does not extend beyond the uterus

Question 25

Stage III of endometrial cancer:

Answer 25

Stage III: Local and/or regional spread of the tumor - Stage 3a: invades serosa, adnexae or peritoneum - Stage 3b: Vaginal and/or parametrial involvement - Stage 3c: Metastasis to pelvic or para-aortic nodes

Question 26

Stage IV of endometrial cancer:

Answer 26

Stage IV: Metastasis to bowel or bladder or beyond - Stage IVa: Metastasis to bowel or bladder mucosa - Stage IVb: Distant metastasis including abdominal structures and/or inguinal lymph nodes.

Question 27

Treatment of stage I endometrial cancer

Answer 27

TAH + BSO Pelvic/para-aortic lymphadenectomy Removal of any visible malignancy - Remove uterus! Otherwise, no treatment.

Question 28

Treatment of stage II endometrial cancer

Answer 28

TAH + BSO Pelvic/para-aortic lymphadenectomy Removal of any visible malignancy - Remove uterus! + Radiation!

Question 29

Treatment of stage III endometrial cancer

Answer 29

TAH + BSO Pelvic/para-aortic lymphadenectomy Removal of any visible malignancy - Remove uterus! + Chemotherapy and radiation!

Question 30

Treatment of stage IV endometrial cancer

Answer 30

TAH + BSO Pelvic/para-aortic lymphadenectomy Removal of any visible malignancy - Remove uterus! + Chemotherapy and radiation!

Question 31

What is the chemotherapy protocol in endometrial carcinoma?

Answer 31

The TAP protocol + added progestins. T - Taxol (Paclitaxel) A - Adriamycin (doxorubicin) P - Platinum (cisplatin)

Question 32

What is endometrial hyperplasia?

Answer 32

endometrial thickening with a proliferation of irregularly sized and shaped glands.Endometrial biopsy is the test of choice when endometrial hyperplasia is suspected.

Question 33

Risk factors of endometrial hyperplasia

Answer 33

Hyperestrogenism Postmenopausal women May be a precancerous lesion Medical conditions: type 2 DM, hypertension, gallbladder disease

Question 34

Symptoms of endometrial hyperplasia?

Answer 34

Abnormal uterine bleeding = most common presentation. Premenopausal: menorrhagia, intermenstrual spotting Postmenopausal women: any bleeding

Question 35

Imaging test of choice for endometrial hyperplasia?

Answer 35

Transvaginal sonography. The thickness of the endometrium is the primary determinant in wheter or not you go forward with a biopsy.

Question 36

What is the criteria to do a biopsy in post vs premenopausal women if suspected endometrial hyperplasia?

Answer 36

Postmenopausal: - Endometrial stripe < 5mm: likely endometrial atrophy - Endometrial stripe > 5 mm: likely endometrial hyperplasia Premenopausal women: - Normal endometrium can vary from 4mm to more than 16mm. - Indications for biopsy are: > 40, risk factors for endometrial carcinoma, significant intermenstrual bleeding or failure of medical treatment for abnormal bleeding.

Question 37

Histological terms of endometrial hyperplasia:

Answer 37

1. Simple: normal arcitecture, but with increased glands and stroma 2. Complex: changes in arcitecture 3. Atypia: changes in the nuclear structure of the cells

Question 38

Which histologic term is the worst, and what is % risk of cancer-progression?

Answer 38

Complex with atypia - 29% progress to cancer

Question 39

Treating endometrial hyperplasia?

Answer 39

- Tx depends on age and wheter or not there is atypia - MDPA (medroxyprogesterone acetate) or megestrol is the medical treatment of choice. - NO atypia: - Premenopaus: MDPA 10-20 mg for 12-14d per month for 3-6m - Postmen: MDPA 2.5mg continuously ATYPIA: - Hysterectomy - If preservation of fertility is desired, high dose MDPA may be started.