Menstrual and Uterine disorders Flashcards
(130 cards)
1
Q
what 3 processes do we need to have normal menses?
A
- intact HPO axis
- endometrium responsive to hormal stimulation
- intact outflow tract from internal to external genitalia
2
Q
what is Primary Amenorrhea
A
Absence of menses…
- By age 13 (if sexual development also impaired)
- By age 15 (if normal sexual development)
3
Q
MCC of primary amenorrhea? other causes?
A
genetic or anatomic abnormality
- 50% - abnml chromosomes → gonadal dysgenesis - ovarian insufficiency due to premature depletion of oocytes
- 20% - Hypothalamic hypogonadism
- Other:
- GU - absent genitalia; transverse vaginal septum; imperforate hymen
- Endo - pituitary disease; androgen insensitivity
4
Q
definition of Secondary Amenorrhea
A
Absence of menses for >3 cycles or 6 consecutive months in a previously menstruating pt
5
Q
MCC of secondary amenorrhea?
other causes?
A
- pregnancy
- Other common causes - galactorrhea, PCOS, hypothalamic or pituitary disease, adrenal hyperplasia
- Less common - premature ovarian failure, drug-induced
- Rare - Other endocrine disease (DM, thyroid, adrenal), cirrhosis, renal failure, malnutrition
6
Q
3 main categories of causes of amenorrhea?
A
- Hypothalamic-Pituitary Dysfunction
- Ovarian causes
- Anatomic Causes
7
Q
what can cause Hypothalamic-Pituitary Dysfunction that ultimately causes amenorrhea?
A
- GnRH deficiency
- Pituitary dysfunction
- Hyperprolactinemia
- Sheehan’s syndrome - postpartum
pituitary necrosis due to hypovolemia - Surgical destruction
- Infiltrative diseases
8
Q
ovarian causes that causes amenorrhea
A
- Gonadal dysgenesis
- Ovarian failure
- Abnormal steroid enzymes - Unable to produce hormones
- Ovarian resistance - Follicles do not respond to gonadotropins
- Polycystic Ovarian Syndrome (PCOS)
9
Q
3 types of ovarian failure?
A
- Primary - directly due to ovaries
- Secondary - due to hypothalamic or pituitary disease
- Premature - onset of menopause in women <40 y/o
10
Q
anatomic causes that causes amenorrhea?
A
- Mullerian Dysgenesis - congenital absence of uterus and upper ⅔ of vagina; May ovulate and have normal secondary sex characteristics
- Vaginal agenesis
- Transverse vaginal septum
- Imperforate hymen
- Asherman’s syndrome - uterine synechiae (adhesions); Often due to dilation and curettage
11
Q
w/u for primary amenorrhea if (+) 2o sex characteristics
A
- Evaluate anatomy → PE, US; check karyotype
- Pregnancy test
Ovaries are producing estrogen
12
Q
w/u for primary amenorrhea if (-) 2o sex characteristics
A
- Evaluate anatomy
- Check prolactin and TSH
- Check LH and FSH
- Low → hypothalamic/pituitary disease, stress, low weight/malnutrition = MRI
- High → ovarian failure = Check karyotype
Ovaries aren’t producing estrogen
13
Q
w/u for secondary amenorrhea
A
- Physical exam +/- imaging
- Pregnancy test
- TSH and Prolactin
- If abnormal TSH → thyroid disease
- If abnormal prolactin → pituitary imaging - Progesterone Challenge Test
- If bleeding occurs, endometrium is intact but progesterone is lacking
- Anovulation - no production of progesterone by corpus luteum - Estrogen + Progesterone Challenge Test
- No bleed → unresponsive endometrium or blockage of outflow
- If bleeding occurs, suspect hypogonadism - FSH and LH
- If high → primary/premature ovarian failure
- If low → secondary ovarian failure
14
Q
complications of amenorrhea
A
- Infertility
- Lack of normal physical sexual development
- Osteoporosis and fractures
- Endometrial hyperplasia and carcinoma
15
Q
tx for amenorrhea
A
- Correction of underlying disease
- If desiring pregnancy - ovulation induction
- Letrozole (Femara), clomiphene (Clomid)
- Less common - dopamine agonist, gonadotropins - If not desiring pregnancy - estrogen/ progesterone
- Maintain bone density, reduce genital atrophy or other menopausal s/s
- Many women do well on COC
16
Q
Painful menstruation that inhibits normal activity and requires medication
A
Dysmenorrhea
17
Q
3 types of Dysmenorrhea
A
- Primary - no organic, demonstrable cause
- Secondary - presence of another disorder that could cause s/s (endometriosis, adenomyosis, PID, cervical stenosis, fibroids, endometrial polyps)
- Membranous - due to passage of a cast of the endometrium through an undilated cervix (rare)
18
Q
Dysmenorrhea is associated with _____ activity during ovulatory cycle
Abnormal uterine contractions → dec blood flow to uterus → uterine hypoxia
Leukotrienes also contribute
Psych factors may also be involved
A
prostaglandin
19
Q
clinical findings of Dysmenorrhea
A
Pain - hallmark characteristic
- intermittent intense cramps or dull, continuous ache
- at menses or up to 1-2 d prior; Subsides 12-72 hrs after menses begins
- MC recurs
- lower abdomen and suprapubic region; lower back and/or thighs possible
- Impact on ADLs
- N/V/D, malaise, and/or HA
- No significant pelvic disease on PE - pelvic tenderness possible
20
Q
tx of dysmenorrhea
A
- NSAIDs; acetaminophen, consider short-term codeine/opioid if severe
- Continuous heat to abdomen - as effective as ibuprofen, more than acetaminophen
- Hormonal Contraceptives - if no relief from NSAIDs
- Other - Exercise, TENS unit, Ca, Mg
- refractory - surgery
21
Q
what is Psychoneuroendocrine disorder
A
- Restricted to luteal phase of menstrual cycle
- Biologic, psychological, and social parameters
- Poorly understood; not associated with pathologic hormone levels - Serotonergic dysfunction and decreased GABA levels found
22
Q
PMs and PMDD MC at what age?
A
late 20s to early 30s
Up to 75% of women experience
23
Q
Non-Pharmacologic tx for for mild-moderate PMS/PMDD
A
- Change in eating habits
- Avoid or limit - caffeine, alc, tobacco, chocolate, sodium
- small freq meals high in complex carbs - Aerobic exercise, stress management and/or CBT
- Chasteberry, Calcium carbonate (bloating, food cravings, pain), Mg (water retention), Vitamin B6 and vitamin E
24
Q
medications for mild-moderate PMS/PMDD
A
- NSAIDs - headache, breast or abdominopelvic pain
- Spironolactone - cyclic edema
- Bromocriptine (dopamine agonist) - breast pain
25
tx for severe PMS/PMDD
1. **SSRIs - first-line**
1. Hormonal contraception - Often use contraceptives with drospirenone ( Yaz, Yasmin, Beyaz)
2. consider alprazolam
3. _Refractory_ - GnRH agonists - Can induce “medical menopause”
4. _Definitive_ - BL oophorectomy +/- hysterectomy
26
Encompasses both abnormal menstrual bleeding and bleeding due to underlying causes or diseases
Pregnancy, GU disease, systemic disease, cancer
Dysfunctional Uterine Bleeding
27
first eval of DUB
1. bleeding hx
2. PE
3. lab test - CBC, hCG, TSH
4. cervical cytology - can help screen for invasive cervical lesions
- Endometrial cells in postmenopausal pt - abnormal unless on MHT
28
further w/u for DUB
1. **Pelvic US**
- Transvaginal - empty bladder - pelvic organs
- Transabdominal - full bladder - less detail, wider visualization
- Sonohysterography - saline injected in intrauterine cavity - increased sensitivity
2. **Endometrial Bx**
3. **D&C**
4. **Hysteroscopy** - _Gold standard_ for eval pathology in uterine cavity
29
when can observation be the mgmt for DUB?
premenopausal - if serious pathology ruled out and not impacting patient functioning or quality of life
30
tx for premenopausal DUB
1. observation
2. hormones - COC, estrogen
2. acute hemorrhage - IV estrogen
3. refractory - levonorgestrel-releasing IUD, D&C (temporary fix) or endometrial ablation
4. Definitive - hysterectomy
31
causes for postmenopausal DUB
1. **Exogenous hormones** - MCC postmenopausal uterine bleed - Menses usually stop 6-12 months after discontinuing MHT
2. **Vaginal Atrophy** - MCC lower GU tract postmenopausal bleed
- lubricants, topical or systemic estrogen; avoidance of trauma
3. **Tumors of Reproductive Tract** - surgery possible
32
Hysteroscopic procedures - destroy or resect endometrium → eumenorrhea
Similar outcomes with bleeding and patient satisfaction between first and second generation procedures
Endometrial Ablations
33
what are the 1st gen Endometrial Ablations
1. Endometrial vaporization (Nd-YAG)
1. Rollerball electrosurgical desiccation
1. Endometrial resection (electrosurgery)
* Direct hysteroscopic guidance
* Advanced skills and training
* Longer operating times; More complications
34
what are the 2nd gen endometrial ablations?
1. Do _not_ require direct hysteroscopic guidance to perform
1. Quicker and less complicated
1. Thermal energy
1. Cryosurgery
1. Radiofrequency electrosurgery
1. Microwave
35
MC sign from endometrial ablations?
* **Decreased menstrual flow** - 70-80% of patients
* Amenorrhea - 15-35%
36
endometrial ablations are CI if patients want what?
What happens if the CI happens?
* **who desire future fertility**
* Patient will still need adequate post-op contraception
* If pregnancy occurs - miscarriage, prematurity, abnormal placentation, perinatal ablation
37
T/F: patients need to be treated prophylactically with abx for endometrial ablation
F: not needed MC
38
pts may premedicate for 1-2 mo with tx that cause endometrial atrophy, what are they?
* GnRH agonist, combination oral contraceptives, progestins
* Alternatively may consider curettage before procedure
39
CIs for endometrial ablations
1. Obstetric - Pregnancy, Women wishing to preserve fertility
1. Endometrial hyperplasia or genital tract cancer
1. Postmenopausal women
1. Acute pelvic infection
1. Expectation of amenorrhea
1. IUD in place
40
concerns if endometrial ablation is done
| not CIs
1. Patients at high risk for endometrial cancer
1. Large or distorted endometrial cavity
1. Prior uterine surgery
41
1. First tool for endometrial ablation
1. Uterus is distended with saline
1. laser fiber touches endometrium and is dragged across endometrial surface - Creates 5-6mm deep furrows in endometrium
Vaporization (Nd-YAG Laser) - 1st gen
42
2-4 mm ball or barrel shaped electrode
Shorter operating time, less perforation than other first gen methods
Does not work for intracavitary lesions
Rollerball Ablation - 1st gen
43
1. Less expensive and larger loop diameter than laser ablation
1. Resectoscope with electrical current used to excise strips of endometrium
1. Higher rates of perforation
Endometrial Resection - 1st gen
44
1. Uncontained saline solution heated and recirculated for 10 minutes
- Low pressure to avoid opening fallopian tubes to peritoneal cavity
- Water seal to avoid leakage into vagina
1. Allows direct observation of endometrium as it is being destroyed
1. Higher burn risk than other 2nd-gen methods
1. Can use with anatomically abnormal uterus
Hysteroscopic Thermal Ablation - 2nd gen
45
1. Fan-shaped mesh device contours to shape of endometrial cavity
- Uses suction to improve contact with mesh and remove vapor
- Radiofrequency run through mesh fan to desiccate endometrium
1. Does not require endometrial preparation
1. Has been used in patients with small submucosal leiomyomas and polyps
Radiofrequency Thermal Ablation - 2nd gen
46
1. Silicone device contours to shape of endometrial cavity
- Filled with RF-heated argon gas
- Liquid produced during procedure is also heated, providing hot liquid thermal ablation
1. Does not require endometrial preparation
1. Has not been studied in patients with fibroids
1. **Higher rates** of normal or no menstrual flow after the procedure
Thermal + RF Thermal Ablation - 2nd gen
47
1. Uterus is sealed off with balloons
- Uterine cavity then filled with high-temperature water vapor
- Thermal injury causes scarring to endometrium
1. Does not require endometrial preparation
1. May be used in patients with irregular uterine cavity contour
Water Vapor Thermal Ablation - 2nd gen
48
1. Generates temperatures -100 to -120 C to produce an iceball in the endometrial cavity
1. Endometrium undergoes cryonecrosis due to low temperatures
1. Less pain than thermal energy procedures
Cryoablation - 2nd gen
49
what are the 2 endometrial ablation that are no longer in the US?
1. Thermal Balloon Ablation
1. Microwave Ablation
50
Aberrant growth of endometrium outside uterine cavity
Most common GYN diagnosis responsible for hospitalization in women 15-44
Endometriosis
51
Endometriosis MC in who?
1. 53% of **adolescents with severe pelvic pain** warranting surgical evaluation
2. 25-35% of infertile women
3. 6-10% of women in reproductive age group
52
possible causes of endometriosis
1. Retrograde menstruation
1. Genetic predisposition
1. Altered immunity → inhibited ability to recognize abnormal endometrial implants
53
common implant sites of endometriosis
1. ovary, uterine cul-de-sac, pelvic ligaments, uterus, fallopian tubes, large intestine
1. _Other sites_ - small bowel, bladder, ureters, vagina, cervix, scars, umbilicus
1. _Distant sites_ - rare - lung, brain, kidney
54
RF for endometriosis
1. (+) Family history
1. Early menarche
1. Nulliparity
1. Long duration of flow
1. Heavy menstrual bleeding
1. Shorter menstrual cycles
55
negative risk factors of endometriosis
1. Regular exercise
1. Late menarche
1. Higher parity
1. Longer duration of lactation
56
s/s of endomentriosis
1. **dysmenorrhea** (79%), pelvic pain (69%) dyspareunia (45%), infertility (26%)
1. Severity does not correlate with extent of lesions
1. May be asx or only present with infertility!
1. constant pelvic pain or sacral backache
- Often worse just before menses, may persist through menses
- May be accompanied by pelvic pressure
57
other sx of endometriosis based on the sites?
* Urinary - hematuria, irritative voiding
* Bowel - bloody stool, diarrhea, constipation, cramping
* Menstrual - in addition to dysmenorrhea, premenstrual spotting is possible
58
1. tender nodules in posterior vaginal fornix or uterosacral ligaments, and pain with uterine motion
- Uterus may be fixed and retroverted (cul-de-sac adhesions)
- Tender adnexal masses may be felt
- Endometrial implants may be found in healed wounds, in the vaginal fornix, or on the cervix
- **MC no findings on PE**
dx?
endometriosis
59
imaging for endometriosis
***limited** use*
1. **TVUS** - modality of choice to detect for rectum or rectovaginal septum
1. **MRI** - may help diagnose equivocal cases
60
definitive dx for endometriosis and findings?
surgery (laparoscopy) with bx
* _Early lesions_ - small, red, petechial
* _Larger_ - cystic, dark brown, dark blue or black appearance
* _Surrounding peritoneum_ - thickened and scarred - “**powder burn**”
* _On ovary_- enlarge to several centimeters - “**chocolate cysts**”
61
tx for min-mild sx of endometriosis
1. **Expectant management**
1. **Analgesics** - NSAIDs
1. **Hormonal Tx** - combination or progestin-only contraceptives - dec dysmenorrhea and may slow progression
62
tx for Moderate to severe symptoms (unresponsive to mild/mod tx) of endometriosis
1. **Hormonal Tx** - GnRH agonists or antagonists, danazol, aromatase inhibitors
1. **Neuropathic Pain** - gabapentin, pregabalin, TCAs
1. **Surgical** - attempt to excise or destroy endometriotic implants
- Can be done at time of diagnostic laparoscopy
- Post-op pregnancy rates - depend on severity: 75% (mild), 50-60% (moderate), 30-40% (severe)
63
testosterone derivative; acts like progestin
Inhibits gonadotropin release and enzymes that produce estrogen
what drug?
what SE?
* Danazol
* oily skin, acne, deepened voice, weight gain, edema, dyslipidemia
64
inhibit enzymes that make estrogens
Can be used as adjuvant treatment to agents such as GnRH agonists
what med?
Aromatase Inhibitors - Anastrozole or letrozole
65
SE of GnRH agonists & GnRH antagonists
lower BMD, vasomotor symptoms, vaginal dryness, mood changes
66
Infection of upper genital tract
Any combination of - endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
Pelvic Inflammatory Disease
67
cause of PID?
| pathogens
* Often **polymicrobial**
* Associated with **gonorrhea** and **chlamydia**
* May be caused by anaerobes, H. flu, G- rods, streptococci
68
what pts are at highest risk for PID?
young, nulliparous, sexually active women with multiple partners
69
PID is the leading cause for ?
how to prevent?
* infertility, ectopic pregnancy
* Use of barrier contraception
70
_lower abdominal pain_ (insidious or acute)
* May begin during or just after menses
* May be worse with coitus, jarring movement
* bilateral; rarely >2 wks duration
* RUQ pain - associated perihepatitis (*Fitz-Hugh-Curtis syndrome*)
* Other sx - abnml menses, cervical/vaginal discharge, irritative voiding, F, chills, N/V
cervical motion tenderness (*“Chandelier sign”*)
> 38.3 C (101 F)
BL lower quadrant abd tenderness
inflammation of Skene or Bartholin glands
PID
71
w/u for PID
* Pregnancy test - negative
* Vaginal - WBC in vaginal fluid; + G/C nucleic acid probe
* CBC - leukocytosis and left shift
* Inflammatory markers - ESR, CRP may be elevated
* Imaging - TVUS
* Laparoscopy
72
TVUS findings that suggest PID?
1. Thickened, fluid-filled fallopian tubes
1. Free pelvic fluid
1. Tubo-ovarian complex
1. Tubal hyperemia
73
dx PID and treat empirically in sexually active young women and at-risk women if:
1. Pelvic or lower abdominal pain with no other cause identified
1. One or more - cervical motion tenderness, uterine tenderness, adnexal tenderness
74
tx for PID
Empiric, broad-spectrum abx for gonorrhea/chlamydia - **ceftriaxone + doxy + metronidazole**
75
when to admit PID?
1. Complicated - Severe illness, N/V, or high F; Pregnancy; Pelvic abscess (including tubo-ovarian abscess)
1. Unable to exclude surgical emergency
1. Failure to respond to, tolerate, or comply with outpt oral tx
76
* Presentation varies from asx adnexal mass to acute abdomen
* pelvic and abd pain, fever, N/V
* severe abdominal tenderness and guarding
* Pressure can cause rupture of abscess and peritonitis - acute abdomen, septic shock
Tubo-Ovarian Abscess
77
classic pt for Tubo-Ovarian Abscess
young, low-parity, hx of pelvic infection
78
imaging of choice for tubo-ovarian abscess
* **US** - Complex, multiloculated adnexal mass
* CT will also diagnose
79
complications of tubo-ovarian abscess?
1. Unruptured - rupture (15%), sepsis (10-20%); Long-term - reinfection, bowel obstruction, infertility, ectopic pregnancy
1. Ruptured - septic shock, intra-abdominal abscess, septic emboli
80
tx for tubo-ovarian abscess
1. Unruptured - similar to inpt PID but duration usually 4-6 weeks; surgical drainage if large or no improvement w/ abx
1. Ruptured - life-threatening emergency; TAH and BSO w/ fluids and abx
1. TOA in postmenopausal pt - high risk of concurrent malignancy
81
types of pelvic organ prolapse
1. **Cystocele** - anterior vaginal wall defect (bladder); **anterior vaginal prolapse**
1. **Uterine prolapse** - descent of the uterus
1. **Vaginal vault prolapse** - post-hysterectomy
1. **Enterocele** - bowel in prolapsed segment of vaginal wall
1. **Rectocele** - posterior vaginal wall defect (rectum); **posterior vaginal prolapse**
82
staging of pelvic organ prolapse
1. Staged based on most severe portion of the prolapse when straining
1. **Pelvic Organ Prolapse Quantification (POP-Q)** - most precise and objective
1. **Baden-Walker Halfway System** - scores each organ prolapse individually
- 0 - Normal
- 1 - halfway to hymen
- 2 - to hymen
- 3 - halfway past hymen
- 4 - Maximum possible descent for site
83
s/s of pelvic organ prolapse
1. Vaginal - fullness, pressure, heaviness, and/or discomfort
- “Something falling out” or “Sitting on a ball”
- Soft, reducible mass bulging into vagina or through introitus - inc w/ strain/coughing
- Coital laxity
2. Pain - back pain, vaginal pain, and/or pelvic pain
3. Urinary - stress incontinence, frequency, hesitancy, incomplete bladder emptying; May need to “splint” bladder to void
4. Defecatory - incomplete emptying, need to strain; May need to “splint” vagina or perineum to defecate
84
RF for pelvic organ prolapse
1. OB/GYN - incr parity, h/o pelvic surgery, Postmenopausal
1. Age
1. Obesity or physical debilitation
1. Chronic coughing (lung disease) or straining (constipation)
1. Neurologic decline
85
Imaging for pelvic organ prolapse is usually only done if ?
other underlying process suspected or equivocal case
86
Physical exam techniques to help dx pelvic organ prolapse
* Inspect vulva and perineum - note prolapse at rest
* Stress test (cough test) for urinary incontinence
* Assess strength - vaginal support with strain, anal sphincter tone, pelvic floor strength
* If no prolapse seen with supine pt, examine in standing position
87
conservative tx options for pelvic organ prolapse
1. Pessary - intravaginal device
2. Pelvic floor exercises (Kegel Exercises), topical estrogens
88
mgmt of pessary for pelvic organ prolapse?
- Must be fitted by provider - can cause pressure necrosis and ulceration
- Re-examine 1-2w after pessary placement, 4w after, then q 3-6m or q 2-3m if pt cannot remove and clean device
89
surgical tx for pelvic organ prolapse
* Multiple methods for repair of fibromuscular vaginal wall
* May involve use of synthetic mesh - Can put at risk for vaginal erosions, dyspareunia, pelvic pain
* Advise pts - risk for recurrence even after surgical repair
90
Uterine enlargement due to ectopic endometrium deep within the myometrium
Adenomyosis
91
cause of Adenomyosis?
pregnancy, surgery, dec hormones may weaken myometrium - Allows endometrium to invade
92
RF for adenomyosis
1. **Parity** - nearly 90% of cases are in parous women
1. **Age** - nearly 80% develop in 40s and 50s
93
1. Menorrhagia, dysmenorrhea
1. global uterine enlargement
- Rarely greater than that of a 12 week pregnancy
- Smooth uterine contour
- Generalized softening of uterus
- Minimal hemorrhage during menses
Adenomyosis
*More areas of invasion = more symptoms*
94
w/u for adenomyosis?
findings?
**TVUS**
* _Myometrium_ - focal thickening, heterogeneous texture, cysts
* _Endometrium_ - projections into myometrium, ill-defined echo
95
difference between adenomyosis vs leiomyomas on imaging?
adenomyosis has poorly defined margins, elliptical shape, lack of calcifications
96
tx options for adenomyosis
symptom relief
1. **NSAIDs** - pain
1. **COCs, progestin-only contraceptives** - pain and bleeding
1. **Endometrial ablation/resection** - help somewhat; Will not treat deep lesions
1. **_Definitive_ - hysterectomy**
97
adenomyosis sx often subside after what?
menopause
98
MC benign neoplasm of female genital tract; Benign smooth muscle tumors
AKA “myomas,” “fibroids,” “fibroid tumors”
Leiomyomas
99
3 types of Leiomyomas
1. Submucous - directly beneath endometrial lining
1. Subserous - directly beneath serosal lining
1. Intramural - completely within myometrium
100
what two things can leiomyomas do that can become a problem?
1. Can become pedunculated and undergo torsion
1. Can become parasitic
101
1. *Most are asx*
1. MC - abnormal uterine bleeding, pelvic pressure/pain
- Pain - if torsion, infarction, degeneration occurs
1. Local compression of other pelvic organs
1. Infertility, miscarriage, pregnancy complications
1. uterus may be enlarged, may have irregular contour
Leiomyomas
102
w/u for Leiomyomas
* May see iron-def anemia; Rare - polycythemia d/t myoma EPO production
* **US** - confirm presence, and monitor growth
* MRI - intramural vs submucous
* Hysterography/Hysteroscopy - confirm cervical or submucous
103
tx for leiomyomas
1. **Asx** - **observation**; annual exam
- No intervention needed unless significant pressure on pelvic organs, severe bleeding/anemia, torsion of pedunculated myoma, or rapid growth
2. **Medical tx** - **NSAIDs, hormonal therapy (contraceptives, GnRH agonists)**
3. **Surgical** - myomectomy, hysterectomy, uterine artery embolization; May treat preop w/ _hormone tx to reduce myoma size_
104
leiomyomas will regress spontaneously after what?
menopause
105
MC GYN malignancy
Endometrial Cancer
106
Endometrial Cancer MC in who?
1. White - 2.4% lifetime risk; Black - 1.3% lifetime risk; 8% better survival for white women
1. Peak onset - 70s
- 20-25% occur in premenopausal women
- 20-30 yrs possible
107
MCC of endometrial cancer
| pathogenesis/physiology
**MC endometrial hyperplasia**
* **Estrogens** - stimulate endometrium
* **Progesterones** - antiproliferative
* Long-term estrogen exposure → hyperplasia → cancer
108
MCC of endogenous overproduction of estrogen
obesity
109
causes of Abnormally high levels of estrogen in/from?
1. **obesity**
2. MetS
3. PCOS
4. Exogenous _unopposed_ estrogen therapy
5. Chronic anovulation
6. Granulosa cell tumors of ovary
7. Tamoxifen (SERM) - 2-3x increased risk
110
other RF for endometrial cancer?
1. **GYN hx** - early menarche, late menopause, low parity
1. History of breast cancer
1. Western society - high animal fat in diet
1. Older age - 75-80% are in _postmenopausal_ women
1. FHx - Hereditary Nonpolyposis Colorectal Cancer (HPNCC)
1. Comorbidities including DM, HTN, gallbladder disease
111
what 2 factors reduce risk of endometrial cancer?
1. **COC** - min 1 yr lasts for 10-20 yrs; Progestin - chemoprotective biologic effect; Progesterone IUDs may also be protective
1. **smoking** - less estrogen, wt reduction, earlier menopause, latered hormonal metabolism, current and past smokers
112
MC sx of endometrial hyperplasia?
abmml uterine bleeding
113
difference between simple vs complex hyperplasia without atypia
* Simple: 1% progress to endometrial cancer w/o tx; 80% spontaneously regress w/o tx
* Complex: 3-5% progress to endometrial cancer w/o tx; 85% regress with progestin therapy
114
Endometrial glands lined with enlarged cells
Considered premalignant
Progress to cancer - 10% of simple atypical, 30% of complex atypical
Endometrial Hyperplasia with Atypia
115
mgmt for Endometrial Hyperplasia with Atypia
* **progestin therapy**; _Higher rate of relapse_ after progestin tx than non-atypical lesions
* If intolerant of progestin therapy or relapse following - **hysterectomy**
116
* 85% of cases
* Younger patients
* More favorable prognosis
* Low grade or well-differentiated
which type of endometrial CA?
type I
117
* 15% of cases
* Older patients
* Poorer prognosis
* Independent of estrogen
* Associated with endometrial atrophy
which type of endometrial CA?
Type II Endometrial Cancer
118
classic presentation of endometrial CA?
obese, nulliparous, infertile, hypertensive, DM white woman
Only **25%** of pts have a known hx of hyperplasia
119
spread of endometrial CA?
direct extension, peritoneal implants, lymphatic and/or hematogenous
120
MC type of cancer in endometrial CA?
adenocarcinoma
121
which type of endometrial CA is More likely to be in older patients; poorer prognosis
Less associated with hyperestrogenic states
Serous
122
which type of endometrial CA is High-grade and aggressive
Not associated with hyperestrogenic state
Clear Cell Carcinoma - 1-4%
123
s/s of endometrial CA
* **abnml bleeding - MC, earliest sx**, Always work-up a postmenopausal pt with bleeding
* abnml vaginal discharge
* Lower ab cramps and pain - Cervical os stenosis → hematometra; Can develop abscess and sepsis
* PE - unremarkable; age-related changes (atrophic vaginitis); +/- Blood; Early - nml uterus, Late - enlarged and/or fixed uterus, local LN and/or ovarian metastases
124
w./u for endometrial CA
1. **Pelvic US**
- **Endometrial thickness >4 mm** in _postmenopausal pt - high suspicion_, do not defer bx with consistent even if < 4 mm
- Can be used to monitor asx high-risk pts
2. **_Definitive - bx_**; endometrial biopsy , D&C, hysteroscopy with bx
125
outpatient, minimal or no anesthesia needed
False negative rate - 10%
which type of bx for endometrial CA
Endometrial biopsy
If symptomatic and negative bx - need D&C
126
more definitive procedure for diagnosis - larger tissue sample
Done inpatient and under anesthesia
Not curative
which type of bx for endometrial CA
D&C
127
other testing for endometrial CA
1. Pap smear
1. CA-125
1. CBC
128
tx for endometrial CA
1. **_Surgery_** - **Total hysterectomy with BL salpingo-oophorectomy** and staging with pelvic and periaortic lymphadenectomy
- Surgery alone may be curative in *low-risk, localized disease*
2. _Adjuvant_ - radiation, progesterone, chemo
- **Doxorubicin** and **cisplatin** are 2 most active chemo agents
3. severe anemia - fluids, blood, uterine tamponade w/ vaginal packing; high-dose radiation if fails.
129
5-year survival rates of each endometrial CA staging?
* Stage I - 80-90%
* Stage II - 70-80%
* Stage III - 35-55%
* Stage IV - 17-22%
130
endometrial CA prognosis worsens with what factors?
1. increasing age
1. higher pathologic grade
1. advanced-stage disease
1. increasing depth of myometrial invasion
1. lymphovascular invasion
