Uterine disorders Flashcards
(29 cards)
For hereditary breast and ovarian cancer syndrome, what is recommended?
surveillance - periodic surveillance with CA-125 and TV-US starting at age 30 or 5-10 years earlier than earliest age of 1st diagnosis of ovarian cancer in family
OCPs if benefit>risk
Sapingo-oophorectomy by age 40 or after childbearing
For lynch syndrome, what is recommended?
TVUS for ovarian cancer starting at age 30 or 3-5 years earlier than earliest age of diagnosis
hysterectomy or bilateral salpingooophorectomy at end of childbearing or age 40
— — — depends on:
Confirming source
Excluding pregnancy + confirming premenopausal
Regular ovulatory or anovulatory bleeding?
Contribution of structural abnormalities (PALM)
Identification of medical conditions that may affect
Contribution of medications (OCPs, anticoags, supplements)
abnormal uterine bleeding
Menstrual bleeding of abnormal quantity, duration, or schedule
PALM + COEIN
Adolescents: persistent anovulation due to immaturity of HPO axis, ovulatory dysfunction
19-39: pregnancy, structural lesions, anovulatory cycles, hormonal contraception, endometrial hyperplasia
abnormal uterine bleeding
LABS: CBC, pregnancy, thyroid, coagulation, urinalysis, cervical cytology?
AUB-O → test progesterone
IMAGING:
– TV US: fibroids, adenomyosis, endometrial thickness
– sonohysterography or hysteroscopy: polyps, subserosal myomas
– MRI (not primary): definitive submucosal myomas and adenomyosis
Endometrial sampling to determine if hyperplasia or carcinoma is present
>/= 45
Younger patients with history of unopposed estrogen exposure (obesity, PCOS)
Failed medical management, persistent
abnormal uterine bleeding
Refer if bleeding not controlled, surgery
Admit if bleeding is uncontrollable with first-line therapy, unstable
abnormal uterine bleeding
how do you treat abnormal uterine bleeding?
Depends on etiology -
Structural abnormalities – targeted therapy
Ovulatory dysfunction: hormonal treatment
Thyroid dysfunction?
Contraceptives – combined OCPs, hormonal IUD
Nonhormonal options: NSAIDs, tranexamic acid
Ineffective results from medical management → surgery
————Structural lesions
Women without structural lesions → endometrial ablation
Endometrial hyperplasia without atypia - surveillance, OCPs, progestin
With atypia: hysterectomy
AUB, heavy menstrual bleeding, dysmenorrhea, cramping
Dyspareunia with deep penetration
Pelvic pressure
Infertility and pregnancy loss
Growth is estrogen dependent
leiomyoma
What are RF for leiomyoma?
Increasing age, AA, first-degree family Hx, early menarche (<10), late menopause, obesity
PROTECT: smoking, exercise, late menarche/early menopause, OCPs
MC benign neoplasm of female genital tract, growths of smooth muscle of uterine wall:
– discrete, round, firm, often multiple composed of smooth muscle + connective tissue
Classified by anatomic location:
Intramural, submucous, subserous, cervical
leiomyoma
Pelvic exam: normal or palpable discrete firm, nontender, asymmetric, mobile mass on bimanual exam
LABS: iron deficiency
IMAGING:
-TV US to confirm
-MRI to delineate location
-Hysterography or hysteroscopy can confirm cervical or submucous myomas
leiomyoma
how do you treat leiomyomas?
NONSURGICAL:
Non hormonal - NSAIDs, tranexamic acid
Hormonal - combined OCP, hormonal IUD, GnRH agonists, GnRH antagonists (relugolix + estradiol + norethindrone OR elagolix + estradiol + norethindrone)
SURGICAL:
Myomectomy in those who wish to preserve fertility
Hysterectomy, hysteroscopic resection
+ preop reduction of myoma size with GnRH analogs!
Many are asymptomatic
Chronic pelvic pain is most common
Dysmenorrhea, AUB (menorrhagia), infertility
adenomyosis
Reproductive age
Benign condition resulting in ectopic placement of endometrial tissue in myometrium
Strong association with leiomyoma and endometriosis
adenomyosis
gold standard = Hysterectomy and histologic observation
TVUS, MRI
Pelvic exam: symmetrically diffusely enlarged “boggy” and “globular” mobile uterus
adenomyosis
how do you treat adenomyosis?
GnRH agonists - decreasing estrogenic stimulation
Progestins + combined OCPs
Definitive = hysterectomy
Infertility, dysmenorrhea, dyspareunia, dyschezia
Constant pelvic pain or low sacral backache premenstrually and subsides after menses begins
Bloody urine or stool in perimenstrual interval (if lesions in urinary/bowel areas)
Premenstrual spotting
Cyclic pelvic pain + dysmenorrhea + dyspareunia
endometriosis
what are RF for endometriosis?
Family Hx, early menarche, long duration of menstrual flow, heavy bleeding during menses, shorter cycles
Prolonged estrogen exposure!
PROTECT: regular exercise >4 hours/week, higher parity, longer duration of lactation
Abnormal growths of endometrium-like tissue present in locations other than uterine lining – commonly on peritoneal surfaces of reproductive organs and adjacent structures of the pelvis
Severity not dictated by symptoms
MCC of secondary dysmenorrhea
endometriosis
Pelvic exam:
tender nodules in posterior vaginal fornix and pain with uterine motion
Uterus fixed and retroverted due to cul-de-sac adhesions
Adnexal masses felt
Lesions in healed wounds, vaginal fornix, cervix
Biopsy may be required
Pelvic US to rule out other causes
Some patients may have no abnormal findings
Final diagnosis can only be mad at laparoscopy or laparotomy with direct observation/biopsy
endometriosis
how do you treat endometriosis?
Empirically with ruling out other causes
Analgesics
–Asymptomatic or mild discomfort, no abnormalities on pelvic exam, no desire for immediate fertility
Hormone therapy
OCPs - monophasic products
Progestins
Danazol
GnRH agonists with use limited to 6 months (leuprolide)
+ AIs - anastrozole and letrozole
Conservative surgical therapy in those who want to preserve fertility, have severe disease, have adhesions
With no desire for future childbearing and severe disease: definitive surgery → total abdominal hysterectomy, bilateral salpingo-oophorectomy, excision of remaining adhesions
Abnormal bleeding
50-70 years
Obesity, nulliparity, DM, PCOS, prolonged anovulation, unopposed estrogen therapy, extended use of tamoxifen in BC, colon cancer family Hx, postmenopausal
endometrial cancer
MC: adenocarcinoma
Reduce risk of hyperplasia with OCPs, cyclic progestins, hormonal IUD, especially in those with chronic anovulation
endometrial cancer
gold standard: Prompt endometrial sampling for all >45 who report abnormal menstrual bleeding and those with postmenopausal uterine bleeding
Differentiate from hyperplasia
Pap smear: atypical endometrial cells
Simultaneous hysteroscopy: localize polyps or other lesions
Pelvic US: determine thickness of endometrium
<4mm is reassuring
endometrial cancer
