women's health uterine d/o

uterine corpus

portion of uterus superior to internal cervical os bordered laterally by broad ligaments

leiomyoma

benign growths of smooth muscle cells on uterine wall, m/c tumor of female reproductive tract

AUB, heavy menstrual bleeding, dysmenorrhea, dyspareunia w/ deep penetration, pelvic pressure, infertility, recurrent pregnancy loss

leiomyoma

m/c reason for hysterectomy

myomas

leiomyoma risk factors

increasing age, Black, first degree fhx, menarche under 10 yo, late menopause, obesity

leiomyoma protective factors

smoking, exercise, increased parity, late mearche/early menopause, OCP use

leiomyoma pathogenesis

poorly understood, arise form alteration in single cell, regulated by hormonal/cytokine stimuli, epigenetic changes, changes in uterine environment, myoma monoclonal cell lines undergo antiapoptotic changes, bulk of fibroid due to expansion of extracellular matrix

FIGO classification system

classifies myomas by location, classification systems have low reproducibility

submucosal fibroids

create change in architecture of uterine cavity

intramural fibroids

lie w/i myometrium, depending on size and positioning can protrude outward to abdominal cavity or inward creating defects in uterine cavity

subserosal myomas

lie under peritoneal layer covering uterus and protrude outward to abdominal cavity but can also alter myometrium

interligamentous myomas

lie w/i broad ligament

myomas beyond uterus are classified as

parasitic or metastatic

myoma pathology

fibroid tumors have white-grey or yellow appearance, myomas are contained inside pseudocapsule

myoma ddx

ovarian and colonic masses can mimic appearance on imaging, other ddx adenomyosis, ovarian cysts, endometriosis, polyps, grossly proliferative endometrium, endometrial hyperplasia/malignancy, ovarian malignancy, leiomyosarcoma

m/c presenting sx of myoma

AUB/HMB, pelvic pressure and pain, infertility, spontaneous abortions

AUB most frequently seen in ____ fibroids

submucosal

myoma related pain directly related to

size and location

how do myomas create pain

infarction and increasing local inflammatory response (cytokines)

fibroids and infertility

submucosal/intramural disrupt endometrial cavity, possibly associated w/ infertility, not necessarily true for myomas that do not disrupt uterine cavity

myoma exam findings

distended abdomen, large mass(es), enlarged uterus w/ masses on bimanual exam

myoma lab findings

none, pt c HMB may have findings consistent w/ anemia, goal of imaging to assess size and location, hysteroscopy cannot detect intramural/subserosal

myoma imaging

SIS>MRI>TVUS

gold standard dx and tx for myomas

hysterectomy

myoma and pregnancy

myomas can grow as result of increasing hormonal stimulus, worsen sx of mass efect, increase maternal discomfort, can impact maternal/neonatal outcomes, myomas can outgrow blood supply and become necrotic, increased risk of primary C section/bloodloss/PPH, increased risk of uterine rupture

myoma tx

asx require no intervention, GnRH agonists, aromatase inhibitors, uterine artery embolization, laparoscopic uterine artery occlusion, magnetic resonance guided focused ultrasound, endometrial ablation, myomectomy, hysterectomy

myoma prognosis

benign condition w/ v good prognosis, hysterectomy definitive tx, 0.1-0.8% transform to sarcoma

adenomyosis

benign condition resulting in ectopic placement of endometrial tissue in myometrium, largely asx, many pts present c complaints of AUB/HMB ± dysmenorrhea

adenomyosis concurrence

40% myomas, 80% endometriosis

adenomyosis pathogenesis theories

invagination of endometrium in myometrial wall, metaplasia of embryonic remnants in myometrial wall developing into adenomyosis, differentiation of stem cells into adenomyosis

adenomyosis pathology

glands and stroma surrounded by myometrium, associated w/ increased production of estrogen, exhibits decreased sensitivity to progesterone due to downregulation of progesterone receptor B, likely a genetic/epigenetic component, no association btwn adenomyosis and endometrial ca

adenomyosis ddx

r/o pregnancy, r/o endometriosis/endometrioma, endometrial hyperplasia/malignancy, leiomyoma, leiomyosarcoma

adenomyosis clinical findings

asx, menorrhagia, dysmenorrhea, dyspareunia, infertility, pelvic pressure, AUB, associated w/ worse neonatal outcomes, preterm delivery, PPROM, SGA infants

gold standard dx adenomyosis

hysterectomy and histologic observation

adenomyosis imaging findings

diffusely enlarged, poorly visualized endometrial-myometrial junction, absent vascular flow to myometrial lesions, cystic lesions in myometrium

adenomyosis TVUS

appearance of cystic lesions in myometrium

adenomyosis complications

anemia due to blood loss, no long term complications, infertility risks

adenomyosis tx

GnRH agonists, progestins and combined OCPs decrease estrogen, definitive is hysterectomy, other surgery undermine serosal layer and excise focal adenoma or diffuse excision around uterine wall

endometriosis

growth of endometrial like tissue outside of uterus, mainly occurs during reproductive years

dysmenorrhea, chronic pelvic pain, dyspareunia, menstrual related/cyclical GI sx, and/or urinary sx or infertility associated w/ one other sx

endometriosis

endometriosis pathophysiology

exact etiology unknown, estrogen key factor, impaired progesterone causes apoptosis of endometriosis tissue, ingestion of dioxins associated w/ endometriosis

endometriosis definitive dx

histology studies of tissues removed during surgery, lesions often described as powder burn or gunshot leasions or chocolate cysts

endometriosis nondefinitive dx

hx and pelvic exam findings, pelvic tenderness, enlarged ovaries, fixed retroverted uterus

endometriosis nonpharm tx

exercise, massage therapy

endometriosis surgical tx

primary recommendation for sx or large endometriomas, cystectomy>cyst drainage, laparoscopic uterosacral nerve ablation, presacral neurectomy, hysterectomy for pts c debilitating sx

endometriosis medication

NSAIDs first line, combined OCPs, progestins, danazol (testosterone derivative), GnRH agonists

endometrial polyps

common, largely benign condition, form as result of focal growth of endometrial glands and stroma, form around vascular core protruding into uterine cavity in either sessile or pedunculated fashion, generally incidental finding on pelvic imaging, could present as part of workup for AUB or infertility

endometrial polyp age range

prevalence increases w/ age, peak incidence 4th decade of life, slight decrease w/ menopause

endometrial polyp pathogenesis

stems from hyperestrogenic tissue response and antiapoptotic alterations, have increased expression of estrogenic receptors which stimulate their growth as well as angiogenesis to growing polypoid tissue, certain meds (tamoxifen) found to increase occurence

endometrial polyp pathology

red or yellow, well defined shape, protrude from endometrial wall, on microscopy EPs are glands and stroma covered w/ surface epithelium on 3 sides surrounding central vascular core

endometrial polyp ddx

r/o pregnancy, endometrial hyperplasia or malignant leiomyoma, leiomyosarcoma, cervical ca, atrophic endometrium

endometrial polyp clinical findings

AUB, intermenstrual bleeding, postcoital bleeding, HMB, decreased reproductive potential

how do endometrial polyps affect reproduction

decrease area for implantation, disrupt embryos that implant adjacent, polypectomy shown to improve pregnancy rates

endometrial polyp imaging

TVUS

endometrial polyp complications

irregular vaginal bleeding

endometrial polyp tx

transcervical poypectomy often curative, hysterectomy can be an option but highly unlikely, low risk of malignancy and prognosis is good