Uterine Disorders - Med II Vosk

pt has benign growths of smooth muscle cells on uterine wall. most common tumor of female reproductive tract. this occurs because cells that should’ve died off don’t and continue to remain in the uterus. pt has AUB, heavy menstrual bleeding, dysmenorrhea, dyspareunia, pelvic pressure, infertility, recurrent pregnancy loss.

leiomyoma

what is the FIGO classification system

classifies myomas by location. not the best form of classification

this type of fibroid creates a change in the architecture of the uterine cavity.

submucosal fibroids

this type of fibroid that lies within the myometrium. depending on size and position it can protrude out to abdominal cavity or inward creating defects in uterine cavity.

intramural fibroids

this type of myoma lies under peritoneal layer covering uterus and protrude outward to abdominal cavity, but can also change the myometrium.

subserosal myomas

this type of myoma lies within the broad ligament

interligamentous myomas

pt has dec QoL like AUB most commonly, HMB, pelvic pressure and pain, lower back pain, constipation, infertility (bc zygote can’t readily implant bc of so many masses), and spontaneous abortions. pts also have heavy or prolonged menses.

myomas

what is the most common presenting complaint of uterine fibroids?

abnl uterine bleeding, usually seen in submucosal fibroids

pt has heterogeneously enlarged uterus that is palpated, often with small, smooth masses. r/o pregnancy and confirm with imaging

uterine fibroids

how do myomas cause pelvic pain and pressure

based on size and location, if greater than 5cm causes more pain. creates local ischemia that causes pain and presents similar to an acute abdomen. they cause inc cytokine production = inc inflammation = pain. submucosal myomas = HMB and clots that make dysmenorrhea worse

how do uterine fibroids contribute to infertility

submucosal or intramural fibroids disrupt endometrial cavity.

pt has distended abdomen that looks similar to advanced gestation. palpable large abdominal mass/es. not always true, can be completely nl looking/feeling. bimanual exam shows heterogeneously enlarged uterus with multiple small smooth masses. this dz is

uterine fibroids

what labs would you order when you suspect uterine fibroids?

SIS>MRI>TVUS. can’t fully dx unless you do a hysterectomy.

how do uterine fibroids cause complications in pregnancy

bc it inc the amount of hs to create worse sx for the pt. they outgrow their blood supply in pregnancy and become necrotic. inc risk of c section and inc blood loss and risk of postpartum hemorrhage. if pt had past myomectomy then inc risk of uterine rupture

what is the gold standard definitive tx for uterine fibroids

hysterectomy

how do you tx asx uterine fibroids

do nothing, no need for medical intervention

how do tx leiomyomas with meds

GnRH agonists like leuprolide acetate, aromatase inhibitors.

how to surgically tx leiomyomas BESIDES a hysterectomy

uterine artery embolization (UAE), laparoscopic uterine artery occlusion (UAO, not good for ppl who want future fertility), magnetic resonance guided focused ultrasound (MRgFS, not for those that want future fertility), endmetrial ablation (EA, useful in managing HMB), myomectomy thru hysteroscopy or laparascopic or open (good for future pregnancy)

complications of leiomyomas in pregnancy

myomas grow bc of inc hormones. bc uterus is soo big in pregnancy that adding additional masses can have worse mass effect sx. inc maternal discomfort. can become necrotic bc can’t outgrow blood supply. pt have further blood loss.

how tot tx leiomyomas

GnRH agonists like Leuprolide. Aromatase inhibitors. Surgical management like Uterine artery embolization, lararoscopic uterine artero occlusion, magnetic resonance guided focused ultrasound, endometrial ablation. myomectomy is common bc for pts who desire future fertility. hysterectomy is for repeat surgical interventions for pts who are not having children.

pt has benign condition resulting in ectopic placement of endometrial tissue in myometrium. pt can have AUB and dysmenorrhea. co-occurs with myomas or endometriosis. pts are usually asx but also have menorrhagia, dysmenorrhea,, infertility, and dyspareunia. pathology shows it as glands and stroma surrounded by myometrium. assoc w inc production of estrogen and dec sensitivity to progesterone bc of downregulation of progesterone b receptor. worse neonatal outcome

adenomyosis

how to dx adenomyosis

hysterectomy and observation is gold standard. imaging shows diffusely enlarged, poorly visualized endometrial myometrial junction, no vascular flow to lesions, cystic lesions in myometrium. TVUS shows cystic lesions.

how to tx adenomyosis

GnRH agonists, Progestins and combined OCPs. surgical like hysterectomy, or less invasive to spare the uterus and cut out the adenoma… but risk of uterine rupture in future pregnancy is high

pt has growth of endometrial like tissue outside the uterus. one of the most common gynecological diseases. pt has dysmenorrhea, chronic pelvic pain, mentrual or cyclical GI sxs, and or urinary sxs, OR infertility associated with 1 sx. Pelvic pain is most common sx. presents in a cyclic manner aligning with onset of menstrual pain. also dysmenorrhea and dyspareunia and infertility. this dz is

endometriosis

what medication is assoc with endometriosis

digoxins

how to diagnose endometriosis

definitive thru histologic study of tissue thru biopsy. non definitive from hx and pelvic exam findings (pelvic tenderness, enlarged ovaries, fixed retroverted uterus). lesions are black “powder burn” or “gunshot” lesions or “chocolate cycts”

how to tx endometriosis surgically

cyctectomy, laparaoscopic uterosacral nerve ablation which dec uterine pain, presacral neurectomy, hysterectomy with salpingo-oophorectomy in pts with debilitating sx who don’t wanna get pregnant

how to tx endometriosis with meds

NSAIDs, combined OCPs, progestins, danazol (test derivative, SE of hirsutism, mood changes, weight inc, myalgias, deep voices), GnRH agonists

pt has a focal growth of endometrial glands and stroma. forms vascular core protruding into uterine cavity in sessile or pedunculated fashion. incedential finding on pelvic imaging. hyperestrogenic tissue and antiapoptotic alterations. inc expression of estrogenic receptors stims growth. pt has intermenstrual bleeding VERY common, AUB, post coital bleeding, HMB, dec reproductive potential.

endometrial polyps

this medication has been found to increase occurrence of endometrial polyps

tamoxifen

this condition appears red or yellow in color, has a well defined shape, and protrude from endometrial wall. on microscopy they’re glands and stroma covered in surface epithelium on 3 sides with a central vascular core.

endometrial polyps

how do you dx endometrial polyps

TVUS

how to tx endometrial polyps

surgery w transcervical polypectomy to cure. if pt has recurrent polyps then hysterectomy is option