Diseases/ Disorders of the Uterus

What uterine procedure

surgical removal of the uterus

hysterectomy

What uterine procedure

series of graduated dilators are inserted into the cervix to dilate- followed by scaring of the endometrium

dilation and curettage (D&C)

What are some indications for D&C?

•AUB

•Incomplete or missed abortion

•Inability to perform EMB in the office

•Postmenopausal bleeding

•Suspected endometrial polyps

What uterine procedure allows direct visualization of the endometrial cavity?

hysteroscopy

What uterine procedure is used to burn away at the uterine lining--- and is tx for AUB in pts that do not wish to become pregnant?

endometrial ablation

What is the radiographic examination of the uterus and fallopian tubes?

hysterosalpingography

What is the ultrasound that is preformed using a transducer inserted into the vagina to view the internal female reproductive organs?

transvaginal ultrasound

What occurs in endometriosis?

Ectopic endometrial tissue implants outside of the uterus, grows and elicits an inflammatory response

What is the MC location of endometriosis?

ovary

What hormone is dependent in endometriosis?

estrogen

What is the term for the implants in endometriosis?

"endometriomas"

What are some common symptoms of endometriosis?

dysmenorrhea (MC), deep dyspareunia, infertility, dyschezia

What are the RFs associated with endometriosis?

•Family history

•Nulliparity

•Early menarche, late menopause

•Shorter menstrual cycles

•Heavy menses

•Outflow obstruction

What are some possible pelvic exam findings for endometriosis?

•Exam may will be NORMAL

•“Classic sign”

•Uterus relatively fixed and retroflexed

•Ovarian endometriomas may be tender, palpable, and freely mobile in the pelvis

What is the definitive diagnosis for endometriosis?

direct visualization during laparoscopic surgery with biopsy confirmation

What are some gross appearances for endometriosis?

-Small, dark red “mulberry” or brown “powder burn” lesions

-Cysts filled with dark- red or brown fluid “chocolate cysts”

What is a form of endometriosis that occurs as a cyst on the ovary and forms a dark fluid-filled cavities that can vary in size

-AKA "chocolate cysts"?

endometrioma

What are some treatment options for endometriosis?

NSAIDs, COCs, Androgen derivative (Danazol), GnRH agonist (Lupron), GnRH antagonist (Orilissa)

What is the definitive surgical treatment for endometriosis (IS NOT A CURE)?

TAHBSO

What occurs when endometrial tissue grows into the myometrium and can cause secondary amenorrhea with PE findings of a tender uterus that is "Boggy"?

adenomyosis

Primary or secondary amenorrhea:

adenomyosis

secondary

What is the typical PE finding for adenomyosis?

Uterus is tender, symmetrically and diffusely enlarged and globular “boggy uterus

In adenomyosis the endometrial tissue grows into what?

myometrium

What is the definitive dx of adenomyosis?

histologic examination of hysterectomy specimen

What is the tx for adenomyosis?

resolves after menopause

- tx similar to endometriosis

What is a benign uterine tumor of SM cells that are surrounded by a pseudocapsule of compressed muscle fibers and high estrogen states like pregnancy can induce rapid growth ?

uterine leiomyoma

What is the MC uterine tumor?

Uterine leiomyoma

What type of uterine leiomyoma:

arise from myometrium at the serosal surface of the uterus

subserosal

What type of uterine leiomyoma:

located within the uterine wall, most common

intramural

What is the MC type of uterine leiomyoma?

intramural

What type of uterine leiomyoma:

protrude into the uterine cavity – associated w. miscarriage

submucosal

What type of uterine leiomyoma is commonly associated with miscarriage?

submucosal

What type of uterine leiomyoma:

on a stalk, arise from anywhere

pedunculated

These are PE findings associated with what?

•Enlarged, mobile uterus with an irregular contour

•Asymmetrical uterus

•Nontender

•Solid/firm

uterine leiomyoma

What is the diagnostic test of choice for uterine leiomyoma?

US

What is heavy bleeding tx for pts with uterine leiomyoma that do not desire fertility?

•Hysteroscopic myomectomy to remove submucosal fibroids

•COCs, Progestin IUD

•TXA on heavy days

What is a uterine artery embolization?

•Viable alternative to myomectomy or hysterectomy

•Create infarction and cut off blood supply feeding the tumor

What do we do for a pt that has compromised infertility due to cavity distortion?

myomectomy

What is the MC indication for hysterectomy?

fibroids

What is the criteria for a hysterectomy?

•Failed prior conservative therapies

•Palpable abdominally and concerning to patient

•Excessive bleeding

•Anemic

•Pelvic discomfort

What are the contraindications for a hysterectomy?

•Desire to maintain fertility

•Asymptomatic leiomyoma of 12 weeks gestation

What is the MC location for ureteral injury?

cardinal ligament

What should you suspect in a pt with a rapidly enlarging uterus?

uterine sarcoma

What are the common symptoms of uterine sarcoma?

postmenopausal women with:

-Rapidly enlarging uterine mass (involves body of uterus)

-Postmenopausal bleeding

-Unusual vaginal discharge

-Pelvic pain

What is the MC presenting symptom of endometrial polyp?

AUB

What is a benign overgrowth of the endometrial gland and stroma?

endometrial polyp

What arises due to proliferation of the endometrial glands?

endometrial hyperplasia

What is the MC precursor for endometrial carcinoma?

atypical hyperplasia

What is a common cause of AUB due to Overgrowth of endometrium in response to excess unopposed estrogen?

endometrial hyperplasia

Continued ____ stimulation can result in endometrial hyperplasia.

estrogen

In a pt with suspected endometrial hyperplasia -

A transvaginal US that shows Lining of _____ in postmenopausal patient, a polypoid mass, or fluid collection requires further evaluation.

> 4mm

What is the GS to confirm endometrial hyperplasia?

endometrial biopsy

If endometrial hyperplasia is left untreated what can it lead to?

endometrial carcinoma

What is the definitive therapy for endometrial hyperplasia?

hysterectomy

What is the preferred tx for endometrial hyperplasia WITHOUT ATYPIA?

progestin therapy

What is the preferred tx for atypical endometrial hyperplasia?

hysterectomy

- progestin therapy alternative

What is the MC cancer of the endometrium commonly occurring in postmenopausal women?

adenocarcinoma

AUB especially in postmenopausal women is what?

endometrial cancer until proven otherwise!!

In a postmenopausal pt these symptoms could be what?

- AUB

- vaginal discharge

- pelvic pain/discomfort

endometrial carcinoma

What will a transvaginal US of endometrial cancer show?

Will show a thickened endometrial lining

-Postmenopausal lining should always be < 5mm

What is the GS diagnostic for endometrial carcinoma?

endometrial biopsy

What is the primary treatment for endometrial carcinoma?

hysterectomy

What marker can we use in predicting the treatment response and surveillance for endometrial carcinoma?

CA-125

What is a condition when scar tissue forms inside the uterus and can cause infertility or increased risk for ectopic pregnancy?

asherman syndrome

What are the diagnostics for intrauterine adhesions (ashermans)?

Hysterosalpingogram or SIS

-Hysteroscopy is gold standard

What is the tx for intrauterine adhesions (ashermans)?

- hysteroscopic lysis of adhesions, catheter balloon placement, estrogen + progestin, followed by repeat HSC

What type of uterine leiomyoma is depicted by #1?

pedunculated

What type of uterine leiomyoma is depicted by #4?

subserosal

What type of uterine leiomyoma is depicted by #3?

submucosal

MC associated with miscarriage!

What type of uterine leiomyoma is depicted by #2?

intramural

MC!

What is the tx for endometrial hyperplasia in a premenopausal women?

MDPA, levonorgestrel IUD, prometrium, COCs

What is the tx for endometrial hyperplasia in a postmenopausal women?

Progestin therapy (NOT COCs) or hysterectomy