Uterine Disorders (CMPP)

Uterine leiomyoma (Fibroids / Myoma)

Local proliferation of smooth muscle cells

Most Common Benign Uterine Tumors

Leiomyoma

Who commonly gets fibroids

Women in 4th-5th decade

Most Common Indication for Hysterectomy

Fibroids

Characteristics of Fibroid Tumors

Large amount of extracellular matrix surrounded by pseduocapsule

Enlarge with estrogen (Pregnancy)

Multiple are usually present

Usually regresses during menopause

Presentation of Fibroids

Can be asymptomatic

Most common symptom = Heavy / Prolonged Bleedings

Bulk Symptoms (Pressure, Congestion, Bloating, Mass, Heaviness, Constipation, Frequency, Retention)

Infertile

Blood Loss → Iron Deficiency Anemia

(Bimanual) Uterus will usually be larger, and irregularly shaped, but mobile

When does pelvic pain occur with fibroids

Degeneration

Torsion

Why does fibroids have reproductive symptoms

Disorts the uterine cavity

What are OB complications of Fibroids

Placental Abruption

IGUR

Malpresentation

Preterm

Miscarriage

Complications of Fibroids

Anemia

OB Complications

Infertility

Endometrial hyperplasia / cancer

Anovulation

Estrogen-producing ovarian tumors

(Rare) Malignancy = Leiomyosarcoma

What are the types of fibroids

Submucous (Below endometrium)

Intramural (Within myometrim)

Subserous (Below serosa / peritoneum)

Cervical

Intraligamentous

Parasitic Myomas

What type of fibroid tends to bleed

Submucosal

What type of fibroid is most common

Subserous

Parasitic Myomas

Pedunculated fibroids on the outside of the uterus

Where do parasitic myomas often get blood supply

Omental or mesenteric

If a mass moves with the cervix, it is likely

Fibroid

A fixed uterus is a red flag for

Malignancy

Endometriosis

What labs are ordered for fibroids

Urine or serum chorionic gonadotropin

CBC +/- ferritin level

Consider endometrial biopsy

Indicaiton for Endometrial Biopsy of Fibroid

AUB with risk factors for endometrial cancer

Risk Factors for Endometrial Cancer

T2DM

Obesity

PCOS

Chronic anovulation

What imaging is done for fibroids

Transvaginal pelvic US

Test of Choice for Fibroids

Transvaginal US

How do fibroids appear on US

Heterogenic, hypoechoic, well-circumscribed

What is the most common treatment plan for fibroids

Observaiton

When do we activly treat fibroids

Tumor > 12-14 weeks in size

Fast growing tumor

HCT falls (Anemic)

Tumor compresses adjacent structures (Bulk Symptoms)

Reproductive Dysfunction

Pain

Medical Treatment Options for Fibroids

OCPs

Levonorgesterel IUD

Lysteada

Progestin-only OCP

GnRH analog

Why are D&Cs done on fibroids

rule out endometrial hyperplasia or endometrial carcinoma in a patient with AUB

Surgical Options for Fibriods

Myomectomy

Hysterectomy

Uterine artery embolization (UAE)

Ablation

Myomectomy

Surgical removal of the fibroid only

Indications for Myomectomy for Fibroids

patients who wish to preserve their fertility

pedunculated fibroids

patients with only one fibroid

Complications from Myomectomy for Fibroid

often more blood loss than hysterectomy

Need Cesarean delivery in future 2° uterine scar

Indication for Hysterectomy for Fibroids

women without future reproductive plans and unremitting symptoms

Uterine artery embolization (UAE)

Catheterization and embolization of the uterine artery, decreases blood flow on both sides

What is the use of GnRH agonists and antagonists for fibroid management

help relieve pain,

decrease the size of the fibroids,

reduce bleeding,

decrease intraoperative blood loss,

Shrinks the uterus temporarily

When is GnRH given for fibroids

up to 6 months

Preoperatively

Endometriosis

Presence of endometrial glands and stroma outside of the endometrial cavity

ectopic menses

ectopic endometrial tissue responds to hormones and goes through cyclic changes, such as menstrual bleeding, and an inflammatory response occurs

Changes from Ectopic Menses

Peritoneal inflammation and pain

Fibrosis

Adhesions

What most commonly causes pain with Endometriosis

Endometriosis

Who is most common to get Endometriosis

age at diagnosis is 15-19

What are the ideas for cause of endometriosis

Retrograde menstruation (Sampson’s theory):

Mesothelial (peritoneal) metaplasia:

Hematogenous/lymphatic transport:

How does Retrograde menstruation cause endometriosis (Sampson’s)

Endometrial tissue fragments are transported through the fallopian tubes and implant into the peritoneal cavity

How does Mesothelial (peritoneal) metaplasia cause endometriosis

Peritoneal tissue becomes endometrial-like and responds to hormones, i.e., the cells are considered multipotential cells

In certain conditions, these cells can develop into functional endometrial tissue

How does Hematogenous/lymphatic transport cause endometriosis

Endometrial tissue is transported via blood vessels and lymphatics

Distant sites of endometriosis are explained by this theory

What causes infertiliy with endometriosis

Anatomic distorion

production of cytokines, proteinoids, or growth factors that are hostile to normal ovarian function, sperm motility, fertilization, and implantation

Endometriosis Triad

Dysmenorrhea

Dysparenia

Dyschezia

Presentation of Endometriosis

Dyspareunia (Deep > Insertion)

Pain Throughout Cycle

Secondary Dysmenorrhea

Premenstrual and Postmenstrual Spotting

Infertility

Tender Fixed Adnexal mass

Retroverted uterus

Tender “barb-wire” uterosacral ligaments

What causes Dyspareunia from Endometriosis

lesions in the cul-de-sac and/or uterosacral ligaments

Most common site for endometriosis

Ovaries

Where can endometriosis form

Ovaries (#1)

uterosacral ligaments,

broad ligaments,

peritoneal surfaces of cul-de-sac,

the rectovaginal septum,

rectosigmoid colon

Endometrioma

Endometriosis cyst of the ovary

What lesion is also called a Chocolate Cyst

Endometrioma

How does Endometriomas present

Filled with thick, chocolate-colored fluid,

adherent to the pelvic side walls

How can endometrial implants present?

Flat, small white or brown discolorations → “powder burns”

Raised, bluish in color → “mulberry spots”

Many have adhesions present

What can elevate CA 125

Any inflammatory condition of the abdominopelvic area

What is needed for defintiive dx of endometriosis

Direct visualization (biopsy recommended) with laparoscopy or laparotomy

Medical Treatment Options for Endometriosis

OCPs and NSAIDs (#1)

Progesterone Therapy

GnRH agonist and anatagonists (Shrink preop)

How is OCPs used for endometriosis

Continous therapy

What is the goal of medical treatment of endometriosis

Supress and atrophy endometrial tissue

MOA of Progesterone for Endometriosis

help suppress gonadotropin release and ovarian steroidogenesis

Will help atrophy the uterine endometrium and, therefore, help decrease endometrial implants

Surgical Options for Endometriosis

Laparoscopic Removal

Hysterectomy + Bilateral Salpingo-Oophorectomy

What should be given after laparoscopic removal of endometrial implants

Levonorgesterl IUD or OCPs x 6 - 24 months

Indication for Hysterectomy and bilateral salpingo-oophorectomy for Endometriosis

severe symptoms are present and the patient has exhausted all other treatments and does not desire future childbearing

Why are the ovaries removed with hysterectomy for endometriosis?

Recurrence risk

Adenomyosis

Endometrial glands and stoma are present within the muscle of the uterus

(endometriosis interna)

Who commonly gets Adenomyosis

nulliparous women in their 40s

Presnetation of Adenomyosis

Severe secondary dysmenorrhea and menorrhagia

chronic pelvic pain

Uterus is symmetrically enlarged (globular)

uterus is softer, often described as “boggy”

may be tender

Test of Choice for Adenomyosis

Transvaginal ultrasound

If US is unclear for Adenomyosis, what other imaging can be used?

MRI

Why is endometrial biopsy done with adenomyosis

rule out endometrial hyperplasia and endometrial cancer

What are the treatment options for Adenomyosis

Conservative

Endometrial Ablation

Hysterectomy

Conservative Treatment for Adenomyosis

NSAIDs

Progesterone (PO or IUD)

OCPs

GnRH Analogs and Antagonsits

When can the ovaries remain after hysterectomy for Adenomyosis

If < 45 y/o

Endometrial hyperplasia

Abnormal proliferation of glandular and stromal elements of the endometrium resulting in histologic alteration in the cellular architecture of the endometrium

Endometrial hyperplasia can progress to

endometrial carcinoma

Risk factors for endometrial hyperplasia

exogenous estrogen alone

history of chronic anovulation

Increasing age

Tamoxifen therapy

Nulliparity

Patients with late menopause (>55 years old)

PCOS

Obesity

DM

Genetic syndromes (Lynch, Cowden)

Presentation for Endometrial Hyperplasia

abnormal or excessive uterine bleeding

Occasionally, uterus enlarged

Who most commonly gets endometrial hyperplasia

perimenopausal or early postmenopausal patients

What is the workup for Endometrial Hyperplasia?

Transvaginal ultrasound (Measure endometrial strip)

Endometrial biopsy

D&C with hysteroscopy

Indication for D&C for Endometrial Hyperplasia

Office sampling is not possible

Inconclusive from endometrial biopsy

What are the histological variants of endometrial hyperplasia

Hyperplasia without atypia (non-neoplastic)

Atypical hyperplasia (neoplastic)

Characterisitcs of Endometrial Hyperplasia without Atypia

Gland-to-stroma ratio is increased

Proliferation of both stromal and glandular endometrial cells

No cytologic atypia is present

Characteristics of Atypical Endometrial Hyperplasia

Contains cellular atypia and mitotic figures in addition to glandular crowding and complexity

more severe the atypia, the more the cancer risk

Simple Endometrial Hyperplasia

Proliferation of stroma and glandular cells

Complex Endometrial Hyperplasia

Proliferation of glandular cells without stromal cells

Complex Atypical Endometrial Hyperplasia

Glandular crowding and cellular atypia

Treatment of Endometrial Hyperplasia without Atypia

Cyclic Progesterone (10-14 days per month x 3-6 months)

Progesterone IUD

OCPs

When is continous progesterone preferred to cyclic for endometrial hyperplasia?

irregular cycle

Bleeding

Treatment for Atypical Endometrial Hyperplasia

Hysterectomy (Preferred)

endometrial curettage, and long-term progesterone use + Yearly Endometrial Biopsy (Fertility Seeking)