Uterine

Uterus

Leiomyoma (fibroids)

  • MC in black pts

  • Hormone sensitive neoplasms (benign) of smooth muscle and C.T.

  • MC tumor of ♀ GU

  • RF: early menarche, nulliparity, obesity, family hx

  • SSX

    • Abnormal menstruation ↑ bleeding with periods ➔ anemia

    • Mass effect ➔ back pain, pelvic/fullness, constipation, LUTS can ➔ hydronephrosis

    • Dyspareunia, infertility

  • DX

    • US: hypoechoic, heterogeneous tumors

    • Calcifications suggest necrosis and may be seen on CT/X-ray

    • Hysteroscopy or saline infused US can better visualize submucosal fibroids

  • TX

    • ASX/incidental finding do not require tx and will ↓ with ↓ estrogen (menopause)

  • SX TX

    • Dual oral contraceptives ➔ ↓ bleeding/pain but can ↑ leiomyoma size

      • F/u US q 6mo

      • Leuprolide (GnRH agonist) for no more than 6mo to shrink tumor

      • Myomectomy - surgical removal of fibroids (preserves fertility)

    • Definitive TX is hysterectomy (no urge to conceive in future/postmenopausal)

Submucosal > intramural in causing infertility

Endometriosis

  • MC in white pts

  • Endometrial tissue outside uterus (ovaries (MC) anterior bladder, bowel)

  • Hormone sensitive

  • Endometrial cells seeding may play a role

    • Iatrogenic implantation (episiotomy/laparotomy)

    • Retrograde menstruation (menstrual backflow)

  • SSX

    • Dysmenorrhea (pain ↑ during periods)

    • Back pain, rectovaginal tenderness

    • Dyschezia (painful BM), infertility, pelvic pain/fullness

    • Can ➔ adhesions

  • DX

    • Trans-vag US shows ovarian chocolate cysts

      • Cyst with hemorrhagic debris ➔ homogeneous ground-glass

    • Laparoscopy confirms

      • Large black/blue spots (large lesions or powder burn)

      • ± Bladder/rectovaginal nodules

  • TX

    • NSAIDs and dual oral contraceptives

    • Danazol (ADR ➔ ♂ sex features)

    • Leuprolide (GnRH agonist) with DOC to inhibit ADR of ↓estrogen

    • Goserelin will force menopause

    • Refractory ➔ surgery

      • No urge to conceive in future/postmenopausal:

        • Ablation or artery ligation

        • Hysterectomy

Adenomyosis

  • Benign growth of endometrial tissue into myometrium

  • In the DfDX of endometriosis

  • MC 35-50yo

  • RF: Endometriosis, fibroids

  • SSX

    • Dysmenorrhea, bleeding, pelvic pain affected by menses

    • Globular, soft, enlarged but tender uterus

  • DX

    • Myometrial wall thickening (asymmetric)

  • TX

    • DOC or progestin only

Endometrial hyperplasia

  • ↑ estrogen ➔ ↑ proliferation

    • PCOS, hormone replacement therapy

    • Without atypia has low risk of carcinoma

    • With atypia has ↑ ↑ risk of carcinoma

  • SSX

    • Bleeding/spotting

  • DX

    • US to assess endometrial thickening: >4mm in postmenopausal, >15mm in premenopausal

      • Still menstruating endometrium ranges from 3-15mm

    • Endometrial biopsy

    • FSH, estrogen to investigate other source of estrogen (ovarian tumors)

  • TX

    • Without atypia: Progestin only (from d12-25 of cycle if premenopausal) and f/u every 3-6mo with US

    • With atypia: Total hysterectomy with bilateral salpingo oophorectomy (TAH/BSO) if no urge to have children

Endometrial Cancer (Adenocarcinoma)

  • MC 65-74yo

  • ↑ estrogen or SERM for breast cancer ➔ atypical endometrial hyperplasia ➔ endometrioid adenocarcinoma

    • Multiparity, dual oral contraceptives is protective

  • Contiguous spread, LN later, rarely hematogenic mets to lungs

    • TYPE 1: from prolonged estrogen exposure ➔ hyperplasia

    • TYPE 2: stronger genetic component

  • SSX

    • Painless vaginal bleeding is endometrial cancer until proven otherwise

      • Peri/premenopausal: metorrhagia (heavy bleeding between periods)

    • Seen incidentally on pelvic US - endometrial stripe

  • DX: Endometrial biopsy

  • TX

    • Stage 1 cancer: TAH/BSO with pelvic and para-aortic LN sampling ± radiation

    • Stage 2 cancer: TAH/BSO with LN excision ± and radiation

Abnormal Uterine Bleeding

  • Heavy menstrual/intermenstrual bleeding

    • Structural (PALM): Polyp, adenomyosis, leiomyoma, malignancy/hyperplasia

    • Nonstructual (COEIN): Coagulopathy, ovulatory, endometrial, iatrogenic, not yet classified

  • DX

    • HCG, CBC, TSH, FSH/LH

    • Endometrial biopsy if >45yo

    • TVUS first

  • TX

    • Dual oral contraceptives, progestins

    • Severe AUB:

      • Uterine curettage first

      • Refractory bleeding ➔ IV conjugated equine estrogen

      • Refractory to IV estrogen ➔ hysterectomy