Download Reproductive Lecture Preview

Reproductive Blueprint
PANCE Blueprint
Uterus
•
Dysfunctional Uterine Bleeding (DUB)-
•
DUB is defined as irregular uterine bleeding not
due to anatomic lesions in the uterus
•
DUB is usually due to anovulation due to
polycystic ovarian disease, exogenous obesity
or adrenal hyperplasia
•
Females with DUB have irregular often heavy
uterine bleeding
•
Women with DUB have chronic estrus. They
have non regular estrogen concentrations that
stimulate growth and development of the
endometrium
Dysfunction Uterine
Bleeding
•
When there is no predictable effect of ovulation, there is no
progesterone induced changes
•
With DUB the endometrium thickens and outgrows its blood supply and
sloughs off causing irregular heavy bleeding that is not predictable
•
If there is chronic stimulation of the uterine lining form low blood
estrogen, the episodes of DUB are infrequent and light.
•
When there is chronic stimulation from high levels of estrogen, the
episodes of DUB are heavy and happen often
•
Midcycle spotting can happen with ovulation and usually is self limited
attributed to the sudden drop of estrogen
Dysfunctional Uterine
Bleeding
•
Before a diagnosis of DUB is made, need to
rule out structural causes such as uterine
leiomyomata, infection or inflammation of the
genital tract, cervical cancer, endometrial
cancer, cervical erosions, cervical polyps, and
lesion in the vagina.
•
Complications of DUB include blood loss,
endometrial hyperplasia that can lead to
carcinoma, and incapacitating everyday living
•
One treatment of DUB includes treatment with
high dose progesterone for at least 10 day
trying to thin the endometrial strip with
withdrawal bleeding.
•
Another alternative is administration of
contraceptives to establish a regular withdrawal
cycle in an effort to make it predictable
•
If medical treatment fails, may need a D and C
Endometrial Cancer
•
Endometrial Hyperplasia is the
abnormal proliferation of both
glandular and stromal elements
showing altered histologic
architecture
•
Endometrial proliferation is an
overabundance of endometrial
whereas endometrial hyperplasia
involves the structural elements.
•
Different types of endometrial
hyperplasia include cystic glandular
hyperplasia, adenomatous
hyperplasia, and atypical
adenomatous hyperplasia
Endometrial Cancer
•
Important concept is with continued estrogen stimulation
through either endogenous or exogenous sources simple
endometrial proliferation will lead to endometrial hyperplasia
•
Risk factors for endometrial hyperplasia and endometrial
carcinoma are anything that lead to an increase in estrogen in
the environment.
•
Diagnosis of endometrial hyperplasia or carcinoma is made by
taking a sample. Common ways to accomplish this are
endometrial biopsy, D and C, or by removing of the uterus.
•
The most common indication for endometrial sampling is
abnormal bleeding especially those that are over 35.
Endometrial Cancer
•
Most endometrial polyps are focal
accentuated benign hyperplastic
processes.
•
Estrogen is implicated in
antecedent hyperplasia; however,
the actual stimulus to malignant
degeneration to endometrial
carcinoma is unclear
•
Endometrial carcinoma usually
occurs in women that are post
menopausal
•
Most primary endometrial
carcinomas are adenocarcinomas
Endometrial Cancer
•
Special consideration for endometrial sampling should be given to those with
post menopausal bleeding that occurs after at least 6 months of amenorrhea.
•
Endometrial carcinoma usually spreads throughout the endometrial cavity first
and then begins to invade the myometrium, endocervical canal and
eventually the lymphatics
•
Once there is extrauterine spread to the abdominal and pelvic cavity, the
spread can be similar to ovarian cancer
•
Common histologic subtypes on endometrial carcinoma include: papillary
serous adenocarcinoma and clear cell adenocarcinoma
•
The biggest prognostic factors is the histologic grade of endometrial cancer
(Grading System is G1-G3)
Endometrial Cancer
•
Surgical treatment is the
cornerstone of therapy for
endometrial carcinoma. The
abdomen pelvic cavity is explored
and a TAHSO is performed
•
Adjunctive therapy may include
external beam radiation to reduce
reoccurrence
•
The first line treatment of recurrent
disease is hormonal and includes
progesterone at high doses.
Chemotherapy is also used
Endometriosis
•
Endometriosis is the presence
of endometrial tissue at
extrauterine locations
•
Endometriosis typical presents
with complaints of infertility,
dysmenorrhea, dyspareunia,
and chronic pelvic pain
•
The definitive diagnosis of
endometriosis requires
histologic confirmation at the
time of laparoscopy
Endometriosis
•
Different approaches to different
patients in treatment
•
Women in late 40's with mild
symptoms may just observe to wait on
menopause because the decrease in
hormones will not stimulate growth of
disease
•
Medical therapy is aimed at inducing
inactivity of endometrial
tissue. Progestins alone have been
administered orally and parenterally
•
Danazol, a 17 alpha ethinyl
testosterone derivative, suppresses
both LH and FSH so this suppresses
estrogen which does not allow the
Endometriosis
•
GnRH Agonist such as leupronlide injections
suppresses LH and FSH which suppresses estrogen
•
Surgical therapy is either conservative or extirpative
•
Conservative surgery includes excision,
cauterization, or ablation of visible endometriosis
and preserving the uterus
•
Definitive surgery includes TAHBSO, lysis of
adhesions, and removal os endometriosis
Leiomyoma
•
Leiomyoma are benign uterine
growths that are also referred to as
fibroids or myomas
•
Leiomyomas the majority of time
produce mild symptoms, but despite
this it it the most common indication
for a hysterectomy
•
The most common symptoms of
leiomyoma are pain, secondary
dysmenorrhea, menorrhagia,
pressure symptoms in the pelvis
•
Leiomyomas are considered
hormonally responsive tumors
related to estrogen production
Leiomyoma
•
0.1-1% of the cases of leiomyoma develop malignancy called
leiomyosarcoma
•
Diagnosis of leiomyoma is based on clinical exam, bimanual
examination, or imaging studies
•
The majority of patients with leiomyoma do not require
surgery. The endometrial tissue can by biopsied and
endometrial cancer or hyperplasia can be ruled out
•
Can use prostaglandin inhibitors (NSAIDS) to minimize uterine
bleeding and also can use intermittent progestin
supplementation. Considered a conservative approach and
can be attempted especially if menopause in eminent
Leiomyoma
•
Surgical treatment can include
myomectomy if considering
having further children or
hysterectomy
•
GnRH analogs can be used for
suppression of estrogen
Uterine Prolapse
•
Uterine prolapse is when the pelvic
muscles laxity cause downward
displacement of the uterus
•
First degree uterine prolapse is
when descent is limited to the upper
two thirds of the vagina
•
Second degree uterine prolapse is
when the uterine structure
approaches the vaginal introits
•
Third degree uterine prolapse is
descent of the uterine structure
outside of the vagina
Uterine Prolapse
•
Non surgical treatment includes support through
pessaries and kegel exercises and strengthening
pelvic muscles
•
Surgical treatment involves repair of tissue defects
•
Estrogen replacement can also be an adjunct in
post menopausal women in the appropriate patients