ࡱ> VXU@ +bjbjFF O,,#6666666*4L*D$#######$6%R'#6#66# 66# # ;#66# iNL0S##$0D$[#,(Fd(#**6666(6#< ##**d **Uterine Disorders Dysfunctional Uterine Bleeding (DUB) Abnormal uterine bleeding without pelvic organic disease or systemic disorder Must exclude: pregnancy, malignancy, infection, leiomyomas, endocervical polyps, systemic disease Can occur in ovulatory and anovulatory cycles If no ovulation then no progesterone induced changes. So endometrium outgrows its blood supply and sloughs from uterus History Age: peri-menopausal and adolescents Amount and duration of bleeding- heavy bleeding may lead to shock On contraceptives- low estrogen state No PMS symptoms- no progesterone Blood estrogen levels are constant and non-cyclic Luteal Phase Defect DUB where ovulation does occur Corpus luteum does not secrete enough progesterone to support endometrium for 14 days So menstrual cycle is shortened, and menstruation occurs earlier than expected Diagnosed by appropriate timed endometrial biopsy Management: clomiphene Diagnosis Diagnosis of exclusion Look for shift in basal body temperature post ovulation Luteal phase progestin Endometrial biopsy Blood work Pap smear, pelvic ultrasound, hysterosalpingography, hysteroscopy, D and C Management Convert proliferative endometrium into secretory endometrium Provera (medroxyprogesterone acetate) for 10 days Oral contraceptives- suppress endometrium and establishes regular predictable withdrawal cycles D and C- Acute episode- Might need endometrial ablation or hysterectomy Leiomyomata Most common benign neoplasm of females Most common indication for hysterectomy Caused by localized proliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers (African American women more likely) Growth related to estrogen production. Estrogen increases progesterone Types Begin growing in myometrium Intramural- embedded in myometrium (most common type) Symmetric enlargement of the uterus Subserosal- located beneath the perimetrium of the uterus. Irregular projections on the uterine surface (can become pedunculated Submucosal- displace endometrium tissue (least common) Can cause bleeding, necrosis, and ulcerate and cause infection Clinical manifestations Asymptomatic Dysmenorrhea/menorrhagia Sensation of abdominal mass, bloating Increased urinary frequency Degeneration will lead to severe pain, urination or constipation Dyspareunia/infertility/spontaneous abortion Bimanual vaginal exam reveals a firm, irregularly shaped uterus with smooth rounded protrusion, nontender Diagnosis Look for malignancy Leiomyosarcoma- more common postmenopausal (1% of women) BhCG CBC Pelvic exam- pelvic enlargement (described in gestational weeks) Pelvic ultrasound Complications Degeneration- ischemia when fibroid outgrows its blood supply Rapid growth can occur in pregnancy Anemia second to menorrhagia Can impinge on the ureter causing hydroureter and hydronephrosis Management Non pregnant asymptomatic Follow with bimanual exam every six months and pelvic ultrasound Symptomatic Conservative Progestin therapy for abnormal bleeding. GnRH agonists- help decrease progesterone and fibroid size Operative Myomectomy- removes fibroid and preserves uterus (laparoscopically) Hysterectomy- when fertility not an issue Endometrial Cancer Peak ages 55-65 years Type I due to prolonged estrogen stimulation (peri-menopausal) Type II (serous carcinoma) due to clones of cancer initiated mutant cells that are poorly differentiated (found more in post-menopausal women, poor prognosis) Other risks: obesity, DM, hypertension, anovulatory cycles, estrogen-secreting neoplasma, unopposed estrogen therapy, inherited Most common type is adenocarcinoma. Other types include clear cell, secretory, squamous, and papillary endometrial carcinoma Clinical manifestations Abnormal, painless bleeding (especially after menopause) Bleeding between periods, excessive prolonged menstrual flow Cramping, pelvic discomfort, postcoital bleeding Diagnosis Endometrial biopsy D and C- for a more thorough exam of the area Transvaginal ultrasound Hysteroscopy- for visualizing mass or abnormality Staging by level of spread (lymph node involvement, depth and metastasis) Management Look for metastatic disease Surgery/radiation Total abdominal hysterectomy with bilateral salpingo-oophorectomy Outcome depends if local (96%), regional (60%), or distant stages (26%) Endometriosis Endometrial glands and stroma found outside the uterine cavity. Most common is in ovaries, Uterosacral ligaments, broad ligament Pathophysiology Retrograde menstruation Lymphatic theory Risks: early menarche, regular periods <27 days, longer duration, heavy flow, pelvic pain In ovary, endometrial tissue may form cysts filled with old blood Rupture can lead to peritonitis or adhesions Elsewhere look like small hemorrhagic lesions that can be black, blue, red Become proliferative and then secretory Clinical Manifestations Dysmenorrhea Dyspareunia Infertility Diagnosis Laparoscopy- direct visualization, needed to make a diagnosis Endometriomas evaluated with ultrasound and MRI Management Pain management, restore fertility Pain relief- NSAIDS Hormones- amenorrhea progesterone (suppresses gonadotropin release), oral contraceptives, Danazol (suppresses LH and FSH), leuprolide (gonadotropin releasing agonist-stops ovulation) Surgery- laser surgery and laparoscopy If childbearing complete, total hysterectomy and bilateral salpingo-oophorectomy Adenomyosis Endometrial glands and stroma are found within the myometrium between smooth muscle fibers Common in Multiparous women 40-50 Can be associated with uterine fibroids or endometrial hyperplasia Resolves with menopause Clinical Manifestations Menorrhagia, Dysmenorrhea Dyspareunia Enlarged, boggy uterus Diagnosis MRI Management Gonadotropin releasing agonists Then hysterectomy (for reoccurrence) Endometritis Inflammation of the lining of the uterus Epidemiology: vaginal deliveries, cesarean sections About 7% of maternal deaths Commonly follows chorioamnionitis, c-section, multiple vaginal exams, bacterial vaginosis or group B strep colonization, prolonged PROM Etiology is polymicrobial involving organisms that have ascended from the lower genital tract (staph, proteus, gardnerella, B, fragilis, chlamydia trachomatis) Clinical Manifestations Temp >101.6F (first 24 hours post partum) or 100.4F (2 of first 10 days post partum) Uterine tenderness/peritoneal irritation Ileus Tachycardia Chills, malaise, headache, anorexia Purulent/malodorous lochia Diagnosis: CBC, blood cultures for sepsis, amniotic fluid gram stain, uterine tissue cultures, usually made clinically Management Inpatient with IV antibiotics- clindamycin and gentamycin Low grade endometritis- Ampicillin, gentamycin, metronidazole (should improve 48-72 hours- otherwise they must be admitted) Curettage of retained products of conception Surgery to drain abscess Surgery to decompress bowel Disorders of Pelvic Support Uterus and pelvic structures are maintained in position by Uterosacral ligaments, round ligaments, broad ligaments and cardinal ligaments Cardinal ligaments- maintain the cervix in position Uterosacral ligaments- hold uterus in forward position Broad ligaments- suspend the uterus, the fallopian tubes, and the ovaries in the pelvis Pelvic diaphragm (pelvic floor) supports the uterus, vagina, urinary bladder and rectum Openings in the pelvic diaphragm Can lead to possible herniation of pelvic viscera through the pelvic floor (prolapse). Loss of anatomic support Risks: overstretching during childbirth, 50-60s, chronic elevated intra-abdominal pressure 4 Types Cystocele- anterior vaginal wall is prolapsed containing the bladder Graded from 1-3 (grade 3 bladder bulges through vagina) Symptoms include urinary urgency, frequency, incontinence Enterocele- Upper portion of the posterior vaginal wall is prolapsed containing the small bowel Symptoms nonspecific Rectocele- caused by childbirth (especially difficult with episiotomy); rectum bulges into or out of the vagina; the lower posterior of the vaginal wall is prolapsed containing the rectum Symptoms: difficulty emptying rectum, digital splinting Clinical Manifestations Backache, pelvic pressure PE: Mild prolapse Advanced Management Kegel exercises- improves tissue turgor Estrogen replacement Pessaries: mechanical devices placed in vagina, place pelvic structures in more normal position artificially; temporary Surgery Anterior and posterior colporrhaphy Total hysterectomy- vaginal or abdominal Uterine Prolapse- bulge of the uterus into the vagina Occurs when cardinal ligaments stretched Ranked by location of the cervix First degree- cervix is in the vagina Second degree- cervix is at the introitus Third degree- uterus and cervix are both prolapsed out of the introitus Clinical manifestations Irritation of exposed mucus membranes Secondary perineal relaxation, cystocele, rectocele Risks: Multiparous, pelvic tumors Management Pessary- holds the uterus in place to avoid surgery Surgery- elective Vaginal hysterectomy and repair of vaginal wall (colporrhaphy) Supportive slings- relieve stress incontinence Kegel exercise 8  ! 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