Uterine Leiomyomas Most common benign uterine tumors Location
Uterine Leiomyomas
Ø Most common benign uterine tumors Ø Location : uterus , cervix , broad ligament Ø Subserosal Ø Intramural Ø Submucosal Ø In reproductive ages Ø Older than 35 years Ø Single or multiple 20% 40 -50%
Ø Increased familial tendency Ø During pregnancy enlarged Ø During menaupouse regress
Ø Microscopic or huge Ø Hard and stony to soft , usually firm or rubbery Ø Do not have a true capsule Ø Margins of the tumor are blant noninfiltrating and pushing (psudocapsul) Ø Degenerative changes in two third Ø Malignant degeneration in less than 0. 5%
Symptoms Ø Ø Ø Ø Ø AUB Pelvic pain Pelvic pressure Uretral obstraction Constipation Infertility Prolapse Venous Sta. Sis Polycythemia Ascites in ½ thrombophlebitis
Management of leiomyomas Ø Observation and periodic examination Ø Medical therapy GNRH agonist RU 486 (progestron antagonist ) Ø Surgical therapy Myomectomy Hysterectomy
GNRH agonists Ø 40 -60% decrease the volume Ø Bone loss Ø Hot plashes Ø Short term use Ø Regrowth of leiomyomas within few months
Uterine cancer Ø Most common malignancy of the female genital tract Ø ½ of all gynecologic cancers Ø Endometrial carcinoma is the fourth most common cancers (ranking behind breast , lung, bowel) Ø Seventh leading cause of death from malignancy in women
Endometrial carcinoma Estrogen dependent Ø Younger Ø Perimenopause Ø History of exposure to estrogen Ø Benign as hyperplastic endometrium and progress to carcinoma Ø More favorable prognosis
Endometrial carcinoma Non estrogen dependent Ø Arise in background of atrophic endometrium Ø Less differentiated Ø Poor prognosis Ø Older postmenopausal Ø Thin Ø African American Ø Asian
Endometrial hyperplasia Simple Ø Dilated gland with round to slightly irregular shapes Ø Increased glandular to stromal ratio Ø No glandular crowding Ø No cytologic atypia
Complex Ø Architecturally complex (budding and folding ) Ø Crowded glands (less intervening stroma) Ø Without atypia
Atypical hyperplasia Complex hyperplasia with atypia Simple hyperplasia with atypia Ø Large nuclei of variable size and shape that have lost polarity Ø Increased nuclear to cytoplasmic ratio Ø Prominant nuclei and irregularly clupmed chromatin
Complex Atypical hyperplasia 25% is associated with well differentiated endometrial carcinoma Ø Progesterone is very effective in reversing endometrial hyperplasia without atypica but less effective for endometrial hyperplasia with atypia Ø Continuous megestrol acetate 40 mg 2 -3 months Ø Biopsy 3 -4 w after completion of therapy
Endometrial cancer screening Ø Lack of an appropriate , cost-effective and acceptable test that reduces mortality Ø Pap smear Ø TVS Ø Endometrial biopsy Ø Screening of high risk individuals could detect ½ of all cases
Clinical symptoms of endometrial carcinoma Ø Ø Ø In sixth and seventh decades Average 60 years 75% are older than 60 years 90% have vaginal bleeding or discharge Seek medical consultation in 3 months Pelvic pressure Pelvic discomfort Hematometra Pyometra Less than 5% are asymptomatic
Diagnosis of endometrial cancer Office endometrial aspiration biopsy (90 -98% accuracy compared with D&C or hysterectomy) Ø Pap smear 30 -50 Ø D&C Ø Hysteroscopy is more accurate in identifying polyps and sub mucous myomas than biopsy or D&C alone. Ø TVS Endometrial thickness greater than 4 mm Polypoid endometrial mass Collection of fluid in the uterus Ø
Pre treatment evaluation Complete history and Ph. E Ø Diabetus Ø Hypertension Ø Bladder or intestinal complains Ø Stool for occult blood Ø Complete blood and platelet counts Ø Serum chemistries (renal and liver function tests) Ø Blood type Ø Urinalysis
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