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