2. Uterine Leiomyomas

3. Most common benign uterine tumors
Location :uterus ,cervix ,broad ligament
Subserosal
Intramural
Submucosal
In reproductive ages %
Older than 35 years %
Single or multiple

4. Increased familial tendency
During pregnancy enlarged
During menaupouse regress

5. Microscopic or huge
Hard and stony to soft ,usually firm or rubbery
Do not have a true capsule
Margins of the tumor are blant noninfiltrating and pushing (psudocapsul)
Degenerative changes in two third
Malignant degeneration in less than 0.5%

6. Symptoms in ½ AUB Pelvic pain Pelvic pressure Uretral obstraction
Constipation
Infertility
Prolapse
Venous StaSis thrombophlebitis
Polycythemia
Ascites

7. Management of leiomyomas
Observation and periodic examination
Medical therapy
GNRH agonist
RU486 (progestron antagonist )
Surgical therapy
Myomectomy
Hysterectomy

8. GNRH agonists 40-60% decrease the volume Bone loss Hot plashes
Short term use
Regrowth of leiomyomas within few months

9. Uterine cancer Most common malignancy of the female genital tract
½ of all gynecologic cancers
Endometrial carcinoma is the fourth most common cancers (ranking behind breast , lung, bowel)
Seventh leading cause of death from malignancy in women

10. Endometrial carcinoma
Estrogen dependent
Younger
Perimenopause
History of exposure to estrogen
Benign as hyperplastic endometrium and progress to carcinoma
More favorable prognosis

12. Endometrial carcinoma
Non estrogen dependent
Arise in background of atrophic endometrium
Less differentiated
Poor prognosis
Older postmenopausal
Thin
African American
Asian

13. Endometrial hyperplasia
Simple
Dilated gland with round to slightly irregular shapes
Increased glandular to stromal ratio
No glandular crowding
No cytologic atypia

14. Complex Architecturally complex (budding and folding )
Crowded glands (less intervening stroma)
Without atypia

16. Atypical hyperplasia Complex hyperplasia with atypia
Simple hyperplasia with atypia
Large nuclei of variable size and shape that have lost polarity
Increased nuclear to cytoplasmic ratio
Prominant nuclei and irregularly clupmed chromatin

17. Complex Atypical hyperplasia 25% is associated with well differentiated endometrial carcinoma
Progesterone is very effective in reversing endometrial hyperplasia without atypica but less effective for endometrial hyperplasia with atypia
Continuous megestrol acetate
40 mg
2-3 months
Biopsy 3-4 w after completion of therapy

18. Endometrial cancer screening
Lack of an appropriate , cost-effective and acceptable test that reduces mortality
Pap smear
TVS
Endometrial biopsy
Screening of high risk individuals could detect ½ of all cases

19. Clinical symptoms of endometrial carcinoma
In sixth and seventh decades
Average age 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

21. Diagnosis of endometrial cancer
Office endometrial aspiration biopsy
(90-98% accuracy compared with D&C or hysterectomy)
Pap smear
D&C
Hysteroscopy is more accurate in identifying polyps and sub mucous myomas than biopsy or D&C alone .
TVS
Endometrial thickness greater than 4 mm
Polypoid endometrial mass
Collection of fluid in the uterus

22. Pre treatment evaluation
Complete history and PhE
Diabetus
Hypertension
Bladder or intestinal complains
Stool for occult blood
Complete blood and platelet counts
Serum chemistries (renal and liver function tests)
Blood type
Urinalysis