Beruflich Dokumente
Kultur Dokumente
PHARMACY N. TESTEMIANU
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Uterine Leiomyoma.
Endometriosis.
CORINA CARDANIUC
Objectives for Uterine Leiomyoma
Discuss the prevalence of uterine leiomyomas
Pedunculated Uterus
subserosal
Pedunculated
submucosal
Subserosal
Intramural
Submucosal
Vagina
Clinical Manifestations
Clinical Manifestations
Bleeding symptoms Bulk symptoms
Menorrhagia Pelvic pressure
heavy bleeding
Metrorrhagia Urinary frequency
bleeding between Infertility and/or
menses recurrent
Dysmenorrhea pregnancy loss
painful menses
Abdominal exam
Palpable mass if uterus > 12-14 wk gestational size
Pelvic exam
Firm, irregularly enlarged uterus
Midline, occasionally adnexal
Mass displaced with cervix
Usually nontender
Physical Exam
Reveals a well-developed, well-nourished
woman in no distress. Vital signs and
general physical exam are unremarkable.
Abdominal examination reveals an irregular-
sized mass into extending halfway between
the pubic symphysis and umbilicus and to
the right of the midline. Pelvic exam reveals
a normal appearing vagina and cervix. The
uterus is markedly enlarged and irregular,
especially on the right side where it appears
to reach the lateral pelvic sidewalls. The
examiner is unable to palpate normal
ovaries due to the mass.
Pathology
Well
circumscribed
white tan firm
masses with a
whorled
appearance
Pathology
Microscopically
leiomyomas are
composed of
bland smooth
muscle.
They can be more
fibrotic than this
example or more
cellular.
Differential Diagnosis
Uterine sarcoma
Ovarian neoplasm
Tubo-ovarian inflammatory mass
Diverticular/inflammatory bowel mass
Colon cancer
Pelvic kidney
Pregnancy
Adenomyosis
Management (Surgical)
No pathognomonic finding
Dont forget the recto-vaginal exam!
Cul-de-sac nodularity and tenderness
Uterosacral nodularity
Tender, fixed adnexal mass
Uterus fixed and retroverted
Diagnosis
Definitive diagnosis
Direct visualization (via laparotomy or laparoscopy)
Histologic and gross findings consistent with endometrial tissue
Other tests
Ca125 - not specific nor sensitive
Pathology
Appearance of
endometriosis with
back raised lesions of
active endometriosis at
the time of laparascopy
Note: Lesions may be
raised or flat with red,
black or brown
coloration; fibrotic
scarred areas that are
yellow or white in hue;
or vesicle that are pink,
clear, or red.
Pathology
Multiple
endometrial cysts
chocolate cysts
of the ovary
Pathology
Endometrial stroma
Differential Diagnosis
There is no clear
relationship between
stage and frequency
and severity of pain
symptoms
Key considerations:
Severity of the symptoms
Extent of the disease
Desire for future fertility
Age of the patient
Threat to GI or urinary tract
Management (Medical)
Fertility preserving
Laparoscopic (or rarely, laparotomy) with ablation or excision
of endometrial implants and adhesions
Endometriomas >3 cm in diameter should be removed
surgically
Most definitive
Hysterectomy (most often laparoscopic) with ablation or
excision of all endometrial implants and adhesions.
Removal of ovaries has been traditional, but newer studies
suggest retention of ovaries is reasonable in many cases.
Always a risk of recurrence!
Bottom Line Concepts
Typical patient with endometriosis is in her reproductive years, and
sub-fertile.
Pathogenesis of endometriosis is not completely understood and
believed to be a combination of factors.
Characteristic triad of symptoms associated with endometriosis is
dysmenorrhea, dyspareunia, and dyschezia.
Staging of endometriosis is not clearly associated with frequency and
severity of pain symptoms.
Appropriate treatment varies widely and should take into consideration
severity of symptoms, extent of disease, and desire for future fertility.
There is a risk of recurrence of endometriosis throughout a womans
life.
In all women, minimization of menstrual flow and suppression of
ovarian cycling can reduce the risk for endometriosis.
References and Resources