Chapter 14

Leiomyoma
Diagnosis
Differentiate submucosal fibroids from polyps
o HSG and SIS
Fibroids vs adenomyomas
o MRI
Treatment
Expectant, w/ f/u every 6mo. (size)
Medicalshrink fibroids by dec circulating estrogen
o Medroxyprogesterone (provera)
o Danazol
o GnRH agonist (nafarelin, Lupron)
Uterine artery embolization
Myomectomyto preserve fertility.
o Hysteroscopically, laparoscopically, abdominally
o Compications: recurrence (50%), adhesions
Hysterectomydefinitive treatment

Leiomyosarcoma differentiation
Rapid growth of tumor in postmenopausal women.

Endometrial polyps
Increase with age, increase with tamoxifen
Sx: metrorrhagia, menorrhagia, menometrorrhagia.

Endometrial Hyperplasia
Pathogenesis
Obese womenexcess adipose tissue results in increased peripheral conversion of androgens (androstenedione and
testosterone) to estrogens (estrone, estradiol) by aromatases in adipocytes.
Classification
Cellular architecturecrowding of glands
Cytological atypiachanges in cellular structure (large nuclei, lost polarity, inc nuclear-to-cytoplasmic ratios).
Progression to endometrial cancer
o Penny: 1% simple hyperplasia
o Nickel: 3% complex hyperplasia
o Dime: 8% atypical simple hyperplasia
o Quarter: 29% atypical complex hyperplasia
Epidemiology
Typically, menopausal, perimenopausal woman, premenopausal w/ prolonged oligomenorrhea &/or obesity
Risk Factors
Unopposed estrogen exposure
o Obesity, nulliparity, late menopause, exogenous estrogen w/out progesterone
o Chronic anovulation, PCOS, estrogen producing tumor (ie granulosa theca).
Presentation
Oligomenorrhea or amenorrhea followed by uterine bleeding
Diagnostic
Pelvic US: thickened endometrial stripe
Tissue dx required.
EMB vs D&C.
o EMB 90-95% accuracy w/out operative and anesthetic risks.
o D&C required in pts with atypical complex hyperplasia (29% will have coexisting endometrial carcinoma).
Treatment
Progestin therapy (for simple, complex, typical, atypical)
o Progestin reverse endometrial hyperplasia activate progesterone receptors resulting in stromal
decidualization, thinning of endometrium.
o Depo-provera (IM), provera (PO medroxyprogesterone), megestrol (megace), norethindrone (Aygestin)
o Micronized vaginal progesterone (Prometrium), levonorgestrel intrauterine system (Mirena)
o Administered for 3mo, then repeat EMB
D&C w/ or w/o hysteroscopyfor patient with no atypia. Reevaulated every 3-6mo
Hysterectomyatypical complex hyperplasia

Ovarian Cysts
Pathogenesis
Follicular cystsfailure of follicular maturation. 3-8cm. Can be greater than 4cmovarian torsion.
o Resolve 60-90d
o Mostly asymptomatic, menstrual disturbance.
o Large onespelvic pain, dyspareunia, ovarian torsion.
Corpus luteum cystsfailure of corpus luteum to regress after 14d, become enlarged >3cm or hemorrhagic .
o Change delay in menstruation, dull LQP
Theca lutein cystslarge bilateral cysts filled w/ clear straw-colored fluid.
o Occur from high B-hcg levels.
Management
Premenarchal >2cmexploratory laparotomy
Reproductive
o <6 observe 8-12 wks, repeat US
o 6-8 cm observe if unilocular; explore if multilocular or solid on US
o >8cm exploratory laparoscopy/laparotomy for ovarian cystectomy
Postmenopausal palpableexploratory laparoscopy/laparotomy for ovarian oopherectomy