Uterine Leiomyomas

Most common benign uterine tumors Location :uterus ,cervix ,broad ligament Subserosal Intramural Submucosal In reproductive ages 20% Older than 35 years 40-50% Single or multiple

Increased familial tendency During pregnancy enlarged During menaupouse regress

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%

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

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

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

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

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

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

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

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

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

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

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

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

Diagnosis of endometrial cancer Office endometrial aspiration biopsy (90-98% accuracy compared with D&C or hysterectomy) Pap smear 30-50 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

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