1. Reproductive Blueprint
PANCE Blueprint

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Leiomyoma
Surgical treatment can include myomectomy if considering having further children or hysterectomy
GnRH analogs can be used for suppression of estrogen

16. 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

17. 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