Table II-4-2. Management of Leiomyomas
| Management | Clinical effect/Method of Treatment |
| Observation | Most |
| Serial pelvic exams | |
| Presurgical shrinkage | ↓ size by 70% |
| GnRH analog 3–6 months; regrowth after stopping | |
| Myomectomy | Preserves fertility |
| Laparotomy, laparoscopy | |
| Embolization | Preserves uterus |
| Invasive radiology | |
| Hysterectomy | Fertility completed |
| Total abdominal hysterectomy, total vaginal hysterectomy | |
Adenomyosis
A 42-year-old woman complains of increasing pain with her menstrual periods for the past 8 months. She also states her periods are getting heavier, leaving her tired and weak. She underwent a postpartum tubal ligation after her last child 10 years ago. She has been treated for chronic hypertension for the past 3 years. On pelvic examination her uterus is 12-week size, globular, soft, and tender. Rectovaginal examination is unremarkable.
Definition. Ectopic endometrial glands and stroma are located within the myometrium of theuterine wall. The most common presentation is diffuse involvement of the myometrium. The lesion is known as an adenomyoma if the involvement is focal, surrounded by a pseudocapsule.
Diagnosis. In most cases the diagnosis is made clinically by identifying an enlarged, symmetric,tender uterus in the absence of pregnancy. The only definitive diagnosis is by histologic confir-mation of the surgically excised tissue.
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Chapter 4 l Disorders of the Cervix and Uterus
Table II-4-3. Differential Diagnosis for Enlarged Non-pregnant Uterus
| Leiomyoma | Adenomyosis |
| Asymmetric | Symmetric |
| Firm | Soft |
| Nontender | Tender |
Symptoms. The majority of women are asymptomatic. Themost common symptoms are sec-ondary dysmenorrhea and menorrhagia.
Examination. The uterus is globular and diffusely up to 2–3 times the normal size. Tendernessis most common immediately before and during menses.
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Imaging. Ultrasound study or MRI imaging shows a diffusely enlarged uterus with cystic areasfound within the myometrial wall.
Management. Medical treatment includes the levonorgestrel (LNG) intrauterine system (IUS),which may decrease heavy menstrual bleeding. Surgery, in the form of hysterectomy, is the definitive treatment.
ENDOMETRIAL NEOPLASIA
Postmenopausal Bleeding
A 65-year-old patient complains of vaginal bleeding for 3 months. Her last menstrual period was at age 52. She has not taken any hormone replacement. She was diagnosed with type 2 diabetes 20 years ago and was treated with oral hypoglycemic agents. She has chronic hypertension, for which she is treated with oral antihypertensives. Her height is 62 inches and weight 200 lb. Physical examination is normal with a normal-sized uterus and no vulvar, vaginal, or cervical lesions.
Definition. A patient is considered to be in menopause after 3 continuous months of cessationof menses and elevated gonadotropins. Menopause usually occurs at approximately 52 years of age. Postmenopausal bleeding is any bleeding that occurs after menopause.
Epidemiology. Endometrial carcinoma is the most common gynecologic malignancy, occur-ring in 1% of women. The mean age at diagnosis is 61 years.
Differential Diagnosis. The differential diagnosis of postmenopausal bleeding includes endo-metrial carcinoma, vaginal or endometrial atrophy, and postmenopausal hormonal replace-ment therapy. Although the most common cause of postmenopausal bleeding is vaginal or endometrial atrophy, the most important diagnosis to rule out is endometrial carcinoma.
Pathophysiology. The mediating factor for most endometrial carcinomas appears to be unop-posed estrogen. This results from excessive hyperstimulation of the endometrium without the stabilizing effect of progesterone.
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Risk Factors. These include obesity, hypertension, and diabetes mellitus. Other risk factorsinclude nulliparity, late menopause, and chronic anovulation conditions, such as PCO disease.
Diagnostic Tests
• Endometrial sampling. Postmenopausal bleeding must be evaluated with an endometrialsampling, which can be done in an office setting. Sometimes in postmenopausal patients cervical stenosis is present, which should be evaluated with a dilatation and curettage.
• Hysteroscopy and ultrasonography. With hysteroscopy, cervical or endometrial polypscan be identified as the cause of the postmenopausal bleeding, and ultrasonography can be used to measure the thickness of the lining of the endometrium. In postmenopausal patients, the endometrial lining stripe should measure <5 mm in thickness.
With permission, Brookside Associates, brooksidepress.org
Figure II-4-13. Ultrasonography Demonstrating Normal Endometrial Stripe (<5 mm)
Staging
Staging is done after an evaluation of the pathology report. Staging is surgical.
Stage I: Spread limited to the uterus (most common stage at diagnosis)
IA. Limited to the endometrium or invasion less than half of myometrium
IB. Invasion more than half of myometrium
Stage II: Extension to the cervix but not outside the uterus
Stage III: Spread adjacent to the uterus
IIIA. Invades serosa or adnexa or positive cytology
IIIB. Invasion of vagina
IIIC. Invasion of pelvic or para-aortic nodes
Stage IV: Spread further from the uterus
IVA. Involves bladder or rectum
IVB. Distant metastasis
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Management. If the endometrial histology sampling reveals atrophy and no evidence of cancer,it can be assumed the patient is bleeding from atrophy and can be treated with hormone replace-ment therapy. With hormone replacement therapy, estrogen and progesterone should be given to the patient. If estrogen is given alone, the risk of endometrial cancer increases.
If the endometrial sampling reveals adenocarcinoma, the patient should be treated surgically.
– Surgical therapy. The mainstay of treatment of endometrial carcinoma is a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO), pelvic and para-aortic lymphadenectomy, and peritoneal washings.
– Radiation therapy. An evaluation of the postoperative pathology report will clas-sify patients into poor or good prognosis category. Patients with poor prognosis should be considered for radiation therapy. Poor prognostic factors include metas-tasis to the lymph nodes, >50% myometrial invasion, positive surgical margins, or poorly differentiated histology.
– Chemotherapy. Medical treatment is used for metastatic disease and involves progestins and cytotoxic agents.
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