Notes

Colposcopy: Punctations and mosaicism represent new blood vessels on end and on their sides, respectively. Atypical vessels usually represent a greater degree of angiogenesis and, thus, usually a more concerning lesion. An ectropion is an area of columnar epithelium that has not yet undergone squamous metaplasia. It appears as a reddish ring of tissue surrounding the external os. Acetowhite epithelium can represent dysplasia but, in most cases, is less concerning than the above vascular changes.
Because the entire lesion cannot be visualized, this colposcopy is unsatisfactory. Severe dysplasia and even invasive cancer cannot be ruled out. A cervical conization should be performed to obtain a pathologic specimen. Alternatively co-testing can be repeated at 12 and 24 months.
Cervical conization is indicated in this patient who has a positive ECC
The major symptom associated with myomas is menorrhagia, thought to be secondary to: 1) an increase in the uterine cavity size that leads to greater surface area for endometrial sloughing; and/or 2) an obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea.
Submucosal or intracavitary myomas are most likely to cause lower pregnancy and implantation rates.
Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-releasing hormone agonists inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis. They can result in a 40-60% reduction in uterine size. This treatment is commonly used for three to six months before a planned hysterectomy in an attempt to decrease the size of the uterus, which may lead to a technically easier surgery and decreased intraoperative blood loss. In patients who are not yet menopausal, once the gonadotropin-releasing hormone agonist therapy is discontinued, the fibroids may grow again with re-exposure to endogenous estrogen. Thus, this therapy may be most useful for women who are close to menopause, as this patient is at age 49.
Particularly in a perimenopausal woman, it is important to first rule out an underlying endometrial malignancy with endometrial sampling.
Adenomyosis may result in a symmetrically enlarged “boggy” uterus, but usually presents with dysmenorrhea in addition to menorrhagia.
Endometrial hyperplasia is more common in perimenopausal women who do not ovulate regularly and postmenopausal women.
Myomectomy is warranted in younger patients whose fertility is compromised by the presence of fibroids that cause significant distortion of the uterine cavity