pediagenosis
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Monday, September 27, 2021

RELATIONSHIPS IN ENDOMETRIAL HYPERPLASIA

RELATIONSHIPS IN ENDOMETRIAL HYPERPLASIA

RELATIONSHIPS IN ENDOMETRIAL HYPERPLASIA

RELATIONSHIPS IN ENDOMETRIAL HYPERPLASIA


The cyclic changes of the endometrium are regulated and controlled, as described previously, by the hormonal secretions of the ovary. When ovulation fails to occur or an inadequate amount of progesterone is secreted, while estrogen secretion continues unabated, then endometrial changes recognized as the progestational or secretory phase of the cycle do not take place. Under the constant stimulus of estrogen, the proliferative phase persists, and this growth phase sometimes— but not always—becomes sufficiently exaggerated to result in endometrial hyperplasia. It is, however, well known that isolated anovulatory cycles often terminate at the expected time with normal flows, even though here, too, the rearrangement of the endometrium in the secretory phase has failed to make its appearance. It appears that in such cases the unopposed estrogen stimulation has not been prolonged enough to fully produce the developed hyperplasia. Why in one case regular bleeding from a proliferative endometrium occurs in spite of an anovulatory cycle whereas in another case failure to ovulate leads to endometrial hyperplasia remains unknown.

CAUSES OF UTERINE BLEEDING

CAUSES OF UTERINE BLEEDING

CAUSES OF UTERINE BLEEDING

CAUSES OF UTERINE BLEEDING


The endometrium is the only tissue in the body in which the regular, periodic occurrence of necrosis and desquamation with bleeding is usually a sign of health rather than of disease. This periodic blood loss is controlled through a delicate balance of pituitary and ovarian hormones and results from the specific response of the target tissue, the endometrium. The normal ebb and flow of estrogen and progesterone, through a monthly cycle, first builds up and then takes away, in regular sequence, the support of the endometrium; therefore, a menstrual flow, characterized by repeated regularity in timing, amount, and duration of bleeding, bears witness to a normal and ordered chain of endocrine events for that individual. Irregularity in any of these characteristics suggests a functional disturbance or organic pathology. The major categories of pathologic states that can cause or be accompanied by either menorrhagia (heavy or prolonged flow) or metrorrhagia (spotting or bleeding between menstrual flows) are discussed below.

CANCER OF CERVIX III—EXTENSION AND METASTASES

CANCER OF CERVIX III—EXTENSION AND METASTASES

CANCER OF CERVIX III—EXTENSION AND METASTASES

CANCER OF CERVIX III—EXTENSION AND METASTASES


Carcinoma of the cervix is initially a locally infiltrating cancer that spreads from the cervix to the vagina and paracervical and parametrial areas following a well-defined pattern of extension: Spread of the disease occurs primarily either through local lymphatic channels or by direct invasion of adjacent organs.

CANCER OF CERVIX II—VARIOUS STAGES AND TYPES

CANCER OF CERVIX II—VARIOUS STAGES AND TYPES

CANCER OF CERVIX II—VARIOUS STAGES AND TYPES

CANCER OF CERVIX II—VARIOUS STAGES AND TYPES


Almost all cancers of the cervix are carcinomas—85% to 90% are squamous carcinoma, and 10% to 15% adenocarcinoma. The average age of patients with cervical carcinoma is 40 to 60 years, with a median of 52 years. Squamous cervical cancer is strongly linked to some serotypes of human papillomavirus (HPV, 99.7% of all cancers have oncogenic HPV DNA detectable) and, like HPV itself, is associated with early sexual activity and multiple partners. Therapy is based on stage of disease. Radical surgery is used for selected patients with stage I and stage II disease. Radiation therapy (brachytherapy, teletherapy) is used for stage IB and IIA disease or greater. Postoperative radiation therapy reduces the risk of recurrence by almost 50%. Chemotherapy does not produce long-term cures but response rates of up to 50% have been obtained with multiagent combinations (cisplatin, doxorubicin, and etoposide; other combinations have also been successful).

CANCER OF CERVIX I—CYTOLOGY

CANCER OF CERVIX I—CYTOLOGY

CANCER OF CERVIX I—CYTOLOGY

CANCER OF CERVIX I—CYTOLOGY


In its early stages, cancer of the cervix is a curable disease. Essentially a slow-growing neoplasm, it is con-fined to the surface epithelium as a noninvasive growth for a period of several years. These in situ lesions are impossible to diagnose by gross examination. The Papanicolaou (Pap) smear dramatically changed both the diagnosis and treatment of cervical cancer. Enhanced understanding of the role of human papillomavirus (HPV) in cervical cancer is adding tools to the assessment of a woman’s risk of cervical cancer, but cervical cytology remains the mainstay of screening.

CERVICITIS I—EROSIONS, EXTERNAL INFECTIONS

CERVICITIS I—EROSIONS, EXTERNAL INFECTIONS

CERVICITIS I—EROSIONS, EXTERNAL INFECTIONS

CERVICITIS I—EROSIONS, EXTERNAL INFECTIONS


Gonorrhea and chlamydial infections of the cervix are common and can ascend into the upper genital tract with potentially serious sequelae, including chronic pelvic pain, infertility, ectopic pregnancy, and an increased risk of hysterectomy. Any exposure of the mucous glands in the endocervical canal predisposes the cervix to chronic low-grade infection. The most common causes of such exposure are eversions due to congenital defects or childbirth injuries. Congenital eversions are occasionally found in nullipara and present a concentric area of red, granular tissue about the external os. Exposure to increased levels of estrogen is thought to be a predisposing risk factor for such eversions.

CERVICITIS II—GONORRHEA, CHLAMYDIAL INFECTIONS

CERVICITIS II—GONORRHEA, CHLAMYDIAL INFECTIONS

CERVICITIS II—GONORRHEA, CHLAMYDIAL INFECTIONS

CERVICITIS II—GONORRHEA, CHLAMYDIAL INFECTIONS


Infection by the obligate intracellular organism Chlamydia trachomatis is the second most common sexually transmitted disease (STD) and most common bacterial STD. More common than Neisseria gonorrhoeae by threefold, infections by C. trachomatis can be the source of significant complications and infertility. Twenty percent of pregnant patients and 30% of sexually active adolescent women experience chlamydial infections. Up to 40% of all sexually active women have antibodies, suggesting prior infection. The most common age for chlamydial infections is 15 to 30 years (85%), with a peak age of 15 to 19 years. The Centers for Disease Control and Prevention recommends screening all sexually active women younger than 26 years. Chlamydia has a long incubation period (average 10 days) and may persist in the cervix as a carrier state for many years.

LACERATIONS, STRICTURES, POLYPS

LACERATIONS, STRICTURES, POLYPS

LACERATIONS, STRICTURES, POLYPS

LACERATIONS, STRICTURES, POLYPS


Parturition rarely fails to leave its mark on the external cervical os. Linear or horizontal lacerations are common, and if no infection occurs, they may heal satisfactorily without specific surgical or postpartum care. More complex lacerations penetrating deeply into the gland- bearing portion of endocervical stroma or extending into the lateral fornix permit eversion of the lining of the endocervical canal. Infection frequently, if not always, results from such severe lacerations unless it is treated promptly and effectively. Lacerations of the cervix may even extend into the lower uterine segment or the parametria. Such lacerations are uncommon in spontaneous deliveries.

PERFORATION

PERFORATION

PERFORATION

PERFORATION


Spontaneous rupture of the uterus almost never occurs except during parturition. During pregnancy, rupture of the fundus has been reported to occur in women with a history of very high parity. Such instances, however, seem to be extremely rare (estimated to be 1 in 15,000 deliveries) and are generally associated with significant uterine distension (polyhydramnios, multiple gestation). Rupture is found in 0.5% to 3.7% of patients with a previous cesarean delivery and 5% of patients for whom vaginal birth after cesarean delivery fails. Uterine rupture rates are higher in women with previous classic incisions and T-shaped incisions ranging between 4% and 9%. The frequency of a rupture of the uterine scar prior to labor is, of course, far lower than in labor. These occurrences should be distinguished from uterine scar dehiscence in which there is separation of an old scar that does not penetrate the uterine serosa or result in complications. Rupture may also occur following surgery on the body of the uterus, such as after myomectomy. Surgical scars have also been found to represent a site of diminished resistance in accidents, such as a fall, which occasionally may cause a rupture of the normally well-protected organ. It is notable that traumatic rupture of the bladder is a far more frequent event than that of the uterus. Roughly 7% of emergency cesarean hysterectomies are for uterine rupture. Surgical rupture of the corpus of the uterus results not infrequently from improper instrumentation of the uterus: passing a uterine sound performing a dilation and curettage or during a hysteroscopy. This can easily happen when a dilation and curettage is performed for incomplete abortion and when the uterine fundus is softened so it offers little resistance to the probing instrument. Perforation can also happen in the post-menopausal atrophic uterus with a thinned-out myometrium. The loss of intrinsic muscle tone after the climacteric allows the corpus to bend sharply forward at the isthmus in acute anteflexion as a result of intra-abdominal pressure. Bimanual examination may fail to detect the small fundus lying under the symphysis, and, in the mistaken impression that a second-degree retro-version is responsible for failure to feel the fundus, a straight uterine probe may be introduced. The end of the probe impinges promptly on the back wall of the canal. If this obstruction is wrongly interpreted as being due to stenosis at the internal os, added pressure may produce perforation through the posterior myometrium into the peritoneal cavity. When the uterus is in retroflexion, the anterior cervical wall offers a certain resistance to the dilating instrument, which, when forced, may enter the uterovesical pouch.

Friday, September 24, 2021

PROLAPSE

PROLAPSE

PROLAPSE

Prolapse is defined as any descent of the uterus down the vaginal canal, so that it lies below the normal position in the pelvis. In the extreme, this may result in the uterus descending beyond the vulva to a position outside the body (procidentia). Some degree of uterine descent is common in parous women.


Prolapse is defined as any descent of the uterus down the vaginal canal, so that it lies below the normal position in the pelvis. In the extreme, this may result in the uterus descending beyond the vulva to a position outside the body (procidentia). Some degree of uterine descent is common in parous women.

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