Understand the Uterus for the Physician Assistant Exam
The Physician Assistant Exam will expect you to understand that without the uterus, reproduction couldn’t occur. Several medical problems can affect the uterus. The organ may move out of place, bleed, or contain abnormal tissue growth.
The uterus and other pelvic structures are supported by pelvic muscles and ligaments. As these muscles weaken from prior pregnancies, obesity, pelvic surgeries, or menopause, the uterus may slip into the vagina. Be aware that uterine prolapse occurs in stages.
Common presenting symptoms of uterine prolapse can include dyspareunia (painful sexual intercourse), pelvic pain, and abdominal pain. The patient may also have significant urinary symptoms, including urgency, frequency, and burning, and the risk for urinary tract infections increases. A vaginal discharge may be present.
On physical examination, you need to do a pelvic examination so you can see the degree of uterine prolapse into the vagina. Treatment can include placing a pessary to help support the uterus. Kegel exercises, which strengthen the pelvic floor musculature, may also be prescribed. In certain cases, the woman may need surgery.
With weakening of the pelvic floor musculature and ligaments, a uterine prolapse may not be all that you see on pelvic examination. In addition, you may see bladder prolapse into the vagina (cystocele) and/or rectal prolapse into the vagina (rectocele).
Rule out causes for dysfunctional uterine bleeding
Bleeding from the uterus has many causes. Dysfunctional uterine bleeding (DUB) is bleeding from the uterus without an identifiable anatomic cause. That is, no tumor or other source of bleeding is present. The most common reason for dysfunctional uterine bleeding is a change in the hormonal milieu. Basically, estrogen sticks around too long, which causes changes in the uterine lining that promote bleeding.
Note that dysfunctional uterine bleeding is diagnosed after other causes are excluded. A full clinical workup is indicated — look for bleeding disorders and chemistries and check a β-hCG level to rule out pregnancy.
You also need to check thyroid levels and hormonal levels. Be sure the woman doesn’t have polycystic ovary syndrome. From an anatomic standpoint, make sure the woman doesn’t have a leiomyoma (fibroid) or endometrial cancer before saying that she has dysfunctional uterine bleeding. This testing can involve a pelvic ultrasound and a dilation and curettage (D&C) to make sure she doesn’t have an abnormality of the uterine lining.
The treatment of dysfunctional uterine bleeding consists of oral contraceptives to try to bring the body’s hormones back into balance.
Leiomyomas: Uterine fibroids
A fibroid is a benign neoplasm of the uterus. It’s actually an overgrowth of the uterus’s smooth muscle. Fibroids (leiomyomas) are a common cause of bleeding in women. They can grow in many places in the uterus; the two most common places are in the submucosa and within the muscular layer of the uterus. Risk factors include being African-American, being obese, and having had early menarche.
You can find fibroids on physical examination. The initial presentation can also be irregular bleeding. Other symptoms include abdominal pain and increased pelvic and abdominal pressure. You can confirm the diagnosis by a pelvic ultrasound. The treatment is usually surgical, including a myomectomy or a hysterectomy, depending on the number and extent of the fibroids. Newer, less invasive techniques include uterine artery embolization.
A not-so-silver lining: Endometriosis
Endometriosis is the abnormal spread or growth of endometrial tissue into other areas of the body, especially the pelvic area. The tissue can go anywhere and stick itself where it shouldn’t, including the ovaries, the Fallopian tubes, and even the intestine.
Symptoms of endometriosis can include significant pelvic pain, pain during intercourse, and dysmenorrhea. If that constellation of signs and symptoms is present, the diagnosis is often confirmed through a diagnostic laparoscopy. The treatment is usually pain relief, with the use of nonsteroidals and/or analgesics.
In addition, medications to change the hormonal milieu of the body are often prescribed. These meds include oral contraceptives, androgens, and gonadotropin-releasing hormone-like medications. The goal is to decrease the size of the ectopic endometrial tissue. Surgery is sometimes indicated in addition to or instead of medical therapy.
How to treat endometrial cancer
Endometrial cancer is a cancer of the uterine lining that you see most often in postmenopausal women. The most common initial symptom is vaginal bleeding. Other symptoms can include a vaginal discharge and dyspareunia, but unexplained vaginal bleeding is the predominant symptom.
Risk factors for endometrial cancer include being nulliparous, having had early menarche, and having late menopause. Other factors include older age and using tamoxifen (Nolvadex).
To diagnose endometrial cancer, you need tissue. The first step is an endometrial biopsy. Sometimes you may need a D&C to further confirm the diagnosis. Other modalities, including transvaginal ultrasound, have also been used. The treatment of choice is often surgical, including a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). The affected woman may also need chemotherapy and/or radiation, depending on the degree of metastases.