6 - Uterine Disorders Flashcards
What are fibroids?
- Tumours of the smooth muscle of the uterus “leiomyomas”
- They are oestrogen sensitive
- Most common in 40-60 year olds and black women
What are the different classes of fibroids?
- Intramural: within the myometrium. As they grow, they change the shape and distort the uterus.
- Subserosal: below the outer layer of the uterus. They grow outwards and can become very large, filling the abdominal cavity
- Submucosal: below the lining of the uterus (the endometrium).
- Pedunculated: on a stalk
What are some risk factors for developing fibroids?
Pregnancy and POP is protective against them!!!
Anything raising oestrogen is a risk factor
- Obesity
- Early age of puberty
- Increasing age
- Black ethnicity
How may fibroids present?
Often asymptomatic or heavy menstrual bleeding
- Prolonged menstruation, >7 days
- Abdominal pain, worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia
- Reduced fertility
What examinations and investigations are done to diagnose fibroids?
Exams
- Abdominal
- Bimanual: palpable pelvic mass with enlarged non-tender uterus
Investigations
- 1st Line: Pelvic US (usually transvaginal over trans abdominal) for HMB
- Pelvic MRI +/- hysteroscopy: if concern about intramucosal fibroids, malignancy or planning for surgery
- FBC: anaemia
How are fibroids classified by their size?
<3cm = small
>3cm = large
How are small fibroids managed? (<3cm)
Treated same way as heavy menstrual bleeding
Medical
- IUS Mirena Coil: 1st line as long as no distortion of uterus
- Symptomatic management with tranexamic acid and NSAIDs
- COCP
- Cyclical oral progestogens
Surgical (if not controlled by medical)
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
How are fibroids >3cm managed?
Need referral to gynaecology for investigations and management!!!!!
Medical
- Symptomatic management with NSAIDs and tranexamic acid
- IUS Mirena coil – depending on size and shape of fibroids and uterus
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
What medication can be given before myomectomy surgery for fibroids?
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap)
Induce menopause like state and lower oestrogen to stop maintenance of the fibroid and shrink it
When is surgical management used over medical management for fibroids?
If medical has not worked or significant pain and mass effect then myomectomy and hysterectomy considered
What is uterine artery embolisation?
Surgical option for large fibroids done by interventional radiologists
Catheter put through femoral artery and guided to uterine artery via x-ray. Particles are then injected to block arterial supply to fibroid
What are the following surgical techniques for fibroids:
- Myomectomy
- Endometrial ablation
- Hysterectomy
Myomectomy: removing the fibroid via laparoscopic or laparotomy. Only treatment known to potentially improve fertility in patients with fibroids
Endometrial ablation: destroy endometrium usually done by Novosure. Cervix dilated and electrical mesh put on endometrium fro 60 seconds
Hysterectomy: removing uterus and fibroids, can leave ovaries or take them out depending on patient preference, risks and benefits. Can be done laparoscopically, laparotomy or vaginally
What are some of the complications of fibroids?
Pregnancy-related
- Infertility (distortion of uterine cavity)
- Malpresentation
- Placental abruption
- Intrauterine growth restriction
- Preterm labour
- Miscarriages
- Red degeneration
Non-Pregnancy related
- Prolapsed fibroid
- Malignant change (leiomyosarcoma very rare)
- Anaemia from HMB
- Urinary flow obstruction
- Constipation
- Torsion of fibroid (especially pedunculated)
What is red degeneration of fibroids?
Occurs during pregnancy
As fibroid rapidly enlarges it outgrows its blood supply and becomes ischaemic. Can also be due to kinking in blood vessels as uterus changes shape during pregnancy
Presentation: severe abdominal pain, low grade fever, tachycardia, vomiting
How is red degeneration of fibroids managed?
- Rest
- Fluids
- Analgesia
What are some causes of severe abdominal pain in women with fibroids?
- Red degeneration
- Torsion of pedunculated fibroids
What is the typical patient with red degeneration of fibroids?
- Severe abdominal pain
- Low grade fever
- Known fibroids
- Second trimester of pregnancy
What are the commonest symptoms of fibroids?
- Menoraghia
- Dysmennorhea
- Asymptomatic
What are some fibroid treatments that preserve fertility?
- Myomectomy
- Uterine artery embolisation
What is endometriosis?
Ectopic endometrial tissue outside of the uterus
- Adenomyosis: deposits of endometrial tissue in the myometrium of the uterus
- Endometrioma: Cystic structures developing on the ovaries in endometriosis. They are frequently referred to as chocolate cysts due to the appearance of the contained, old and altered blood.
What are some theories for the aetiology of endometriosis?
- Retrograde menstruation
- Lymphatic spread of endometrial cells
- Cell metaplasia outside uterus
- Embryonic cells meant for endometrial tissue remain outside uterus during fetal development
What are some risk factors for endometriosis?
How may endometriosis present?
- Cyclical abdominal or pelvic pain
- Deep dyspareunia
- Dysmenorrhoea
- Infertility
- Cyclical bleeding from other sites e.g haematuria, blood in stool
- Urinary and bowel symptoms
What is the pathophysiology of the following symptoms in endometriosis?
- Cyclical abdominal/pelvic pain
- Non-cyclical abdominal pain
- Reduced fertility
Cyclical abdominal/pelvic pain
Ectopic endometrial tissue responds to hormones and sheds it lining same as endometrium causing irritation and inflammation of tissues surrounding endometriosis.
Can also bleed in urine and stools
Burning, dull, heavy pain
Non-cyclical abdominal pain
Bleeding and inflammation leads to adhesions causing chronic non-cyclical pain that can be sharp, stabbing, pulling and associated with nausea
Reduced** **fertility
Adhesions blocking release of eggs or changing shape of fallopian tubes obstructing route of egg to uterus
Endometriomas in ovary may also damage eggs
What might you find on examination of a patient with endometriosis?
- Visible endometrial tissue in vagina or on speculum exam (posterior fornix)
- Fixed cervix on bimanual exam
- Tenderness in vagina, cervix and adnexa
How is endometriosis investigated and diagnosed?
1st Line: Transvaginal Pelvic US but often unremarkable. Can also do MRI
Gold Standard: Laparoscopic Surgery with biopsy of lesions. Can also remove lesions during this surgery
How is endometriosis staged?
American Society of Reproductive Medicine
- Stage 1: Small superficial lesions
- Stage 2: Mild, but deeper lesions than stage 1
- Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
- Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
What are the different management options for endometriosis?
Initial
- Establish a diagnosis and provide clear explanation
- Listen to patient ICE and screen for anxiety/depression
- Analgesia (Paracetamol and NSAIDs)
Hormonal (not option if wanting to conceive)
- COCP
- IUS
- POP
- Medroxyprogesterone Acetate IM (Depo)
- Implant
- GnRH agonist (induce menopause!!)
Surgical
- Laparoscopic surgery to excite or ablate tissues and do adhesiolysis. Only way to improve fertility and symptoms
- Hysterectomy
What is done before surgery for endometriosis?
3 months of GnRH agonists
What treatments can improve fertility chances in women with endometriosis?
- Excision or ablation of ectopic tissue
- Adhesiolysis
- Ovarian cystectomy with excision of the cyst wall if Endometriomas
What is the last resort option for endometriosis treatment?
Hysterectomy and Bilateral Salpingooopherectomy
Not guaranteed to resolve symptoms and induces menopause
How do GnRH agonists help endometriosis? e.g goserelin (Zoladex)
Endometriosis improves in menopause as lack of hormones. GnRH agonists induce menopause like state by shutting down ovaries temporarily so can help pain
SE: hot flushes, night sweats, risk of osteoporosis
What is the prognosis with endometriosis?
Improves after menopause entirely!!! Unless on HRT with oestrogen in
Can have recurrence after surgeries to treat e.g ablation
What is adenomyosis and who does it typically affect?
Endometrial tissue in myometrium
Usually in later reproductive years and have had several pregnancies
Hormone dependent like endometriosis and fibroids so improves after menopause
How may adenomyosis present?
- Heavy periods
- Painful periods
- Pain during intercourse
- Asymptomatic
- May have fertility issues
What may you find on examination of a woman with adenomyosis?
Enlarged tender uterus
Will be more soft than a uterus with fibroids
How is adenomyosis diagnosed?
1st line: Transvaginal US
2nd Line: MRI or trans abdominal US
Gold Standard: Histological exam after hysterectomy
How is adenomyosis treated?
Usually treated same way as HMB according to NICE
No Contraception wanted:
- Mefenamic acid (for pain)
- Tranexamic acid (for bleeding - antifibrinolytic)
Contraception wanted
- IUS/Mirena (1st Line)
- COCP
- Cyclical progestogen
Specialist Treatment
- GnRH agonists
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
What issues can adenomyosis cause during pregnancy?
What is Asherman syndrome and some causes of this?
Adhesions form within the uterus
- Following Dilatation and Curettage Procedure (e.g retained products of conception)
- After Uterine Surgery
- Pelvic Infections e.g STI
How may Asherman syndrome present?
- Secondary amenorrhea: due to uterus sealed off
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
How is Asherman’s syndrome diagnosed and managed?
Dx
- Hysteroscopy (GOLD STANDARD) as can dissect and treat adhesions whilst doing it
- Hysterosalpingography: contrast x-ray
- Sonohysterography: fluid and pelvic US
- MRI
Mx
- Dissection of adhesions whilst performing hysteroscopy. High recurrence rate
