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 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 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
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
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 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
How is adenomyosis diagnosed?
1st line: Transvaginal US
2nd Line: MRI or trans abdominal US
Gold Standard: Histological exam after 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 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
