Benign conditions of the uterus Flashcards
What is endometriosis?
A chronic condition
The presence of endometrial tissue outside of the uterus
Its driven by oestrogen
Who gets endometriosis?
People who are exposed to oestrogen
Pre-menopausal women, often nulliparous
Where can endometrial tissue be found in endometriosis?
Where is it most commonly found?
Anywhere in the body except the brain
It the pelvis, most commonly in the pouch of Douglas
In scars, such as the umbilicus
What is the pouch of Douglas?
Why is endometriosis most likely to occur here?
The area between the rectum and the vagina
Because of retrograde menstruation, blood containing endometrial cells flows back through F tubes and into the pelvic cavity
The pouch of Douglas is the lowest point in the pelvic cavity so blood flows down there.
The endometrial cells invade and start to grow there
In what ways do endometrial cells spread around the body?
Via retrograde menstruation
Metaplasia: cells transform into endometrial cells b/c of genetic predisposition and oestrogen
Haematogenous dissemination
Via lymph system
Women will have endometriosis for life. True or false?
False
They’ll suffer with it until they go through the menopause
Presentation of endometriosis?
Sometimes asymptomatic
Pain:
- cyclical
- deep dyspareunia
- pain on defaecation
Infertility
Why does endometriosis cause cyclical pain?
Because during the follicular phase of menstrual cycle, the endometrium proliferates
The endometrial tissue becomes swollen and painful
Endometrium proliferates even if its in the wrong place
When is the follicular phase of the cycle?
After the period up to ovulation, as the endometrium is proliferating
Why do women with endometriosis sometimes get referred with suspected ovarian cancer?
Because a lump is found in the ovary, which is endometrial tissue
Also their Ca 125 levels are raised
Investigations of women with suspected endometriosis?
Trans-vaginal USS
MRI
Laparoscopy
Can also make them temporarily menopausal with GnRH analogues, if symptoms don’t improve it’s not endometriosis
What are the management options for a 21 yr old woman with endometriosis who doesn’t want children now but may in the future?
How does these work?
The OCP taken triphasically (back to back for 3 months)
Removes the cyclic nature of oestrogen levels, so no cyclic pain
A progesterone contraceptive: pill, Depo, Mirena
Works by thinning endometrium
What is the downside of using a progesterone contraceptive (pill, depo, mirena) as a treatment for endometriosis?
Can cause irregular spotting
What are the management options for a 30 yr old woman with endometriosis who wants to start a family now?
Laparoscopic surgery
Ablation or excision of endometrial tissue
What are the management options for a pre-menopausal 47yr old woman with endometriosis who’s completed her family?
Would it change your management if she’d had lots of pelvic surgery in the past?
Hysterectomy
If pelvic surgery in the past, surgery not recommended b/c adhesions increase risk of complications
Give GnRH analogues and ‘add back’ therapy of HRT
How do GnRH analogues work as treatment for endometriosis?
The hypothalamus releases GnRH in pulses to stimulate the pituitary to release FSH + LH. The time between pulses allows the pituitary to make and store up FSH and LH ready for release after a pulse.
Giving GnRH analogues means the pituitary is constantly being stimulated to release FSH and LH, so there’s no time between pulses to make FSH + LH.
So no FSH and LH is produced, so they’re effectively menopausal
Why do you give ‘add back’ therapy when giving GnRH analogues?
Do you give OE alone or OE + P?
To alleviate the symptoms of menopause
Give OE + P if they have a uterus, as unopposed OE can lead to excessive endometrial thickening and endometrial cancer
You see a 46 yr old lady who has 3 children. She has endometriosis-like symptoms.
What do you think it could be?
Less likely to be endometriosis because of her age and her parity
Could be adenomyosis
(Always rule out endometrial cancer)
What is adenomyosis?
The presence of endometrial tissue in the myometrium
Affects older, multiparous women
Presentation of adenomyosis?
Constant pain
Menorrhagia
Dyspareunia
Management of adenomyosis?
Hysterectomy
What is removed in a hysterectomy?
The uterus
And commonly the ovaries, fallopian tubes and cervix
What are fibroids?
Benign smooth muscle tumours in the uterus
What causes fibroids?
Oestrogen causes the growth of fibroids
