Benign Conditions of uterus, cervix, endometrium

Question 1

What is cervical ectropion?

What can lead to the development of the ectropion?

Answer 1

Cervical ectropion is when the columnar epithelium that usually lines the endocervix is visible on the ectocervix.

Commonly develops under influence of the 3 Ps:

• Puberty
• Pill
• Pregnancy

Question 2

How might a patient with cervical ectropion present?

Answer 2

• Many are asymptomatic.
• Some women present with IMB or PCB or odourless discharge.

Question 3

How would you manage a woman with cervical ectropion?

Answer 3

Conservative:

• If there are no symptoms, exclude malignancy and infection. Reassure the woman
• With symptoms:
  
  • Consider swithing to a non-oestrogen based contraception
  • Cervical ablation (e.g. with cryocautery)

Question 4

What is a nabothian follicle?

Answer 4

A nabothian follicle is like a pimple in the endocervix: the glands in the columnar epithelium of the endocervix can become sealed over leading to small mucus-filled cysts.

No treatment us usually required, but large ones can be drained.

Question 5

What are the symptoms cervical polyps?

How can you treat them?

Answer 5

They are benign tumours arising from the endocervical epithelium.

Same symptoms as ectropion. They are usually asymptomatic but can cause:

• Vaginal discharge
• PCB
• IMB

They are easily removed by plucking them off with polyp forceps.

Question 6

What is cervical stenosis?

How is this managed?

Answer 6

There is pathological narrowing of the cervical canal.

Causes include iatrogenic (surgical events).

It can lead to haematometra when the blood in the uterus cannot get out.

Treatment is surgical dilation if the canal under USS or hysteroscopic guidance

Question 7

How might a woman with an endometrial polyp present?

Answer 7

They can be asymptomatic or:

• IMB
• PCB
• HMB
• Subfertility

Question 8

What is the worry with endometrial polyps?

Answer 8

10-25% of endometrial polyps have hyper plastic changes, and 1% are malignant.

Question 9

How can you diagnose endometrial polyps?

Answer 9

• TVUSS
• Outpatient hysteroscopy is preferred (Better visualisation)

Question 10

How do you manage endometrial polyps?

Answer 10

Whilst smaller polyps might spontaneously resolve, due to their malignant potential and their effect on fertility/AUB, polypectomy should be performed.

This can be done as an outpatient hysteroscopy or as a day-case under general anaesthesia.

Question 11

What is Asherman syndrome?

Answer 11

This is irreversible damage to the endometrial lining, preventing normal regeneration. The endometrial cavity therefore undergoes fibrosis and forms adhesions.

Question 12

What are symptoms of Asherman syndrome?

Answer 12

There might be reduced or absent uterine bleeding.

If the woman is trying to conceive, she might present with subfertility.

Question 13

What are causes of Asherman Syndrome?

Answer 13

• Endometritis, e.g. after pregnancy
• Overzealous curettage during surgical management of miscarriage or retained products of conception (the uterus is in a soft state so easy to scrape away too much)
• In HMB, some treatment forms aim at inducing Asherman (endometrial ablation

Question 14

What is the management of Asherman syndrome?

Answer 14

• The management of Asherman is difficult, as it involves surgery, win itself a risk factor for developing Asherman’s.
• Surgery consists of adhesiolysis.

Question 15

What are fibroids?

How common are they?

Answer 15

A fibroid is a leiomyoma, i.e. a benign tumour of the uterine smooth muscle.

They are oestrogen dependant (hence resolve during menopause).

Around 40% of women of reproductive age have a fibroid.

Question 16

Describe the epidemiology of fibroids

Answer 16

They area associated with rare mutations, but are more commonly associated with oestrogen. They are rare before puberty, common with advancing reproductive age and shrink after menopause. They are also more common in Afro-Caribbean women.

They are the most common tumour in women and are through to occur in around20% of white and around 50% of black womenin the later reproductive years.

Question 17

What symptoms might a woman with fibroids complain?

Answer 17

The vast majority of women are asymptomatic

• AUB, e.g. HMB and IMB
• Reproductive issues:
  
  • Subfertility/Reproductive Failure
  • Recurrent pregnancy loss
• Mass effect:
  
  • Pressure feelings/Abdominal distension
  • Pressure and pain
  • Bladder/Bowel dysfunction

Question 18

What investigations might you perform in a woman with suspected fibroids?

Answer 18

1. Conduct an abdominal and bimanual pelvic examination to assess for the presence of any masses.
2. Arrange a blood test to check for iron deficiency anaemia. Severe anaemia associated with heavy menstrual bleeding invariably indicates the presence of significant fibroids.
3. Transvaginal ultrasound (TVUSS) is the mainstay of diagnosis and helps distinguish fibroids from other uterine or ovarian tumours. Occasionally, MRI may be needed to demarcate the fibroid prior to surgery.

Special tests:

• Hysteroscopy (for submucosal fibroids)

Question 19

Name the different types of fibroids.

Answer 19

Question 20

How would you manage a woman with fibroids?

Answer 20

Management depends on the signs/symptoms of fibroids and the woman’s wish to conceive.

Conservative:

• Most fibroids are harmless and don’t cause the woman any symptoms. Reassure the woman.

Medical:

• Treat HMB (i.e. Mirena), but might not be effective
• Temporary induction of menopause: GnRH analogues, Ulipristal acetate (but fibroids regrow once stopped)

Surgical:

• Fertility Sparing:
  
  • Endocervical resection of fibroids (minimally invasive)
  • Myemectomy (often laparoscopic, using morcellation). Warn the patient that extreme bleeding might mean hysterectomy has to be performed
• Hysterectomy

Radiological:

• Uterine artery embolisation (probably not compatible with fertility)

Question 21

What is adenomyosis?

Answer 21

This is a disorder in which the endometrial glands & stroma (usually well demarcated from myometrium) invade the underlying myometrium.

Question 22

What are symptoms of adenomyosis?

Answer 22

• Cyclical pain (increasingly severe secondary dysmenorrhoea)
• HMB
• Uterine enlargement

Question 23

What investigations can help with the diagnosis of adenomyosis?

Answer 23

Imaging:

• TVUSS
• MRI

Question 24

What are your management options for adenomyosis?

Answer 24

What are your management options for adenomyosis?

Conservative includes pain management (NSAIDS, relaxation incl. yoga, meditation)

Treatments that induce amenorrhoea are helpful, including LNG-IUS and other LARCs (depot or implant). The COCP/POP as well as transexamic acid/mefenamic acid, and short-term GnRH agonists can also be tried. On ceasing treatment however, the symptoms rapidly return in the majority of patients.

Endometrial ablation and hysterectomy remain the only definitive treatment.

Question 25

What organisations can you refer a woman with adenomyosis to for more information?

Answer 25

• Adenomyosis advice association
• Pelvic Pain support network
• Hysterectomy association

Question 26

What complication can fibroids cause during preganncy?

Answer 26

Pregnancy is a hyperoestrogenic state, the fibroid is therefore encouraged to grow.

When they outgrow their blood supply, this leads to red degeneration. There is haemorrhage and necrosis within the fibroid usually mid second trimester.

This is acutely painful.