Benign Lesions Flashcards
Definition of Asherman’s syndrome
Fibrosis and adhesion formation within the endometrial cavity that may partially or completely occlude it. Occurs following damage of the single layer thick basal endometrium- preventing normal regeneration of the endometrium. May alternatively be fibromuscular or purely connective tissue damage.
Complications of Asherman’s syndrome
- Leads to menstrual disturbance (reduced or absent menstrual shedding) and subfertility
Causes of Asherman’s syndrome
- With or without haemorrhage after delivery (complicated by endometritis)
- Elective termination of pregnancy
- Dilation and curettage for a procedure for excessive bleeding (not recognised procedure- idea is to create adhesions to control bleeding), sampling for endometrial cancer, removal of endometrial polyps or uterine fibroids
Presentation of Asherman’s syndrome
- Reduced/ absent menstrual bleeding, cyclical abdominal pain- dysmenorrhoea (indicates adhesions are preventing menstrual flow within the cervix)
- Subfertility and recurrent miscarriage- may cause abnormal placentation in pregnancy
Investigations for Asherman’s syndrome
- Hysteroscopy- gold standard for diagnosing the extent of the disease and allows for simultaneous treatment
- Hysterosalpingogram (HSG) is used to check if the uterus is normal and if the fallopian tubes are patent- utilises fluoroscopy
- Saline hystersonogram- injection of saline into the uterus to using a catheter and USS is used to detect abnormalities
Management of Asherman’s syndrome
- 1st line- Hysteroscopic adhesiolysis- (cervical dilatation and hysteroscope insertion → excision of adhesions). BUT Treatment risks further uterine trauma
- Cu-IUD can be inserted post-operatively to prevent the formation of further adhesions
- Oestrogens can be used pre-operatively to aid in identifying endometrial deposits and can also be used post-operatively to encourage endometrial regeneration
Definition of atrophic vaginitis
A condition which commonly occurs in post-menopausal women due to oestrogen deficiency. There is a potential negative impact on all urogenital tissue quality including the vulva, vagina, bladder and urethra (associated with urinary symptoms).
Disease course of atrophic vaginitis
Unlike other menopausal symptoms, urogenital atrophy is associated with a chronic progressive course.
Presentation of atrophic vaginitis
- Symptoms may not become apparent for several years after the menopause and therefore any association is lost, with women accepting symptoms as a normal part of the aging process
- May present with vaginal dryness, dyspareunia, occasional spotting
- May present with concomitant urinary symptoms including increased urinary frequency, urgency, recurrent UTIs
- On examination, atrophy of the vulva and vagina may be apparent. The vaginal epithelium usually becomes thin and loses its rugae and elasticity. It can be visibly paler due to the reduced blood supply and petechial haemorrhages may be present
Management of atophic vaginitis
- Offer vaginal oestrogen to women with urogenital atrophy (including those on systemic HRT) and continue treatment for as long as needed to relieve symptoms
- A vaginal ring can be inserted into the vaginal posterior fornix and changed every 3 months
- Consider vaginal oestrogen for women in whom systemic HRT is contraindicated
- If vaginal oestrogen does not relieve symptoms of urogenital atrophy, consider increasing the dose after seeking advice from a healthcare professional with expertise in menopause
- Advise women with vaginal dryness that moisturisers and lubricants can be used alone or in addition to vaginal oestrogen
- Do not offer routine monitoring of endometrial thickness during treatment for urogenital atrophy
Explain to the women that:
* Symptoms often return when treatment is stopped
* Adverse effects from vaginal oestrogen are very rare
* They should report any unscheduled vaginal bleeding to their GP
What are the Bartholin’s glands
Two glands behind the labia minora which secrete lubricating mucus for coitus. Blockage of the duct causes cyst formation, whilst infection with S.aureus causes formation of an abscess.
What is a bartholins cyst
A non-infectious occlusion of the distal Bartholin’s duct with resultant retention of secretions
* The most common type of vulval cyst, others include skene gland cyst, mucous inclusion cyst
* Occurs in young women, often with concomitant STI
What is the presentation of a Bartholin’s cyst
- Worse symptoms are usually present in the case of an abscess
- Unilateral vulval swelling, vulval mass, often painless but may present with dyspareunia and difficulty walking
- Abscess: pain, erythema, tenderness, possible pus discharge, may have systemic symptoms (fever, malaise)
- A cyst usually appears as a medially protruding cystic structure at the inferior aspect of the labia majora. As opposed to an abscess which is unilateral, fluctuant, tender, posterior labial mass
Investigations for a Bartholin’s cyst
- Diagnosis is usually made by physical examination (clinical diagnosis)
- Biopsy of vulval lesion (particularly if over 40 years old- increased risk of adenocarcinoma of the Bartholin glands) if malignancy is suspected based on clinical assessment
- Cavity swab for MC&S
- Consider an STI screen- N.gonorrhoea is cultured from 20% of abscesses (80% are mixed vaginal flora)
Management of an asymptomatic Bartholin’s cyst
Conservative management with analgesia, warm baths and compress to aid drainage. Asymptomatic cysts are usually excised in women over 40 due to risk of malignancy
Management of a symptomatic Bartholin’s cyst
- Marsupialization: A surgical procedure performed under local anaesthesia or pudendal nerve block that involves draining the cyst and inverting its wall with absorbable sutures to create a tract that will re-epithelialise. Should give Abx (trimethroprim)
- Incision and drainage
- Silver nitrate insertion
- Balloon catheter insertion- incision is made and catheter is inserted to promote drainage (requires antibiotics)
What is a cervical polyp, when are they usually detected
A benign tumour of the endocervical epithelium. Usually asymptomatic (may cause Post-menopausal, inter-menstrual or post-coital bleeding) and appear as a smooth, reddish protrusion
* Usually detected on routine cervical smears- common in women >40 years old and usually <1cm in diameter
What is the management for a cervical polyp
Small polyps can be removed by avulsion using polyp forceps as an outpatient, however, still need to examine histologically and investigate any bleeding abnormalities
What is an endometrial polyp
Small, usually benign tumours that grow into the uterine cavity (‘focal endometrial outgrowths’) and contain a variable amount of glands, stroma and blood vessels.
* Most intrauterine polyps are endometrial in origin and can be derived from submucous fibroids
What is the peak age of incidence of endometral polyps
- Common in women aged 40-50, when oestrogen levels are high. Can also be found in postmenopausal women on tamoxifen for breast cancer
Risk factors for developing endometrial polyps
Obesity, late menopause, use of tamoxifen, possibly use of HRT
Presentation of endometrial polyps
- Endometrial polyps can be pedunculated or sessile, single or multiple and can vary in size (0.5-4cm)
- Can be asymptomatic
- Abnormal uterine bleeding: HMB, IMB, PMB, PCB
- Most are resistant to cyclical hormonal changes, leading them to persist and cause unscheduled vaginal bleeding
- Can also cause infertility
- Contain hyper plastic foci in 10-25% of symptomatic cases and 1% are frankly malignant (risk is increased in use of tamoxifen)
How are endometrial polyps diagnosed
Diagnosed by TVUSS or during hysteroscopy (usually arranged for abnormal bleeding)
What is the management of endometrial polyps
- Some small polyps may resolve spontaneously
Polypectomy is recommended to alleviate AUB symptoms, optimise fertility and exclude hyperplasia/cancer
* Can be performed as a day-case under GA, or even as outpatient under LA
* Hysteroscope is used to visualise the polyp and small instruments are used to remove polyp
What are Nabtholian cysts/follicles
- Occur when the columnar glands within the transformation zone become sealed over, forming small, mucousfilled cysts visible on the ectocervix
- They have NO pathological significance
- NO treatment is required
- Very large ones may need drainage
What is a cervical ectropian, what causes them
A condition in which columnar epithelium of the endocervix is visible as a round, red area surrounding the external cervical os.
* Caused by eversion, usually in younger women, especially in pregnancy and whilst taking the COCP (3 Ps: Puberty, Pill, Pregnancy)
* This is a common, benign finding
Presentation of a cervical ectropian
- Usually asymptomatic
- A large cervical ectropian may be fragile, predisposing to intermenstrual and postcoital bleeding. May also cause pain during or after cervical screening
- Some women may complain of excessive, clear, odourless mucosal discharge
Investigations for a cervical ectropian
- Usually identified during a smear screening
- Cervical and lower genital tract swabs should be taken to exclude STI (prone to infection)
- A smear should be taken to exclude malignancy
Management of a cervical ectropian
Management involves cauterisation of the ectropion using silver nitrate or cold coagulation (ablation) during colposcopy. Changing from oestrogen-based hormonal contraceptives can also hep reduce symptoms
