Endometrial Disease

Question 1

Adenomyosis is

Answer 1

characterized by the presence of endometrial tissue within the myometrium

Question 2

Adenomyosis is more common in

Answer 2

multiparous women towards the end of their reproductive years.

Question 3

Adenomyosis features

Answer 3

dysmenorrhoea
menorrhagia
enlarged, boggy uterus

Question 4

Adenomyosis mx

Answer 4

GnRH agonists

hysterectomy

Question 5

Uterine fibroids are sensitive to

Answer 5

oestrogen

Question 6

fibroids decrease in pregnancy

Answer 6

false

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy

Question 7

What is carneous degeneration?

Answer 7

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration

Question 8

Sx carneous degeneration

Answer 8

with low-grade fever, pain and vomiting.

Question 9

Mx carneous degeneration

Answer 9

The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.

Question 10

Endometriosis is

Answer 10

common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity.

Question 11

10% of women of a reproductive age have a degree of endometriosis.

Answer 11

true

Question 12

Endometriosis gynae sx

Answer 12

chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility

Question 13

Endometriosis non-gynae sx

Answer 13

urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)

Question 14

Endometriosis pelvic exam

Answer 14

on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Question 15

Endometriosis ix

Answer 15

laparoscopy is the gold-standard investigation

there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis

Question 16

Endometriosis first line mx

Answer 16

NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief

if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried

Question 17

Endometriosis management depends on laparoscopy findings

Answer 17

false
Management depends on clinical features.
There is poor correlation between laparoscopic findings and severity of symptoms.

Question 18

Endometriosis Secondary care mx

Answer 18

Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates

surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Question 19

Endometriosis - secondary care referal is indicated when?

Answer 19

If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care.

Question 20

Endometrial hyperplasia is?

Answer 20

defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle

Question 21

Majority of patients with endometrial hyperplasia may develop endometrial cancer

Answer 21

false

minority

Question 22

Types endometrial hyperplasia

Answer 22

simple
complex
simple atypical
complex atypical

Question 23

endometrial hyperplasia features

Answer 23

abnormal vaginal bleeding e.g. intermenstrual

Question 24

endometrial hyperplasia mx

Answer 24

simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised

Question 25

Endometrial cancer is classically seen in

Answer 25

post-menopausal women but around 25% of cases occur before the menopause.

Question 26

Endometrial cancer usually carries a bad prognosis

Answer 26

false

It usually carries a good prognosis due to early detection

Question 27

The risk factors for endometrial cancer are as follows

Answer 27

obesity
nulliparity
early menarche
late menopause
unopposed oestrogen.
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
hereditary non-polyposis colorectal carcinoma

Question 28

unopposed oestrogen. The addition of what reduces rx endometrial cancer

Answer 28

progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously

Question 29

Endometrial cancer sx

Answer 29

postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features

Question 30

Endometrial cancer ix

Answer 30

women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy

Question 31

Endometrial cancer mx

Answer 31

localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Question 32

Uterine fibroids are?

Answer 32

Fibroids are benign smooth muscle tumours of the uterus.

Question 33

Uterine fibroids epidemiology?

Answer 33

They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.

Question 34

Uterine fibroids associations

Answer 34

more common in Afro-Caribbean women

rare before puberty, develop in response to oestrogen

Question 35

Uterine fibroids sx

Answer 35

may be asymptomatic
menorrhagia
may result in iron-deficiency anaemia
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility

Question 36

Uterine fibroids rare features

Answer 36

polycythaemia secondary to autonomous production of erythropoietin

Question 37

Uterine fibroids diagnosis

Answer 37

transvaginal ultrasound

Question 38

Asymptomatic fibroids mx

Answer 38

no treatment is needed other than periodic review to monitor size and growth

Question 39

Management of menorrhagia secondary to fibroids

Answer 39

levonorgestrel intrauterine system (LNG-IUS)
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen

Question 40

Management of menorrhagia secondary to fibroids - levonorgestrel intrauterine system (LNG-IUS) is useful when

Answer 40

useful if the woman also requires contraception

cannot be used if there is distortion of the uterine cavity

Question 41

Treatment to shrink/remove fibroids

medical

Answer 41

GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity

Question 42

Treatment to shrink/remove fibroids

surgical

Answer 42

myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization

Question 43

Uterine fibroids prognosis

Answer 43

Fibroids generally regress after the menopause.

Question 44

Uterine fibroids complications

Answer 44

Some of the complications such as subfertility and iron-deficiency anaemia

Other complications
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy