Endometrial Disease Flashcards
Adenomyosis is
characterized by the presence of endometrial tissue within the myometrium
Adenomyosis is more common in
multiparous women towards the end of their reproductive years.
Adenomyosis features
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
Adenomyosis mx
GnRH agonists
hysterectomy
Uterine fibroids are sensitive to
oestrogen
fibroids decrease in pregnancy
false
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy
What is carneous degeneration?
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
Sx carneous degeneration
with low-grade fever, pain and vomiting.
Mx carneous degeneration
The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Endometriosis is
common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity.
10% of women of a reproductive age have a degree of endometriosis.
true
Endometriosis gynae sx
chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility
Endometriosis non-gynae sx
urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
Endometriosis pelvic exam
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Endometriosis ix
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
Endometriosis first line mx
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
Endometriosis management depends on laparoscopy findings
false
Management depends on clinical features.
There is poor correlation between laparoscopic findings and severity of symptoms.
Endometriosis Secondary care mx
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
Endometriosis - secondary care referal is indicated when?
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care.
Endometrial hyperplasia is?
defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle
Majority of patients with endometrial hyperplasia may develop endometrial cancer
false
minority
Types endometrial hyperplasia
simple
complex
simple atypical
complex atypical
endometrial hyperplasia features
abnormal vaginal bleeding e.g. intermenstrual
endometrial hyperplasia mx
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
Endometrial cancer is classically seen in
post-menopausal women but around 25% of cases occur before the menopause.
Endometrial cancer usually carries a bad prognosis
false
It usually carries a good prognosis due to early detection
The risk factors for endometrial cancer are as follows
obesity nulliparity early menarche late menopause unopposed oestrogen. diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma
unopposed oestrogen. The addition of what reduces rx endometrial cancer
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
Endometrial cancer sx
postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
Endometrial cancer ix
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
Endometrial cancer mx
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
Uterine fibroids are?
Fibroids are benign smooth muscle tumours of the uterus.
Uterine fibroids epidemiology?
They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Uterine fibroids associations
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Uterine fibroids sx
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
Uterine fibroids rare features
polycythaemia secondary to autonomous production of erythropoietin
Uterine fibroids diagnosis
transvaginal ultrasound
Asymptomatic fibroids mx
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids
levonorgestrel intrauterine system (LNG-IUS) NSAIDs e.g. mefenamic acid tranexamic acid combined oral contraceptive pill oral progestogen injectable progestogen
Management of menorrhagia secondary to fibroids - levonorgestrel intrauterine system (LNG-IUS) is useful when
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
Treatment to shrink/remove fibroids
medical
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
Treatment to shrink/remove fibroids
surgical
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
Uterine fibroids prognosis
Fibroids generally regress after the menopause.
Uterine fibroids complications
Some of the complications such as subfertility and iron-deficiency anaemia
Other complications
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
