Fibroids and hysteroscopy Flashcards
What is a hysteroscope?
A hysteroscope is a narrow lumen camera which is passed through the cervical os to enable visualisation of the uterine cavity. It is also used to take biopsies of the endometrium and any suspicious areas.
Where is a hysteroscopy performed?
A hysteroscopy is usually performed in the outpatient’s department without the need for anaesthetic however in cases where cervical dilatation is needed, injections of cervical local anaesthetic can be used.
Which conditions can be treated with a hysteroscopy?
Fibroids, polyps and adhesions within the endometrial cavity can also be treated via hysteroscopy.
What should you consider when agreeing treatment options for heavy menstrual bleeding?
- The woman’s preferences
- Any comorbidities
- The presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis
- Other symptoms such as pressure and pain.
What is the treatment if there is no identified pathology?
- Consider LNG-IUS as the first treatment .
* Treatment for fibroids that are less than 3 cm or suspected/diagnosed adenomyosis as well.
What should you prescribe a woman who declines LNG-IUS for no identified pathology?
non-hormonal: -tranexamic acid -NSAIDs hormonal: -combined hormonal contraception -cyclical oral progestogens.
What is the next management when a woman declines pharmacological treatment or symptoms are severe?
o Investigations to diagnose the cause of heavy menstrual bleeding, if needed, taking into account any investigations the woman has already had and
o Alternative treatment choices, including:
Pharmacological options not already tried (see above)
Surgical options:
- Second-generation endometrial ablation
- Hysterectomy.
- For women with submucosal fibroids, consider hysteroscopic removal.
Treatment for fibroids 3 cm or more
o Pharmacological: Non-hormonal: • Tranexamic acid • NSAIDs Hormonal: • LNG-IUS • Combined hormonal contraception • Cyclical oral progestogens • Uterine artery embolisation Surgical: • myomectomy • hysterectomy.
What is endometrial ablation?
During the procedure, most of your womb (uterus) lining will be destroyed or removed. This may stop your periods completely or they may become lighter.
Although your womb isn’t removed, endometrial ablation isn’t a suitable treatment if you plan to have children in the future.
You can have the procedure any time, but your doctor may decide to do the ablation just after your period ends. This is when your womb lining is at its thinnest.
Methods for endometrial ablation
o Radio-frequency. Your doctor will put a probe through your cervix and into your womb, which will send electromagnetic energy into the lining of your womb. The energy destroys the lining.
o Freezing. Your doctor will put a thin probe into your womb and freeze its lining. They’ll use an ultrasound scan to help guide them.
o Heated fluid. Your doctor will pass fluid through a hysteroscope into your womb. The fluid is heated and stays in your womb for about 10 minutes. The heat destroys the lining of your womb.
o Heated balloon. Your doctor will put a balloon into your womb and pass heated fluid into it, which expands the balloon until it touches the lining of your womb. The heat from the balloon destroys your womb lining.
o Electrosurgery. Your doctor will put a device called a resectoscope through your cervix and into your womb. The resectoscope has an electrical wire loop or roller-ball that destroys the lining.
What is fibroids?
- Uterine fibroids (leiomyomata) are benign tumours of the uterus primarily composed of smooth muscle and fibrous connective tissue.
- There are often multiple tumours in a single uterine specimen.
Pathophysiology of fibroids
Uterine fibroids arise from the myometrial layer of the uterine corpus or, less commonly, the uterine cervix, and may occur singly or multiply.
Fibroids may remain within the muscular layer (intramural) or protrude outwardly to become subserosa in location or inwardly towards the endometrial cavity, where they become known as submucous fibroids. Subserosal and submucosal fibroids may become pedunculated.
Hx and examination of fibroids
Menorrhagia Irregular firm central pelvic mass- the absence of morbid obesity. Pelvic pain Pelvic pressure Dysmenorrhoea Bloating
Risk factors for fibroids
Increased patient weight Age in the 40s Black ethnicity HTN Menstrual hx Obstetric hx
Investigations for fibroids
- Ultrasound- sonographic appearance of uterine fibroids
- Endometrial biopsy- normal
- Hysteroscopy- space-occupying lesions of the endometrial cavity such as endometrial polyps.
- MRI- pelvic or abdominal masses involving the uterus and adjacent structures.
- Laparoscopy- visualisation of irregular protrusion from uterine surface.
