Gynae: Fibroids, Endometriosis, Adenomyosis, Polyps Flashcards
what are fibroids? and what are they sensitive to?
benign tumours of the smooth muscle of the uterus which are oestrogen sensitive and grow in response to oestrogen
aka uterine leiomyomas
which ethnic groups are fibroids most common in?
black women
describe the 4 types of fibroids
- intramural - within the myometrium and they distort the shape of the uterus
- subserosal - just below the outer layer of the uterus and they grow outwards filling the abdominal cavity
- submucosal - just below the endometrium
- pendunculated - on a stalk
how can fibroids present?
- often asymptomatic
- heavy menstrual bleeding
- prolonged menstruation
- Abdominal pain often worse during menstruation
- bloating/feeling full in abdomen
- urinary or bowel symptoms
- deep dyspareunia
- reduced fertility
what may be seen on abdominal and bimanual examination of someone with fibroids?
palpable pelvic mass or an enlarged firm non-tender uterus
how are fibroids investigated?
hysteroscopy - initial investigation for submucosal fibroids presenting with HMB
pelvic ultrasound - larger fibroids
MRI scanning - helps to determine size and shape and blood supply before surgery
NICE guidelines on fibroids are included within the heavy menstrual bleeding guideline from 2018.
Management for less than 3 cm
medical = same as HMB
- Mirena coil (1st line) – fibroids must be < 3cm with no distortion of the uterus
- Symptomatic management with NSAIDs & tranexamic acid
- COCP
- Cyclical oral progestogens
surgical
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
what is the management of fibroids >3cm
Referral to gynaecology
Medical
- Symptomatic management with NSAIDs and tranexamic acid
- Mirena coil – depending on the size and shape of the fibroids and uterus
- COCP
- Cyclical oral progestogens
Surgical
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
what can be used prior to fibroid surgery to reduce the size of the fibroids?
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
they induce a menopause-like state and reduce the amount of oestrogen maintaining the fibroid
what are the complications of fibroids?
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
what is uterine artery embolisation?
surgical option for larger fibroids, performed by IR. inset catheter into femoral artery and passed through to uterine artery. particles injected that cause a blockage in the arterial supply to the fibroid = shrinks
what is myomectomy?
surgical removal of the fibroid via laparoscopic surgery or laparotomy
only treatment known to potentially improve fertility in pt with fibroids
what is endometrial ablation?
way of destroying the endometrium. now done using balloon thermal ablation where a specially designed balloon is inserted into the endometrial cavity and filled with a high temperature fluid that burns the endometrial lining
what is a hysterectomy?
removing the whole uterus and fibroids
can be keyhole, laparoscopic or vaginal approach
ovaries can be left or removed
what is red degeneration of fibroids?
refers to ischaemia, infarction and necrosis of fibroids due to disrupted blood supply.
when is red degeneration of fibroids most likely to occur?
in larger fibroids >5cm during the second and third trimester of pregnancy
may occur as the fibroid enlarges during pregnancy outgrowing its blood supply and becoming ischeamic.
may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy
how does red degeneration present and how is it managed?
presents with severe abdominal pain, low-grade fever, tachycardia, vomiting
managed is supportive with rest, fluid and analgesia
what is endometriosis?
a condition where there is ectopic endometrial tissue outside the uterus
what is a lump of endometrial tissue outside the uterus called?
an endometrioma
what is an endometrioma in the ovary known as?
chocolate cysts
what is the aetiology of endometriosis?
exact cause unknown - numerous theories
- no specific genes identified but some genetic component
- retrograde menstruation
- embryonic cells destined to become endometrial tissue remain outside the uterus during development of the fetus
- lymphatic spread (similar to cancer)
- metaplasia
one of the main symptoms of endometriosis is pain. describe the pathophysiology of this
endometrial tissue outside the uterus responds to hormones the same way the endometrial tissue inside the uterus does so during menstruation is sheds its lining and bleeds as the endometrial tissue inside the uterus would. this causes irritation and inflammation of the tissues around the sites of endometriosis resulting in cyclical dull, heavy or burning pain during menstruation
localised bleeding and inflammation can lead to adhesions - lead to chronic, non-cyclical pain that can be sharp, stabbing or pulling and is associated with nausea
why is it though that women with endometriosis struggle with fertility?
- adhesions around ovaries and fallopian tubes may block release of eggs or kinking them may obstruct route
- endometriomas in the ovary may damage eggs and prevent effective ovulation
how does endometriosis present?
- can be asymptomatic
- cyclical abdominal or pelvic pain
- deep dyspareunia
- Dysmenorrhoea
- infertility
- cyclical bleeding from other sites - bladder and bowel
what may be seen on examination of endometriosis? - speculum/bimanual
- endometrial tissue visible in the vagina on speculum exam, particularly in posterior fornix
- fixed cervix on bimanual examination
- tenderness in the vagina, cervix, adnexa
how is endometriosis diagnosed?
- pelvic ultrasound - reveal large endometriomas and chocolate cysts but may be normal
- laparoscopic surgery is gold standard - definitive diagnosis made with biopsy of a lesion (can also remove some in same procedure)
NICE recommend documenting a detailed description of the endometriosis rather than using a staging system. the American Society of Reproductive Medicine (ASRM) have a staging system, describe the stages?
- Stage 1: Small superficial lesions
- Stage 2: Mild, but deeper lesions than stage 1
- Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
- Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
what are the 3 categories of management for endometriosis?
- initial management
- hormonal management
- surgical
what is the initial management of endometriosis?
- establishing a diagnosis
- providing a clear explanation
- listen to the pt, establish ICE
- analgesia as required for pain - NSAID and paracetamol 1st line
what are the hormonal management options for endometriosis?
can be tried before establishing a definitive Diagnosis - improves symptoms but not fertility
- COCP
- POP
- Progesterone injection/implant
- Mirena coil
- GnRH agonists
surgical management of endometriosis?
- laparoscopic surgery to excise or ablate endometrial tissue and remove adhesions
- Hysterectomy
more about menopause treatment options
Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.
The cyclical pain tends to improve after the menopause when the female sex hormones are reduced. Therefore, another treatment option for endometriosis is to induce a menopause-like state using GnRH agonists. Examples of GnRH agonists are goserelin (Zoladex) or leuprorelin (Prostap). They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis.
Laparoscopic surgery can be used to excise or ablate the ectopic endometrial tissue. In women where there is chronic pelvic pain due to adhesions, surgery can be used to dissect the adhesions and attempt to return the anatomy to normal.
Hysterectomy and bilateral salpingo-opherectomy is the final surgical option. During the procedure, the surgeon will attempt to remove as much of the endometriosis as possible. Importantly, this is still not guaranteed to resolve symptoms. Removing the ovaries induces menopause, and this stops ectopic endometrial tissue responding to the menstrual cycle.
Infertility secondary to endometriosis can be treated with surgery. The aim is to remove as much of the endometriosis as possible, treat adhesions and return the anatomy to normal. This improves fertility in some but not all women with endometriosis.
what is adenomyosis?
endometrial tissue inside the myometrium (muscle layer of the uterus)
more common in later reproductive years and following several pregnancies
hormone dependent so symptoms tend to resolve after menopause
how does anenomyosis present?
- painful periods
- heavy periods
- pain during sexual intercourse
- infertility or pregnancy related complications
- can be asymptomatic
what can examination show in someone with adenomyosis?
enlarged and tender uterus
will be softer than someone with fibroids
how is adenomyosis diagnosed?
transvaginal ultrasound - 1st line
MRI and transabdominal ultrasound scan
gold standard - perform histological examination of the uterus after hysterectomy
how is adenomyosis managed?
- dependent on womans wishes, symptoms, plans for pregnancy
- woman who does not want contraception = symptomatic treatment during menstruation
- tranexamic acid where there is no associated pain
- mefenamic acid when there is associated pain
- when woman does want contraception
- mirena coil
- COCP
- cyclical oral progesterone
specialist options for adenomyosis management
- GnRH analogues to induce a menopause-like state
- endometrial ablation
- uterine artery embolisation
- hysterectomy
what pregnancy complications are associated with adenomyosis?
- infertility
- miscarriage
- preterm birth
- small gestational age
- preterm premature rupture of membranes
- malpresentation
- need c section
- post partum haemorrhage
