The Uterus And Cervix Flashcards
1
Q
Leiomyomata
A
- Fibroids - benign tumours of the myometrium.
- Present in 25% of women.
- More common near menopause, Afro-caribbeans and in those with a family history.
- Less common in parous women and with cocp.
2
Q
Fibroids - in menopause and pregnancy
A
- They are oestrogen and progesterone dependant so shrink following the menopause.
- Variable in pregnancy - can shrink, stay the same or grow in size - difficult to predict.
3
Q
Fibroids - Symptoms
A
- 50% are asymptomatic and only discovered during abdo or pelvis examination.
- Cause menorrhagia, dysmenorrhoea, pain if torsion occurs, urinary frequency if pressure on the bladder, hydronephrosis if pressure on ureter.
- Fertility is affected if tubal ostia are blocked or if fibroids affect implantation.
4
Q
Fibroids - Complications
A
- Red degeneration - caused by inadequate blood supply - pain, uterine tenderness, haemorrhage and necrosis.
- Hyaline or cystic degeneration can occur after the menopause.
- 0.1% are leiomyosarcoma - malignant tumour.
5
Q
Fibroids - investigations
A
- Ultrasound is helpful but MRI or laparoscopy can sometimes be required to distinguish fibroids from an ovarian mass.
- Hysteroscopy can be used to assess distortion if fertility is an issue.
- Hb can be low due to bleeding or high as some fibroids produce erythropoetin.
6
Q
Fibroids - Medical Management
A
- Large fibroids that remain in situ should be monitored regularly for malignant change.
- Tanexamic acid, nsaids or progesterones can be tried but often ineffective for menorrhagia.
- GnRH agonists cause amenorrhoea and fibroid shrinkage - induce temporary menopause. Use is limited for a maximum of 6 months due to side effects e.g. loss of bone density.
7
Q
Fibroids - Surgical Management
A
- Hysteroscopic - 3-4cm fibroids can be removed following pretreatment with GnRH agonist.
- Uterine artery embolisation by radiologists - reduces fibroid volume by 50%.
- Myomectomy if fertility to be preserved.
- Hysterectomy if fertility not required.
8
Q
Adenomyosis
A
- Presence of endometrium in the myometrium.
- Associated with fibroids and endometriosis.
- Sx - can be asymptomatic but usually painful, regular and heavy menstruation.
- Ix - adenomysis can be identified on MRI.
9
Q
Adenomyosis - Management
A
- IUD, cocp and nsaids can be used to control sx.
- GnRH agonists can help but max use is 6 months due to side effects - can be used to see if a hysterectomy would be beneficial.
10
Q
Endometritis
A
- Infection of the uterine cavity - can potentially spread to the pelvis if left untreated.
- Organisms - Chlamydia, gonococcus, E Coli, Staphylococcus or clostridia.
11
Q
Endometritis - Causes and Features
A
- Causes - secondary to STI, as a complication of surgery e.g. C section or TOP, due to foreign tissue e.g. IUD or malignancy.
- Features - painful and tender uterus, pv bleeding, open cervical os and systemic upset.
12
Q
Endometritis - Ix and Mx
A
- Ix - high vaginal and cervical swabs and bloods.
- Mx - broad spectrum abx and ERPC (evacuation of retained products of conception) if required.
13
Q
Intrauterine Polyps
A
- Small and usually benign tumours commonly found in women aged 40-50 years especially when oestrogen levels are high e.g. tamoxifen.
- Sx - can cause menorrhagia or IM bleeding.
- Ix - diagnosed on ultrasound or hysteroscopy.
- Mx - resection with cutting diathermy or avulsion.
14
Q
Endometrial Carcinoma
A
- The most common genital tract malignancy.
- Only 15% cases in premenopausal women.
- >90% are adenocarcinoma and the next most common is adenosquamous carcinoma.
15
Q
Endometrial Ca - Risk Factors
A
Principle is high ratio of oestrogen to progesterone - exogenous unapposed oestrogen, obesity (androgen converted to oestrogen), PCOS, nulliparity, late menopause, ovarian granulose cell tumour or use of Tamoxifen.
16
Q
Endometrial Ca - Features
A
Most commonly post-menopausal bleeding but also intermenstrual bleeding or recent onset menorrhagia in premenopausal women.
17
Q
Endometrial Ca - Staging
A
- Confined to the uterus - 1a endometrium only, 1b < half or 1c > half of myometrium.
- There is spread to the cervix - 2a - endocervical glands or 2b - cervical stroma.
- Invades through the uterus - 3a - ovaries or fallopian tube, 3b - vagina and 3c - pelvic LNs.
- Distant spread - 4a - to bowel or bladder and 4b - metastases further afield.
18
Q
Endometrial Ca - Ix and Mx
A
- Ix - USS, hysteroscopy and endometrial biopsy. An MRI is performed is spread suspected.
- Mx - Surgery - 75% present in stage 1 and undergo hysterectomy and bilateral salpingo-ooprectomy unless unfit for surgery. Radiotherapy also used in patients at high risk of lymph node involvement.
19
Q
The Cervix - Histology
A
- The endocervix is lined with columnar epithelium and ectocervix is lined with squamous epithelium.
- The transformation zone - when columnar epithelium is exposed to vaginal ph and undergoes metaplasia to squamous epithelium. These cells are susceptible to neoplastic change.
20
Q
Cervical Ectropion
A
- The columnar epithelium of the endocervix is visible at the os. Common in young women especially those on the cocp.
- Can cause discharge or PC bleeding.
- Can be treated with cryotherapy if problamatic following exclusion of carcinoma.
21
Q
Cervicitis
A
- Acute - caused by STIs. Ulceration and infection are sometimes found in severe prolapses.
- Chronic - often seen with an ectropion and causes abnormal discharge. Treat with abx.
22
Q
Cervical Polyps
A
- Benign tumours of the endocervical epithelium.
- Common in women over 40 years.
- Can cause IM or PC bleeding.
- Mx - polyps can be removed without anaesthetic and examined to exclude neoplasm.
23
Q
Nabothian Follicles
A
Where squamous epithelium has formed by metaplasia over endocervical cells. The columnar cell secretions are trapped and form cysts - white swellings.
24
Q
Cervical Intraepithelial Neoplasm (CIN)
A
- Cervical dysplasia - atypical cells within the squamous epithelium.
- Grade 1 - atypical cells in inner third.
- Grade 2 - atypical cells in inner two thirds.
- Grade 3 - atypical in full thickness - this is carcinoma in situ and if abnormal cells invade basement membrane its malignancy.
25
Cervical Ca - Risk Factors
* Human Papilloma Virus - sexually transmitted so number of sexual contacts is a risk factor.
* Others - cocp, smoking, immunocompromise and long term steroid use.
26
CIN - Mx
A large loop excision of the transformation zone (LLETZ) or diathermy loop excision (DLE) is performed under local anaesthetic for grades 2 and 3.
* Complication - higher risk of preterm labour.
27
Cervical Ca
* Incidence is 1 in 80,000 women in the UK. Can affect women aged between 30-80 years.
* 90% are squamous cell carcinoma and 10% are adenocarcinomas - worse prognosis as less are detected on smear tests.
28
Cervical Ca - Clinical Features
Can be asymptomatic, post-coital bleeding, vaginal discharge, intermenstrual or postmenopausal bleeding are common.
29
Cervical Ca - Staging
1. Confined to the cervix.
2. Invasion of the vagina.
3. Invasion of lower vagina or pelvic walls.
4. Invasion of bladder or rectal mucosa.
30
Cervical Ca - Management
* Microinvasive 1a disease - cone biopsy or hysterectomy in older women.
* Other stage 1 and 2a - radical abdominal hysterectomy or chemo/radiotherapy in older women.
* Stage 2b and upwards - chemo/radiotherapy.
