The uterus and it's abnormalities Flashcards
What are fibroids?
Benign tumours of the myometrium.
What age are fibroids most common?
More common near the menopause
In what race are fibroids more common?
Afro-caribbean
What contraceptives decrease your risk of fibroids?
The combined oral contraceptive and injectable progestogens
What are the different sites of fibroids?
They can be intramural, subserosal or submucosal
What type of fibroid can occasionally form intracavity polyps?
Submucosal fibroids
What tissue is used to form fibroids?
Smooth muscle and fibrous elements are present, and in transverse section the fibroid has a ‘whorled’ appearance.
What happens to fibroids during pregnancy?
They are equally likely to grow, shrink or have no change
What happens to fibroids after menopause?
They regress due to the reduction in circulating oestrogen.
Is it more likely that site or size of fibroids affects symptoms?
Site not size
What are the symptoms of fibroids?
may be asymptomatic (50%)
menorrhagia
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
What type of fibroids cause intermenstrual bleeding?
Submucosal or polypoid
When would fibroids cause pain?
They seldom cause pain, unless torsion, red degeneration or, rarely, sarcomatous change occur.
When would fibroids affect fertility?
Fertility can be impaired if the tubal ostia are blocked or submucosal fibroids prevent implantation. Intramural fibroids not distorting the cavity also reduce fertility through the mechanism is unclear.
What often happens to fibroids after menopause?
Fibroids stop growing and often calcify after the menopause, although the oestrogen in HRT may stimulate further growth.
Why does fibroid degeneration take place?
It is normally the result of an inadequate blood supply
What are the symptoms of fibroid ‘red degeneration’?
It is characterised by pain and uterine tenderness; haemorrhage and necrosis occur.
What physiological thing increases the risk of red degeneration?
Red degeneration is common in pregnancy.
Should fibroids be cut out at caesarean section?
No, bleeding can be heavy
Can fibroid secrete anything, if so, what?
Yes, they can secrete erythropoietin, which can raise Hb levels
How do you treat fibroids?
symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
other options include tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
surgery is sometimes needed: myomectomy, hysteroscopic endometrial ablation, hysterectomy
uterine artery embolization
What is adenomyosis?
The presence of endometrium and its underlying storm within the myometrium
What age is adenomyosis most common?
It is most common around the age of 40
What other diseases are associated with adenomyosis?
Endometriosis and fibroids
What happens to symptoms of adenomyosis after menopause?
They subside
What are the symptoms of adenomyosis?
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
What investigation would you use to detect adenomyosis?
It is not easily diagnosed by ultrasound but can be seen on MRI
What is the treatment for adenomyosis?
Medical treatment with the progesterone intrauterine system (IUS) or the combined oral contraceptive pill with or without NSAIDs for dysmenorrhoea and menorrhagia but often hysterectomy is needed
What are some of the causes of secondary endometriosis?
Endometriosis is often secondary to sexual transmitted infections, as a complication of surgery, particularly C section and intrauterine procedure, or foreign bodies
What are intrauterine polyps?
These are small, usually benign tumours that grow into the uterine cavity.
What age are intrauterine polyps most common?
They are common in women aged 40-50 years and when oestrogen levels are high.
What are the symptoms of intrauterine polyps?
Although sometimes asymptomatic, they often cause menorrhagia and intermenstrual bleeding and very occasionally prolapse through the cervix
What is the treatment of intrauterine polyps?
Resection of the polyp with cutting diathermy or avulsion normally cures bleeding problems
What is haematometra?
This is menstrual blood accumulating in the uterus because of outflow obstruction.
What normally causes a haematometra?
The cervical canal is usually occluded by fibrosis after endometrial resection, cone biopsy or by a carcinoma
What other organs are associated with congenital uterine malformations?
Women with a congenital uterine anomaly have an increased incidence of renal anomalies and should undergo renal tract imaging
What is the most common genital tract cancer?
Endometrial carcinoma
What age is endometrial cancer most common?
Prevalence is highest at the age of 60 years, with only 15% of cases occurring premenopausally and <1% under 35
Does endometrial cancer normally present early or late?
Early
What is the pathology of endometrial cancer?
Adenocarcinoma os columnar endometrial gland cells accounts for >90%
What hormones are linked with endometrial cancer?
High ratio of oestrogen:progestogen so it is most common when oestrogen production is high
What are the risk factors for endometrial carcinoma?
obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a 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 diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma
What is protective against endometrial carcinoma?
The combined oral contraceptive
What are the symptoms of endometrial carcinoma?
Postmenopausal bleeding is the most common presentation. Premenopausal symptoms have irregular or intermenstrual bleeding, or, occasionally, only recent-onset menorrhagia
Pain and discharge are unusual features
What would a cervical smear show during endometrial carcinoma?
A cervical smear may contain abnormal columnar cells(cervical glandular intraepithelial neoplasia)
What staging is used to stage endometrial cancer?
FIGO 2009, it is surgical and histological and, in contrast to cervical carcinoma, includes lymph node involvement
What is stage 1 of endometrial cancer?
Lesions confined to the uterus
What is stage 2 of endometrial cancer?
Lesions confined to the uterus and the cervix
What is stage 3 of endometrial cancer?
Tumour invades through the uterus
What is stage 4 of endometrial cancer?
Further spread into the bowel, bladder or distant metastases
What is the treatment of endometrial cancer?
- 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
What is the prognosis of endometrial cancer?
Recurrence is most common in the vaginal vault, normally in the first 3 years
What are poor prognostic features of endometrial cancer?
Older age, advanced clinical stage, deep myometrial invasion, high tumour grade and adenosquamous histology
What ix are done in endometrial cancer?
- 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
