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Gynaecology > The uterus and its abnormalities > Flashcards

The uterus and its abnormalities Flashcards

1
Q

Anatomy and function of the uterus

blood supply and lymph

endometrium

A

uterosacral and cardinal ligaments support inferior end of uterus at the cervix

endometrium (glandular) -> myometrium (smooth muscle) -> serosa (peritoneum posteriorly)

uterine arteries cross over ureter lateral to servix and pass inferiorly and superiorly, supplying myometrium and endometrium

at cornu arterial anastomosis with the overian blood supply, inferiorly anasotmosis with vessels of upper vagina

lymph drainage of uterus mostly via internal and external iliac nodes

endometrium

  • supplied by spiral (menstruation and nourishment of growing fetus) and basal arterioles
  • responsive to P+O
  • 14 days of menstrual cycle = proliferates, glands elongate and endometrium thickens under oestrogen influence (proliferative)
  • after ovulation = glands swell and blood supply increases under progesterone influence (luteal/secretory phase)
  • progesterone levels drop, secretory endometrium disintegrates as blood supply can no longer support it and menstruation occurs
  • poor homronal control commonly causes errativc bleeding patterns
    *
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2
Q

Fibroids (leiomyomata): definition and epidemiology

size and sites

A

benign tumours of myometrium

common with increasing age during reproductive years (more in black, asian, obese, early menarche, affected first degree relative women), less common in parous women and those taking COCP/injectable progestogens

single/mulitple, few millimetres/massive tumours filling abdomen, intramural/subserosal/submuscosal/intracavitu

‘whorled’ appearance in transverse section

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3
Q

Fibroids: aetiology

A

growth is P+O dependent

pregnancy = grow/shrink/no change

regress after menopause due to reduction in circulating sex hormones

monoclonal origin

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4
Q

fibroids: clinical features (hx and o/e)

A

hx:

  • 50% asymptomatic + only discovered at phys/USS exam
  • sx related to site than size
    • submucosal fibroid -> abnormal menstrual bleeding
    • subserosal fibroids -> asymptomatic
  • menstrual problems: HMB in 30%, IMB if submucosal/polyploid
  • common in perimenopausal women
  • DYSMENORRHOEA RARE= seldom cause pain unless torsion, red degeneration (uterine leiomyeloma infarct), sarcomatous change
  • large fibroid on bladder = urinayr frequency/retenion
  • on ureters = hydronephrosis
  • fertility impaitred if tubal ostia blocked/submucosal fibroids prevent implantation

sx:

  • none 50%
  • menorrhagia (30%)
  • erratic/bleeding (IMB)
  • pressure effects
  • subfertility

o/e:

  • solid mass may be palpable on pelvic/abdominal exam, arise from pelvis and continuous with uterus
  • multiple small fibroids cause irregular ‘knobbly’ enlargement of the uterus
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5
Q

fibroids: natural history/complications

A

enlargement slow = stop growing and calcify after menopause

enlarge:

  • oestrogen in HRT may stimualte further growth
  • englarge mid-pregnancy

pain and degenerations:

  • pedunculated fibroids -> torsion
  • red degreneration = pain and uterine tenderness, haemorrhage and necrosis
  • hyaline/cystic calcificaiton (postmenopausal/asymptomatic)

malignancy:

  • 0.1% leiomyosarcomata = diagnosed only on histology
  • consider when fibroid growth in postmenopausal women or rapidly enlarging fibroids or sudden onset of pain in women of any change
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6
Q

fibroids and pregnancy

A

premature labour, malpresentations, transeverse lie, obstructed labour and PPH can occur

red degeneration common in pregnnacy -> severe pain

should NOT be removed at C-section as bleeding can be heavy

pedunculated fibroids may tort postpartum

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7
Q

fibroids and HRT

A

cause continued fibroid growth after menopause

tx is as for premonopausal women or the HRT is withdrawn

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8
Q

fibroids ix

A

establishing diagnosis:

  1. examination
  2. USS = screening, number/size/position of fibroids (MRI is diagnosis unclear or greater accuracy is required e.g. fibroids vs adenomyosis)
  3. hysteroscopy, saline TV ultrasonography or HSG = assess distortion of uterine cavity, particularly if fertility is an issue

establishing fitness:

  1. Hb concentration may be low from HMB but also high as fibroids can secrete EPO
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9
Q

fibroids tx

medical

A

ONLY TX when cause symptoms/QoL affected/desire for fertility

Injectable GnRH agonist:

  • bone density loss restrict use to only 6 months so used near menopause or to make surgery easier and safer
  • concomitant use of ‘add-back’ hRT prevents these effects without enlargement allowing longer adminsitration
  • fibroids return back to their normal size once stopped

SUMMARY:

  • 1st line symptomatic: LNG-IUS
    • Other options: tranexamic acid, COCP
    • GnRH agonists may be used to reduce the size of the fibroid (usually only iN the short-term prior to surgery)
  • Surgery:myomectomy, hysteroscopic endometrial ablation, hysterectomy
  • Interventional Radiology: uterine artery embolisation
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10
Q

fibroids: surgical tx

A
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11
Q

fibroids: radiological tx

A
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12
Q

Fibroids: PACES tips

A
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13
Q

is the fibroid malignant?

A

uncommon, but more likely if there is:

  • pain and rapid growth
  • growth in postmenopausal woman not on HRT
  • poor response to GnRH agonists or ulipristal acetate
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14
Q

Fibroids at a glance

A
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15
Q

Adenomyosis definition and epidemiology

aetiology

A

endometrium grows into myometrium

common around 40 years, associated with endometriosis and fibroids

sx subside after menopause

oestrogen dependent

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16
Q

adenomyosis clinical features

A

history = sx may be absent, but painful, regular, heavy menstruation is common

examination = the uterus is mildly enlarged and tender

17
Q

adenomyosis ix and tx

A

ix = suspected on USS, clearly diagnosed on MRI

tx:

  • progesterone IUS or
  • COCP with or without NSAIDs cto contorl menorrhagia and dysmenorrhoea
  • hysterectomy often required
18
Q

other benign conditions of the uterus: endometritis

A

an inflammation or irritation of the lining of the uterus

2o to STIs, as a complication of surgery (C-section and intrauterine procedures), or because of foreign tissues (IUDs) and retained products of conception

infection in postmenopausal uterus is commonly due to malignancy = uterus tender and pelvic and systemic infection may be evident

pyometra = pus accumulates and unable to escape

tx = abx and ERPC

19
Q

other benign conditions of the uterus = intrauterine polyps

A

small benign tumours that grow into uterine cavity

  • occasionaly contain endometrial hyperplasia or carcinoma

most endoemtrial in origin but some drived from submucous fibroids

common women 40-50 years and when oes levels are high

in post-menopausal women = in pts on tamoxifen for breast carcinoma

occasionally prolapse through cervix, sometimes asymptomatic, often menorrhagia and IMB

Ix:

  • USS or when hysteroscopy performed because of abnormal bleeding

Tx:

  • ​resection of polyp with cutting diathermy or avulsion normally cures bleeding problems
20
Q

other benign conditions of the uterus: haematometra

A

menstrual blood accumulte in uterus because of outflow tract obstruction, uncommon

cervical canal usually occluded by fibrosis after endometrial resection, cone biopsy or a carcinoma

imperforate hymen, blind rudimentary uterine horn, present in adolescence as primary amenorrhoea

21
Q

other benign conditions of the uterus: congenital uterine malformations

A

abnormalities from differeing degrees of failure of fusion of the two Mullerian ducts at about 9 weeks

25% cause pregnancy-related problems that lead to their discovery

  • transverse lie/malpresentations, preterm labour, recurrent miscarriage (<5%) or retained placenta

tx

  • simple septa can be resected hysteroscopically
  • rudimentary horns need removal at either open or laparaoscopic surgery
  • bicornuate uteri are no longer treated surgically as the complication rates were too high
22
Q

Endometrial carcinoma: epidemiology

A

most common GYN cancer, 1% risk developing it by 75

prevalence highest at 60 years, <15% occurs premenoapusally and <1% under 35 years of age

23
Q

Endometrial carcinoma: pathology (2 types)

A

Type 1 (most): low-grade endometrioid cancers which are oestrogen sensitive, associated with obesity, and usually less aggressive, atypia as a precursor

Type 2: high-grade endometrioid, clear cell, serous or carcinosarcoma cancers which tend to be more aggressive and not oestrogen sensitivie, not related to obesigty

24
Q

Endometrial carcinoma: risk factors

tamoxifen

protective factors

A

main RF = exposure to endogenous/exogenous oestrogens associated with obesity, diabetes, early age at menarche, nulliparity, late-onset menopause, older age >55 years, unopposed oestrogen HRT, and use of tamoxifen

tamoxifen

  • although an oes antagonist in breast and used to tx breast cancer, it is an agonist in postmenopausal uterus

protective factors = COCP and pregnancy

25
Q

endometrial carcinoma: premalignant disease (endometrial hyperplasia with atypia)

what happens after diagnosis

A

unopposed/erratic oestrogen -> hyperplasia of endometrium

menstrual abnormalitis or PMB = premalignant

hyperplasia with atypia often coexists (40%) with carcinoma elsewhere in the uterine cavity, uncommon in women of reproductive age

after diagnosis:

  • hysterectomy discussed
  • fertility is a concern, progestogens (IUS or continuous oral) and 3-6 monthly hysteroscopy and endometrial biopsy are used along with referral to a fertility specialist for consideration of treatment
26
Q

premalignant disease (endometrial hyperplasia with atypia) mx

A
27
Q

Endometrial carcinoma: clincial features

A

History: PMB (10% risk carcinoma) is the most common presentation, premenopausal patients have irregular bleeding or IMB

Examination: pelvis often appears normal, atrophic vaginitis may coexist

28
Q

Endometrial carcinoma: spread and staging

A

Spread:

  • spreads through myometrium to cervix and upper vagina, ovaries may be involved
  • lymphatic spread to pelvic and then para-aortic lymph nodes
  • blood-borne spread is late

Staging

  • sugical and histological and includes lymph node involvement (cervical carcinoma does not)

Histological grade:

  • G1-3 is also included for each stage, G1 being a well-differentiated tumour
29
Q

Endometrial carcinoma: Ix

A

abnormal vaginal bleeding investigated

depending on age, menopausal status and sx (i.e. likelihood of underlying cancer) = USS and/or endometrial biopsy with Pipelle or hysteroscopy is performed

  • endometrial buipsy required to make the diagnosis
  • staging only possible following hysterectomy

MRI to estimate myometrial invasion and so guide appropriate referral to a cancer centre in cases with deep invasion

CXR to exclude rare pulmonary spread

Assess pt fitness:

  • FBC, renal function, glcuose testing and ECG normally required as most patients are elderly
30
Q

Endometrial carcinoma tx: surgery

A
31
Q

General indications for radiotherapy in endometrial carcinoma

A

high risk for extrauterine disease: deep myometrial or cervical stromal spread, poor grade

proven extrauterine disease

inoperable and recurrent disease

palliation for symptoms e.g. bleeding

32
Q

endometrial cancer prognosis

A

recurrent most common at vaginal vault, normally in the first 3 years

poor prognostic features are older age, advanced clinical stgae, deep myometrial invasion in stage 1 and 2 patients, high tumour grade and adenosquamous histology

33
Q

Uterine sarcomas: 2 examples

A

rare

leiomyosarcomas are ‘malignant fibroids’ and present with rapid, painful uterine ‘fibroid’ enlargement

tx with hysterectomy but early recurrence is common due to haematogenous spread, radiotherapy or chemotherapy can be used following hysterectomy but overall survival only 30% at 5 years

endometrial stromal tumours are tumours of stroma beneath the endometrium (benign endometrial stromal nodule to highly malignant endometrial stromal sarcoma), most common in perimenopausal women

34
Q

Endometrial carcinoma at a glance

A

Gynaecology (12 decks)

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