The Uterus and Its Abnormalities. Flashcards
Define fibroids.
Non-cancerous growths that develop in the muscle (myometrium) of the womb (uterus). A woman can have one fibroid or many, and they can be of different sizes. Fibroids are sometimes known as uterine myomas or leiomyomas.
Who tends to get fibroids? Describe the epidemiology.
- Uterine fibroids are the most common benign uterine tumours in women and are the leading reason for hysterectomy.
- The incidence of fibroids increases with age until the menopause
- Peak incidence is in women in their 40s, with a crude incidence of 22.5 per 1000 women-years
- The prevalence of fibroids is higher in black women than white women
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Risk factors associated with fibroids include:
- Increasing age — the risk of fibroids increases progressively from puberty until the menopause.
- Early puberty — the risk of fibroids is increased in women who experienced early puberty and decreased in women who experienced late puberty.
- Obesity — weight gain and central distribution of body fat increase the risk of fibroids.
- Black ethnicity — incidence is higher in black and Asian women than in white women, and multiple fibroids are more common. In addition, they tend to occur at an earlier age, are larger, and are more likely to be symptomatic.
- Family history — risk is higher in women who have first-degree relatives who have fibroids.
- The risk of fibroids is reduced by pregnancy and decreases with an increasing number of pregnancies.
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Note: there is no evidence that combined hormonal contraceptives (CHCs) increase the risk of developing fibroids.
- Progestogen-only injectable contraceptives and oral contraceptives reduce the risk of fibroids.
How do fibroids form? Where do they form?
- Fibroids can develop at any time between puberty and the menopause.
- The course of fibroids is unpredictable.
- Generally, they develop slowly and rarely cause symptoms in women aged less than 30 years.
- The maximum size of fibroids is dependent on their blood supply — they may occasionally reach the size of a full-term pregnancy.
- Once formed, fibroids tend to persist until the menopause when they usually shrink.
- Occasionally, fibroids may degenerate before the onset of the menopause
- Occasionally, regression occurs when the blood supply is cut off due to torsion of a pedunculated fibroid.
- Rarely a pedunculated fibroid on the uterine surface may detach and establish a blood supply from an adjacent organ.
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Fibroids may develop anywhere within the myometrium. They are described as:
- Subserosal fibroids — when they develop near the outer serosal surface of the uterus and extend into the peritoneal cavity. They are commonly asymptomatic or minimally symptomatic even when relatively large. When they are sufficiently large they may cause symptoms due to pressure on adjacent structures (such as urinary symptoms due to pressure on the bladder).
- Intramural fibroids — when they develop within the myometrium without extending predominately into the uterine cavity or peritoneal cavity. They may cause menorrhagia and dysmenorrhea by interfering with the constriction of blood vessels during menstruation.
- Submucosal fibroids — when they develop near the inner mucosal surface of the uterus and extend into the uterine cavity. Even relatively small submucosal fibroids may cause significant menorrhagia and dysmenorrhea or reduce fertility.
What are the complications of fibroids?
- Abnormal uterine bleeding — this occurs as a result of distortion of the endometrial lining and is therefore much more common with submucosal fibroids.
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Compression of adjacent organs by large fibroids — this may cause symptoms including:
- Dyspareunia, pelvic pain or discomfort.
- Constipation and abdominal cramps, or urinary symptoms (frequency, or retention). Very large fibroids may occasionally cause hydronephrosis.
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Infertility (low incidence).
- Submucosal fibroids — distortion of the uterine cavity causes a 70% reduction in pregnancy rates compared with women who do not have fibroids.
- Intramural fibroids — may reduce pregnancy rates.
- Subserosal fibroids — do not appear to significantly reduce rates of pregnancy.
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Problems during pregnancy (rare) — this may include:
- Acute pain — this is thought to be due to degenerative changes when rapid growth of a fibroid, promoted by high levels of sex hormones, outgrows its blood supply.
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Adverse pregnancy outcomes. These may include:
- Higher rates of caesarian delivery.
- Malpresentation.
- Pre-term delivery.
- Miscarriage.
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Torsion of a pedunculated fibroid (rare) — this may cause acute pelvic or abdominal pain, and it may become infected.
- Pedunculated fibroids may prolapse through the cervix.
What are the clinical features of fibroids?
- Fibroids are commonly asymptomatic and may be identified incidentally by examination or investigation for gynaecological problems (such as failure to conceive) or during a routine pregnancy assessment.
- Symptoms relate to site rather than size
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If a woman does experience symptoms, they may include:
- Heavy menstrual bleeding (menorrhagia)
- IMB - submucosal or polypod
- Pelvic pain.
- Dysmenorrhea
- Abdominal distention or distortion.
- Pelvic pressure or discomfort.
- Urinary tract problems such as frequency, urgency, urinary incontinence, and hydronephrosis.
- Non-specific bowel problems, such as bloating or constipation.
- Subfertility.
- Distortion of cavity (intramural)
- Prevention of implantation (submucosal)
- Obstruction of tubal ostia
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On pelvic examination:
- A firm, enlarged, and irregularly shaped non-tender uterus is characteristic of uterine fibroids.
- The mass can be moved slightly from side-to-side (knobbly)
- A firm, enlarged, and irregularly shaped non-tender uterus is characteristic of uterine fibroids.
- In cases of large tumours, a central irregular mass can be palpated on transabdominal examination.
How do fibroids affect pregnancies?
- Associated with premature labour, malpresentations, transverse lie, obstructed labour and post
partum haemorrhage - Red degeneration = common and can cause severe pain
- Should not remove at C-section due to heavy bleeding
- Torsion of pedunculated fibroids post-partum
How do we diagnose fibroids?
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Take a detailed medical and gynaecological history, and ask the woman about:
- Her cervical screening history — to confirm she has attended as scheduled and results were normal.
- Risk factors, including family history of fibroids.
- A history of fertility problems.
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Ask about symptoms, including:
- Unscheduled bleeding, or painful cramping associated with menstruation.
- Urinary symptoms — if urinary symptoms are present, arrange a mid-stream urine test to exclude urinary tract infection (UTI).
- Gastrointestinal symptoms — for example bloating, or constipation.
- Pelvic pain.
- Conduct an abdominal and bimanual pelvic examination to assess for the presence of any masses.
- Arrange a blood test to check for iron deficiency anaemia.
- Arrange a routine ultrasound scan (transabdominal and transvaginal) for women with typical features of uterine fibroids and no features of cancer.
- Consider other causes for the symptoms.
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Refer the woman:
- Urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously due to uterine fibroids).
- Using a suspected cancer pathway referral (for an appointment within 2 weeks) if she has a pelvic mass associated with any other features of cancer (such as unexplained bleeding, or weight loss).
Nina Cooper:
- Laparaoscopy
- Adenomyosis – fibroid-like mass, differentiated by MRI
- Hysteroscopy or hysterosalpingogram - assess distortion of uterine cavitiy, particularly if fertility is an
issue - Also asses Hb
How do we manage fibroids?
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Medical Treatment
- Conservative management if asymptomatic fibroids
- Common symptom of fibroids is HMB, therefore treatment can include:
- LNG-IUS
- Non-hormonal = tranexamic acid/ NSAIDs
- Hormonal = COCP or oral progesterones
- May be ineffective in the presence of submucous fibroid or an enlarged uterus that is palpable abdominally
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Injectable GnRH Agonist
- Only effective medical treatment
- Induces a menopausal state (shuts down ovarian oestradiol production)
- Poorly tolerated because of severe menopausal symptoms
- Ulipristal Acetate (selective progesterone receptor modulator) - currently use is suspended due to safety review regarding liver injury
- NOTE: neither of the above options are long-term - fibroids regrow as soon as ovarian function return
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Surgical Treatment
- Depends on presenting complaint and patient’s preferences re menstrual function and fertility
- Minimally invasive hysteroscopic surgery can be used to remove submucous fibroids and fibroid polyps (which relieved HMB symptoms)
- If the patient has a bulky fibroid uterus causing pressure symptoms or where HMB is refractory to medical interventions:
- Myomectomy
- Preferred if preservation of fertility is required
- Can be done laparoscopically (power morcellation is used to shrink the fibroids for removal)
- There is a small but significant risk of uncontrolled life-threatening bleeding during myomectomy which may require a hysterectomy
- Hysterectomy
- Hysterectomy and myomectomy could be preceded by GnRH agonist pre-treatment for 3 months to reduce the bulk and vascularity of the fibroids
- This can facilitate a suprapubic incision and vaginal hysterectomy rather than midline abdominal incision and abdominal hysterectomy
- This is associated with quicker recovery and fewer complications
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Radiological Treatment
- Uterine artery embolisation (UAE) – only offered if not desiring fertility
- Embolisation induces infarction and degeneration of fibroids leading to a reduction in fibroid volume of around 50%
- Patients usually require admission to deal with the pain associated with uterine artery occlusion (opiate analgesia)
- Complications: fever, infection, fibroid expulsion, potential ovarian failure
- 1/3 of women require further medical, radiological or surgical treatment within 5 years
- As effective as myomectomy for alleviating fibroid-related HMB and pressure sx
Summarise the management of fibroids.
• 1 st line symptomatic: LNG-IUS
o Other options: tranexamic acid, COCP
o GnRH agonists may be used to reduce the size of the fibroid (usually only in the shortterm prior to surgery)
- Surgery: myomectomy, hysteroscopic endometrial ablation, hysterectomy
- Interventional Radiology: uterine artery embolisation
How should we counsel a patient with fibroids?
Define adenomyosis
Presence of endometrium and underlying stroma within the myometrium
Endometriosis in the muscle wall of the uterus.
How common is ademonyosis? Who does it present in?
Present in up to 40% of hysterectomy specimins
- Most common around late 30s and early 40s
- Associated with endometriosis and fibroids
- Symptoms subside after menopause
Women usually multiparous
Describe the pathology and aetiology of adenomyosis.
- Endometrium grows into myometrium to form adenomyosis → extent is variable
o Severe cases → pockets of menstrual blood can be seen in myometrium
o Can show atypia or invasion
How would adenomyosis present? What investigations would you do?
Hx: painful, regular and heavy menstruation (or no symptoms)
Ex: bulky, mildly enlarged, tender uterus
Ix: US can be helpful, MRI ix of choice
What is the treatment for adenomyosis?
Anything that induces amenorrhea.
Tx: mirena IUS, COCP + NSAIDs
Hysterectomy often required
GnRH analogues may be used to determine if sx attributed to adenomyosis would improve with hysterectomy
Oestrogen dependent condition but cause not fully known – effects on fertility unclear
Define endometritis.
Inflammation of the lining of the womb, causing discomfort or pain
What is endometritis caused by?
Secondary to STIs, IUDs, RPCs or complication of surgery (C-section and intrauterine procedure, e.g. surgical termination)
Infection in post-menopausal uterus = malignancy
How does endometritis present?
Tender uterus, pelvic/systemic infection evident
Pyometra = pus accumulates and unable to escape
How would we manage endometritis?
- The Royal College of Obstetricians and Gynaecologists (RCOG) guideline for sepsis following pregnancy recommends IV piperacillin/tazobactam or a carbapenem plus clindamycin for severe sepsis. Other options for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed.
- ?ERPC
Define intrauterine polyps.
Small, usually benign tumours that grow into the uterine cavity
Most endometrial in origin, can be derived from submucous fibroids
What abnormalities can occur in the uterus?
How do we investigate for endometrial cancer?
Abnormal vaginal bleeding ix in same way as premenopausal women
Depending on age, menopausal status and symptoms, TVUSS and/or endometrial biopsy (pipelle or hysteroscopy)
On TVUSS, if endometrium less than 4mm in postmenopausal women (or less than 10mm in premenopausal) → cancer unlikely and further ix not needed.
Endometrial biopsy required for diagnosis (gives type and grade)
MRI if spread suspected – high risk histology seen or symptoms (stage)
Assess patient’s fitness with FBC, renal function, glucose testing and ECG
How do we grade and stage endometrial cancer?
Spreads directly through myometrium to the cervix and upper vagina
Ovares may be involves
Lymphatic spread = pelvic, then para-aortic
Late blood-borne spread
FIGO staging used
Histological grading: G1-3, G1 = well differentiated (less aggressive)
How do we manage endometrial cancer?
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Adjuvant Therapy
- Postoperative radiotherapy reduces local recurrence rate but does not improve survival
- Local radiotherapy or brachytherapy are options
- Chemotherapy is used for advances or metastatic disease (little evidence to support its use)
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Hormone Treatment
- High-dose oral or intrauterine progestins (LNG-IUS is preferred)
- Useful for women with complex atypical hyperplasia and low-grade stage 1A endometrial tumours
- Relapse rates are high
- May be suitable for women who are not fit for surgery or want to avoid surgery for fertility reasons
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Endometrial Cancer and Fertility
- Primary infertility due to PCOS is a risk factor for pre-menopausal endometrial cancer
- Alternatives to hysterectomy for pre-menopausal women are only possible for pre-cancer or early-stage low-grade endometrial cancers
- Hormone therapy (oral progestogens or LNG-IUS) is associated with moderate response and high relapse rates
- Women faced with losing their fertility should be referred to a specialist to discuss ovarian conservation and/or stimulation for egg retrieval and surrogacy
How would you counsel someone who had endometrial cancer?
Describe the prognosis of endometrial cancer.
When should you refer a suspected endometrial cancer?
