The uterus and its abnormalities Flashcards
Explain the blood supply of the uterus
Blood supply is from the uterine arteries which pass inferiorly and superiorly lateral to the cervix to supply the endometrium and myometrium.
They anastomose superiorly with the ovarian blood supply at the cornu and inferiorly with the upper vaginal vessels.
The endometrium is supplied by the spiral and basal arterioles.
What increases the chances of a woman having fibroids?
More common with - Increasing reproductive age - In black and Asian women - In obese women - Those with early menarche (before 11) - Affected first degree relative (they are less common in parous women and those who have taken the COCP or injectable progestogens)
Which hormones does fibroid growth depend on?
Oestrogen and progesterone
Which fibroid types are more likely to cause symptoms?
Submucosal or polypoid fibroids.
Subserosal are unlikely to cause symptoms.
What are the symptoms of fibroids?
None (50%) Menorrhagia Erratic/bleeding (IMB) Pressure effects Subfertility
50% are asymptomatic - depends more on position than size.
Menstrual problems: HMB. IMB if submucosal or polypoid.
Pain: can cause dysmenorrhoea. Rarely cause pain unless there is torsion, red degeneration or (rarely) sarcomatous change.
Other symptoms: urine frequency or retention if pressing on bladder. Reduced fertility.
What stage of pregnancy can fibroids enlarge?
Mid-pregnancy
What types of degenerations can fibroids undergo?
Red degeneration - pain and uterine tenderness; haemorrhage and necrosis.
Hyaline degeneration and cystic degeneration - fibroid is is soft and partially liquefied.
Calcification - post menopausal and asymptomatic.
What is the chance of a fibroid being malignant?
0.1% chance. Risk of tumour spread during intra-abdominal morcellation of an unsuspected leiomyosarcoma needs to be considered.
What complications can fibroids cause in pregnancy?
Transverse lie, premature labour, red degeneration, malpresentations, postpartum haemorrhage.
Fibroids should not be removed at caesarian section as bleeding can be heavy.
How does HRT affect fibroids?
Causes growth due to oestrogen and progesterone.
How do you diagnose fibroids?
Ultrasound initially - determines number, size and position.
MRI - used if diagnosis is unclear or if greater accuracy is required.
Hysteroscopy, saline transvaginal ultrasonography or hysterosalpingogram is used to assess distortion of the uterine cavity, particularly if fertility is an issue.
What condition can look like fibroids on ultrasound?
Adenomyosis.
Why can haemoglobin be both high or low in fibroids?
Low - blood loss vaginally.
High - some secrete erythropoietin.
What medical treatments can you use for fibroids?
Fibroids only treated if causing symptoms.
GnRH agonists - can only be used for 6 months or with add-back HRT.
Selective progesterone receptor modulators (SPRMs) such as ulipristal acetate. This reduced HMB, cause reversible amenorrhoea and shrink fibroid by 50% (like GnRH).
Both can be used for preparation for surgery.
Both are not ideal for those willing to conceive.
What are the surgical treatments of fibroids?
- Hysteroscopic surgery –> small ones can be resected at hysteroscopy if a polypoid or submucosal. Use GnRH 1-2 months before.
- Myomectomy –> preceded by 2-3 months GnRH/ulipristal acetate. Used when medical treatment has failed but preservation of reproductive function is required. If open rather than laparoscopic, or there are many/large fibroids, caesarian is is indicated in future pregnancies.
- Hysterectomy - 2-3 months GnRH or ulipristal acetate will shrink fibroids and uterine size to allow for a possibly less invasive operation (vaginally).
What is uterine artery embolisation used for? Explains some pros/cons.
Fibroids.
80% success rate, can reduce size by 50%.
Fertility affects are not clear so not usually offered to those hoping to conceive.
Can end up re-admitted and undergoing surgical removal anyway.
What is the difference between endometriosis and adenomyosis?
Endometriosis is the presence of endometrial tissue outside the womb.
Adenomyosis is the presence of endometrium within the myometrium.
What are the symptoms and clinical features of adenomyosis?
Enlarged uterus which may be tender.
Symptoms may be absent but include heavy, painful menstruation.
How is adenomyosis diagnosed?
Can be suggested in ultrasound but diagnosed definitively with MRI.
What is the treatment of adenomyosis?
Progesterone dominant IUD COCP NSAIDs Can try GnRH (it is oestrogen dependent) Hysterectomy
What can cause endometritis?
Sexually transmitted diseases
Surgery complications (caesarian, termination)
IUD or retained products of conception
Malignancy (common post menopause)
What is the treatment for endometritis?
Antibiotics and occasionally evacuation of products of conception.
What are the origin of intrauterine polyps?
Endometrium mostly. Some will be polypoid fibroids.
Which hormone is associated with polyps?
Oestrogen - those on tamoxifen are likely to have them.
