Uterine Abnormalities Flashcards
Define uterine fibroids
Benign tumour of the uterine smooth muscle (leiomyoma), i.e of the myometrium
Classify the different types of fibroids based on location
Based on location relative to the uterine wall • Submucous • Cervical • Intramural • Subserosal
What is the macroscopic appearance of fibroids?
Looks like a well-demarcated, firm, whorled tumour
Outline the aetiology of fibroids
Hormone dependent: contain lots of oestrogen and progesterone receptors
- Enlarge in pregnancy (due to oestrogen), shrink in menopause
- Cause known
Outline some risk factors and protective factors for developing fibroids
RF: nulliparity, family history, obesity, smoking, afro-carib, HRT causing continued fibroid growth following menopause
Protective: smoking, parous women, long term hormonal contraceptive use
Outline 3 different types of fibroid degeneration (occur when the fibroids outgrow their blood supply) that can occur in its natural history
Red degeneration:
• Haemorrhage and necrosis occurs within the fibroid typically presenting in the mid-second trimester pregnancy with acute pain
Hyaline degeneration:
• Asymptomatic softening and liquefaction of the fibroid
Cystic:
• Asymptomatic central necrosis leaving cystic spaces at the centre
• Degenerative changes can initiate calcium deposition leading to calcification
• Suspicion is greatest in the postmenopausal period when there is rapidly increasing size of the fibroid
Give some symptoms that can be clinically present due to fibroids
- None (50%)
Symptoms are mainly related to location rather than size
- Menorrhagia (more likely in submucosal, polypoid)
- Erratic bleeding (IMB)
- Pressure effects: pressure sensation, bladder/bowel defects
- Subfertility (tubal ostia blockage, submucous fibroids blocking implantation)
- Pain (rarely cause pain, unless torso or red degeneration occurs)
Give some signs of fibroids on physical examination
On examination
o Abdo – palpable pelvic mass, continuous with uterus
o Vaginal – enlarged, firm, smooth or irregular non-tender uterus
Outline investigations for fibroids
- Bloods – FBC – anaemia
- USS – TVUS
- Other – hysteroscopy if submucosal, MRI if diagnosis is unclear/greater accuracy required
What needs to be considered when deciding treatment strategies for fibroids?
?Symptomatic
?Functional impact on QoL
?Desire for fertility
?Desire for preservation of uterus
Outline medical treatment for fibroids
Main treatments for HMB
• LNG-IUS (levonorgestrel/progesterone intrauterine system)
• Tranexamic acid/Mefenamic acid
• COCP
These treatments are mainly effective in women with HMB without fibroids, but can be worth trying first-line
Injectable GnRH Agonist
• Only effective medical treatment
• Induces a menopausal state (shuts down ovarian oestradiol production)
• Poorly tolerated because of side effects and bone density loss (can only be used for 6 months)
Ulipristal Acetate (selective progesterone receptor modulator, SPRM)
• As effective as GnRH agonists in reducing fibroid volume and alleviating HMB symptoms
• Not yet widely accepted into clinical practice
• Does NOT induce a menopausal state (therefore no GnRH agonist side effects)
• Can be taken orally
NOTE: neither of the last two options are long-term as fibroids regrow as soon as ovarian function returns
Outline surgical management for fibroids
Hysteroscopic surgery (minimally invasive)
- Fibroid polyps
- Small (up to 3cm) submucous fibroids
Myomectomy (open or laparoscopic)
- If medical treatment has failed, but preservation of reproductive function is required
- Preceded by 2-3 months of GnRH agonists/ulipristal acetate to shrink fibroid
- Risk of bleeding, which may then require hysterectomy
- Adhesions can form at site of myomectomy - can affect fertility (C-sections recommended for future pregnancies to prevent uterine rupture)
Hysterectomy (laparoscopic, vaginally or abdominally)
- Preceded by 2-3 months of GnRH agonists/ulipristal acetate
- Not suitable for women wanting to preserve fertility
Outline radiological treatment for fibroids
Uterine artery embolisation (UAE)
• Embolisation of both uterine arteries under radiological guidance, to shrink fibroids
• Shorter hospital stay
• Complications: fever, infection, fibroid expulsion, potential ovarian failure
• Adequate counselling is important because the effect on reproductive function are uncertain
Give some complications of fibroids
- Degenerations
- Malignancy (~0.1% of fibroids are leiomyosarcomas)
- Anaemia, miscarriage, infertility
- In pregnancy: premature labour, transverse lie, PPH (should not be removed at C-section as bleeding may be heavy)
Under what conditions are malignant fibroids more likely
- Pain and rapid growth
- Growth in postmenopausal women not on HRT
- Poor response to GnRH agonist or ulipristal acetate
Outline the prognosis with fibroids
- 10 year recurrence rate after myomectomy is 20%
- Fibroids regress and calcify after menopause
Define adenomyosis
Presence of endometrium and its underlying storm within the myometrium
Give some risk factors for developing adenomyosis
Most common around 40 yrs
Associated with endometriosis and fibroids
Outline the aetiology of adenomyosis
Oestrogen dependent
Cause unknown
Effects on fertility are unclear
Outline the clinical features of adenomyosis
History: asymptomatic, painful, regular HMB may be common
Examination: uterus mildly enlarged and tender
What investigations are undertaken for adenomyosis
- Ultrasound
- Clearly diagnosed on MRI
Outline the management for adenomyosis
Medical treatment (for menorrhagia)
- Progesterone IUS
- COCP +/- NSAIDs
- Trial of GnRH analogue to determine if symptoms attributed to adenomyosis will improve with hysterectomy
Surgical
- Hysterectomy
What is endometritis?
Inflammation of the endometrial lining
Give some risk factors for developing endometritis
Occurs secondary to:
- STIs
- Complications of surgery (C-section, surgical termination)
- Foreign tissue (IUDs)
- Retained products of conception
- Malignancy (particularly in postmenopausal uterus)
