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)
What is the treatment for endometritis?
- Antibiotics
- Occasionally ERPC (evacuation of retained products of conception) is required
Outline the aetiology of intrauterine polyps
- Benign tumours that grow into uterine cavity (most are endometrial, some are sub mucous fibroids)
- Common when oestrogen levels are high
- Post-menopausally: often found in pts on tamoxifen for breast cancer
Outline the symptoms of intrauterine polyps, and how it is diagnosed
- Sometimes asymptomatic
- Menorrhagia, IMB
- Can prolapse through the cervix
Diagnosis:
- Ultrasound
- During hysteroscopy due to abnormal bleeding
How are intrauterine polyps treated?
- Resection (cutting diathermy or avulsion)
What is haematometra?
Menstrual blood accumulating in the uterus due to outflow obstruction
Define endometrial cancer
Malignancy arising from endometrial tissue
Give the two main subtypes of endometrial cancer
Type 1: endometrioid adenocarcinomas
• Oestrogen-driven, associated with obesity, less aggressive
• Arise from a background of endometrial hyperplasia
Type 2: high-grade serous and clear cell carcinomas
• Not oestrogen sensitive, not associated with obesity and more aggressive
• Arise from an atrophic endometrium
Outline risk factors for the development of endometrial cancer
Main risk factor is exposure to oestrogen (endogenous or exogenous)
Exogenous
- Oestrogen-only HRT, tamoxifen (oestrogen agonist in postmenopausal women)
Endogenous
- Nulliparity or infertility (due to increase number of anovulatory cycles)
- Early menarche/late menopause (also related to number of anovulatory cycles)
- PCOS, oestrogen producing ovarian tumours (granulosa/theca)
- Obesity (aromatisation of fat-derived peripheral androgens)
- Diabetes (?due to raised BMI)
Outline the main epidemiology of endometrial cancer
- Prevalence highest at 60 years of age
- Only 15% of cases occur premenopausally, with <1% occurring before the age of 35
Describe the premalignant stages of disease in endometrial cancer
- Oestrogen acting unopposed –> hyperplasia of endometrium
- -> Abnormalities of cellular/glandular architecture –> atypical hyperplasia
If diagnosis of endometrial hyperplasia with atypic is made, hysterectomy should be considered.
If fertility is a concern, try P-IUS with 6 monthly hysteroscopy and endometrial biopsy
Outline the clinical features of endometrial cancer
History:
- PMB (10% RISK OF CARCINOMA) - perform speculum to rule out vulval, vaginal, cervical carcinoma
- Premenopausal: IMB, recent onset menorrhagia
- Other symptoms: abdominal pain, urinary dysfunction, bowel disturbance
Examination:
- May be normal
- Bimanual: bulky uterus probable
Describe the FIGO staging system for endometrial cancer (1-4b)
Stage 1 (confined to uterus)
- 1a: <1/2 myometrial invasion
- 1b: >1/2 myometrial invasion
Stage 2
- Cervical stromal invasion, but not beyond uterus
Stage 3 (invades through the uterus)
- 3a: serosa or adnexae
- 3b: vaginal and/or parametrium
- 3ci: pelvic node
- 3cii: para-aortic node
Stage 4 (further spread)
- 4a: bowel or bladder
- 4b: distant mets
In addition, grades 1-3 are classified (grade 1 is well-differentiated)
Outline investigations for endometrial cancer
- Bloods: FBC, U&E, LFT, glucose testing (to assess baseline fitness of patient)
- Imaging: pelvic USS, TVUS (depth of myometrial invasion, if <4mm very unlikely to be EC), MRI (staging), CXR (pulmonary spread)
- Tissue diagnosis: pipelle biopsy, hysteroscopy and biopsy
Outline the stages of management for endometrial cancer
Surgery (abdominal or laparoscopic)
- Stage 1 – total abdominal hysterectomy (TAH) with bilateral salpingo oophorectomy (BSO) with peritoneal washings
- Stage 2/3 – modified radical or radical hysterectomy
- Pelvic/para-aortic lymphadenectomy may be required
Adjuvant therapy (following surgery)
- External beam radiotherapy (in patients considered high risk for LN involvement)
- Vaginal vault radiotherapy (reduces local recurrent rate, but does not improve survival)
- Chemotherapy
Hormone Treatment
• High-dose oral or intrauterine progestins
• Useful for women with complex atypical hyperplasia and low-grade stage 1A endometrial tumours
• May be suitable for women who are not fit for surgery or want to avoid surgery for fertility reasons
What is the management approach for pre-menopausal women with endometrial cancer who want to preserve their fertility?
Mainly in PCOS causing endometrial cancer pts
- Alternatives to hysterectomy: only possible for pre-cancer or early-stage low-grade endometrial cancers
- Hormone therapy (oral progestogens or LNG-IUS): but associated with high relapse rates
Referral to a specialist to discuss ovarian conservation and/or stimulation for egg retrieval and surrogacy
Outline the prognosis for endometrial cancer
5-year survival rates Stage 1: 90 Stage 2: 75 Stage 3: 60 Stage 4: 25 Overall: 75
Recurrence is most common with vaginal vault radiotherapy
Poor prognostic factors: older age, advanced stage, deep myometrial invasion, high grade
