Uterine disorders Flashcards
fibroids epidemiology
incidence 20-40%
most common benign tumour in women
pathophysiology of fibroids
benign smooth muscle tumour arising from myometrium
intramural most common
submucosal
subserosal
growth stimulated by oestrogen
risk factors for developing fibroids
obesity early menarche increasing age FH african-american
history of fibroids
pressure symptoms +/- abdominal distension
urinary frequency or chronic retention
heavy menstrual bleeding
subfertility
acute pelvic pain (rare), rapidly growing fibroid undergoes necrosis and haemorrhage. rarely, pedunculated fibroids can undergo torsion
examination of fibroids
solid mass or enlarged uterus may be palpable on abdominal or bimanual examination
uterus is usually non-tender
DD for uterine fibroids
endometrial polyp
ovarian tumours
leiomyosarcoma
adenomyosis
investigations in fibroids
pelvic ultrasound
MRI: rarely required, unless sarcoma is suspected
medical managment of fibroids
tranexamic or mefanemic acid
hormonal contraceptives
GnRH analogues
selective progesterone receptor modulators
hormonal contraceptives for fibroids
Useful to control menorrhagia
Includes the COCP, POP and Mirena IUS
GnRH analogues
Zolidex
fibroid management
Suppresses ovulation, inducing a temporary menopausal state.
Useful pre-operatively to reduce fibroid size and lower complications.
Can be used for 6 months only, due to the risk of osteoporosis
Selective progesterone receptor modulators in fibroids
fibroid management
Ulipristal/ esyma
Reduces size of fibroid and menorrhagia
Useful pre-operatively or as an alternative to surgery
Use of Ulipristal is restricted due to risk of severe liver injury
surgical management of fibroids
hysteroscopy and transcervical resection of fibroid
myomectomy
uterine artery embolization
hysterectomy
presentation of fibroids
Asymptomatic
Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility
initial investigation in submucosal fibroids presenting with heavy menstrual bleeding
hysteroscopy
initial investigation for larger fibroids
pelvic USS
<3cm fibroid medical mx
Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens
<3cm fibroid surgical mx
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
> 3cm fibroid medical mx
gynae referral
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil – depending on the size and shape of the fibroids and uterus
Combined oral contraceptive
Cyclical oral progestogens
> 3cm fibroid surgical mx
Uterine artery embolisation
Myomectomy
Hysterectomy
GnRH agonists for fibroids
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.
They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid.
Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
uterine artery embolization for fibroids
Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists.
The radiologist inserts a catheter into an artery, usually the femoral artery.
This catheter is passed through to the uterine artery under X-ray guidance.
Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid.
This starves the fibroid of oxygen and causes it to shrink.
myomectomy surgical mx for fibroids
Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery).
Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.
endometrial ablation surgical management for fibroids
Endometrial ablation can be used to destroy the endometrium.
Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation.
This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.
hysterectomy surgical mx fibroids
Hysterectomy involves removing the uterus and fibroids.
Hysterectomy may be by laparoscopy (keyhole surgery), laparotomy or vaginal approach.
The ovaries may be removed or left depending on patient preference, risks and benefits.
complications of fibroids
Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare (<1%)
red degeneration of fibroids
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.
Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
endometriosis epidemiology
25-40 age
endometriosis definition
chronic condition in which endometrial tissue is located at sites other than uterine cavity
sites of endometriosis
ovaries pouch of Douglas uterosacral ligaments pelvic peritoneum bladder umbilicus and lungs
what are chocolate cysts?
endometriomas in the ovaries
pathophysiology of endometriosis
retrograde menstruation
endometrial tissue is sensitive to oestrogen
symptoms depend on enstrual cycle
inflammation and scarring can lead to adhesions
symptoms reduced during pregnancy and menopause
risk factors with endometriosis
early menarche Family history of endometriosis Short menstrual cycles Long duration of menstrual bleeding Heavy menstrual bleeding Defects in the uterus or fallopian tubes
presentation of endometriosis
cyclical abdominal or pelvic pain deep dyspareunia dysmenorrhea cyclical bleeding from other sites, such as haematuria deposits in bladder/bowel can lead to blood in urine or stools, dyschezia dysuria reduced fertility haemothorax from tissue in lungs
examination findings in endometriosis
fixed, retroverted uterus
uterosacral ligament nodules
general tenderness
endometrial tissue visible in the vagina on speculum examination
tenderness in vagina, cervix and adnexa
enlarged, tender and boggy uterus
adenomyosis
endometriosis diagnosis
pelvic USS: large endometriomas and chocolate cysts
laparoscopy
endometriosis staging
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
initial management for endometriosis
Establishing a diagnosis
Providing a clear explanation
Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
Analgesia as required for pain (NSAIDs and paracetamol first line)
hormonal management for endometriosis
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists
surgical management for endometriosis
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy
differentials for endometriosis
PID
ectopic pregnancy
fibroids
IBS
diagnosis of endometriosis
laparoscopy: chocolate cysts, adhesions, peritoneal deposits
pelvic USS
suppressing ovulation in endometriosis
Suppressing ovulation for 6-12 months can cause atrophy of the endometriosis lesions and therefore a reduction in symptoms.
A low dose combined oral contraceptive pill or norethisterone can be used. Injected hormones or intrauterine devices such as the Mirena coil can also be used. The Mirena has the benefit of containing a low dose of hormone.
surgery for endometriosis
The surgical option is used if the endometriosis symptoms seriously affect the patient’s life. Surgery such as excision, fulgaration and laser ablation aim to completely remove the ectopic endometrial tissue in the peritoneum, uterine muscle and pouch of Douglas to reduce pain.
Relapses will almost certainly occur and surgery may have to be repeated. Ultimate management may be a hysterectomy and removal of the ovaries with subsequent replacement of hormones until the age of the menopause.
adenomyosis
Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus.
This benign invasion of the middle layer of the uterine wall has been described as a variant of endometriosis – and although the conditions can occur together, they are distinct diagnoses.
epidemiology of adenomyosis
Adenomyosis is found in up to 40% of hysterectomy specimens regardless of a previous history of pelvic pain and occurs most often in multiparous women at the end of their reproductive life
symptoms subside post-menopause
pathophysiology of adenomyosis
endometrial stroma is allowed to communicate with the underlying myometrium after uterine damage
usually in posterior wall
adenomyoma
When a collection of endometrial glands form grossly visible nodules
risk factors for adenomyosis
high parity
uterine surgery, e.g. any endometrial curettage, endometrial ablation
previous C-section
hereditary occurrence has been reported
symptoms of adenomyosis
menorrhagia dysmenorrhea deep dyspareunia irregular bleeding progressive dysmenorrhea; cyclical-> daily pain
signs of adenomyosis
symmetrically enlarged tender uterus may be palpable
differential diagnosis of adenomyosis
Endometriosis
Fibroids
Endometrial hyperplasia/endometrial carcinoma
Endometrial polyps (not commonly associated with dysmenorrhoea)
Pelvic Inflammatory Disease (pelvic pain rather than cyclical pain/dysmenorrhoea)
Hypothyroidism and coagulation disorders (menorrhagia)
investigations of adenomyosis
transvaginal USS
MRI
hormone therapy adenomyosis
Combined oral contraceptives
Progestogens (oral or Intrauterine system e.g. Mirena)
Gonadotropin-releasing hormone agonists
Aromatase inhibitors
non-hormonal treatments adenomyosis
hysterectomy
uterine artery embolisation
endometrial ablation and resection
laparoscopic excision
