Uterine Disorders Flashcards
What are uterine fibroids?
AKA leiomyomata
Benign smooth muscle tumours of the uterus arising from the myometrium
Most common benign tumours in women (incidence 20-40%)
What is the risk of a fibroids becoming malignant?
0.1%
How are fibroids classified?
According to their position in the uterine wall
Intramural (most common) - confined to the myometrium of the uterus
Submucosal - develops immediately underneath the endometrium of the uterus and protrudes into the uterine cavity
Subserosal - protrudes into and distorts the serosal surface of the uterus. They may be pedunculated (on a stalk)
What is the pathogeneis of fibroids?
Poorly understood.
Thought to be stimulated by oestrogen.
What are the risk factors for developing fibroids?
Obesity
Early menarche
Family history (1st degree relative - 2.5x)
African-Americans 3x more likely than Caucasians
What are the clinical features of fibroids?
Majority asymptomatic (discovered incidentally on pelvic/abdominal exam) Urinary frequency/chronic retention Abdominal distension Heavy menstrual bleeding Subfertility (obstructive effects) Acute pelvic pain (rare) - may occur in pregnancy due to red degeneration - necrosis/haemorrhage of fibroid - torsion of pedunculated fibroid
What can be seen on examination of a woman with fibroids?
Solid mass/enlarged uterus may be palpable on abdominal or bimanual examination
Uterus usually non-tender
What are the differentials for fibroids?
Endometrial polyps
Ovarian tumours
Leimyosarcoma
Adenomyosis
What are the investigations for fibroids?
Pelvic USS
MRI (rarely required unless sarcoma suspected)
What is the medical management for fibroids? (If the patients are asymptomatic with small fibroids may no need treatment).
Tranexamic/mefanamic acid
Hormonal contraceptives to control menorrhagia (COCP, POP, Mirena IUS)
GnRH analogues (zolidex)
- suppresses ovulation - temporary menopausal state (useful pre-operatively to reduce fibroid size and lower complications)
Selective progesterone receptor modulators (ullipristal/esmya)
- reduces size of fibroid and menorrhagia
- useful preoperatively/as an alternative to surgery
How long can GnRH analogues be used for and why?
6 months only
Due to osteoporosis risk
What is the surgical management of fibroids?
Hysteroscopy and transcervical resection of fibroid (TCRF)
- useful for submucosal fibroids
Myomectomy
- for women wanting to preserve their uterus
Uterine artery embolisation (performed by a radiologist via the femoral artery, commonly causes pain and fever post-operatively)
Hysterectomy
What is endometriosis?
It is a chronic condition in which endometrial tissue is located in sites other than the uterine cavity.
What is the common age range of women affected by endometriosis?
25-40
What is adenomyosis?
Endometrial tissue found in the uterine muscle.
What is a theory for the aetiology of endometriosis?
Retrograde menstruation
Endometrial cells travel backwards from the uterine cavity, through the Fallopian tubes and deposit on pelvic organs where they can seed and grow
May then travel to distant sites through the lymphatic system and vasculature
What is the pathophysiology of endometriosis?
Endometrial tissue is sensitive to oestrogen
Bleeding from ectopic tissue during menstruation
Results in pain, bloating and distension at the ectopic sites
Repeated inflammation and scarring can lead to adhesions
During pregnancy and menopause symptoms will be reduced
What are the risk factors for endometriosis?
Early menarche FH of endometriosis Short menstrual cycles Long duration of menstrual bleeding Heavy menstrual bleeding Defects in the uterus or Fallopian tubes
What are the clinical features of endometriosis?
Cyclical pelvic pain (at time of menstruation) though pain may be constant where adhesions have formed
Dysmenorrhea, Dyspareunia, Dysuria, Dyschezia
Subfertility
Focal symptoms of bleeding at distant sites
On examination - fixed retroverted uterus, uterosacral ligament nodules, general tenderness
Enlarged tender and boggy uterus is indicative of adenomyosis
What are the differential of endometriosis?
PID
Ectopic pregnancy
Fibroids
IBS
What are the investigations for endometriosis?
Laparoscopy - gold standard (differentiated from chronic infection) Pelvic USS (determines severity, needs to be undertaken before surgery)
What are the typical findings in endometriosis on laparoscopy?
Chocolate cysts
Adhesions
Peritoneal deposits
What are the findings on pelvic USS for endometriosis?
Kissing ovaries (bilateral endometrioma are adherent together)
Pelvic mobility
Involvement of bowel if any
What is the management for endometriosis?
No treatment if asymptomatic
Analgesia for pain
Suppress ovulation for 6-12 months
- causes atrophy and reduces symptoms
- low dose COCP/norethisterone/mirena coil
Surgery
- if symptoms seriously affect the patient’s life
Excision, fulgaration and laser ablation
- relapses will certainly occurand the surgery will have to be done again
Ultimate management is hysterectomy and removal of ovaries with subsequent replacement of hormones until the age of menopause
Describe the aetiology of endometrial cancer.
Most commonly adenocarcinoma
Stimulation of the endometrium by unopposed oestrogen
Longer periods of anovulation predispose to endometrial cancer (progesterone produced by the corpu luteum)
Unopposed oestrogen can also cause endometrial hyperplasia with can predispose to malignancy
What are the risk factors for endometrial cancer?
Anovulation (early menarche, late menopause, low parity, PCOS, HRT with O alone, tamoxifen)
Age (peak 65-75)
Obesity (faster peripheral aromatisation of androgens to oestrogen)
Genetics (e.g. hereditary non-polyposis colorectal cancer)
Why is early menarche/late menopause a risk factor for endometrial cancer?
At the extremes of mistrial age, menstrual cycles tend to be anovulatory
This increases exposure to unopposed oestrogen without the protective factor of progesterone from the corpus luteum
What are the clinical features of endometrial cancer?
Post-menopausal bleeding Clear/white vaginal discharge Abnormal cervical smears If premenopausal - irregular/IMB Abdo pain/weight loss if advanced or metastatic
What may be seen on examination of a woman with endometrial cancer?
Abdo exam: abdo or pelvic masses
Speculum exam: vulval/vaginal atrophy/cervical lesions
Bimanual exam: assess size and axis of uterus prior to endometrial sampling
What are the differentials for endometrial cancer?
Vulval causes (vulval atrophy, vulval pre-malignant/malignant conditions) Cervical causes (polyps/cancer) Endometrial causes (hyperplasia, polyps, atrophy)
What are the investigations for endometrial cancer?
Transvaginal USS (1st line)
Endometrial biopsy and histology (often using Pipelle biopsy)
If high risk - hysteroscopy with biopsy
MRI/CT - staging
Before operation - baseline bloods + group and save
What are the indications for an endometrial biopsy?
If there is an endometrial thickness of >4mm in a postmenopausal woman on transvaginal USS
If <4mm watch and wait
What are the indications for a hysteroscopy with biopsy in suspected endometrial cancer?
High risk patients
Heavy bleeding, multiple risk factors, very thickened endometrium on USS, patient unable to tolerate outpatient sampling
Describe the staging for endometrial cancer.
FIGO staging
I - confined to uterine body
II - may extend to cervix, not beyond uterus
III - beyond uterus but confined to pelvis
IV - involves bladder/bowel or has metastasised to distant sites.
What is the management for endometrial hyperplasia?
Without atypia - protgestogens e.g. mirena IUS. Surveillance biopsies to identify progression to atypia/malignancy Atypical hyperplasia (highest rate of progression to malignancy) - total abdominal hysteroscopy + bilateral salpingooophorectomy - regular surveillance biopsies if surgery contraindicated
What is the management for stage I endometrial cancer?
Total hysterectomy and bilateral salpingo-oophorectomy
Peritoneal washings should be taken
Generally by laparoscopic surgery
How is stage II endometrial cancer managed?
Radical hysterectomy (vaginal tissue surrounding the cervix and supporting ligaments also removed).
Assessment and removal of pelvic lymph nodes (lymphadenectomy)
May be offered adjuvant radiotherapy
How is stage III endometrial cancer managed?
Maximal de-bulking surgery if possible
Additional chemotherapy usually given prior to radiotherapy
What is the treatment for stage IV endometrial cancer?
Maximal de-bulking surgery if possible
But in many a palliative approach is preferred (low dose radiotherapy/oral high dose progestogens)
What follow up is required for endometrial cancer?
Frequent follow-up up to 5 years post-op due to recurrence risk
Describe the aetiology of adenomyosis.
Endometrial stroma allowed to communicate with the underlying myometrium after uterine damage (e.g. pregnancy, child birth, C-section, uterine surgery, surgery for miscarriage/termination)
Describe the pathophysiology of adenomyosis.
Invasion can be focal or diffuse.
More commonly on the posterior wall of the uterus.
Severe - pockets of mentrual blood can be seen in the myometrium of hysterectomy specimens
Responsive to hormones.
What are adenomyoma?
When a collection of endometrial glands form grossly visible nodules
What are the risk factors for adenomyosis?
High parity
Uterine surgery e.g. endometrial curettage, endometrial ablation
Previous C section
Genetics
What are the clinical features of adenomyosis?
Menorrhagia
Dysmenorrhea (can begin as cyclical and then become daily pain)
Deep dyspareunia
Irregular bleeding
Symmetrically enlarged, tender uterus may be palpable
What are the differentials for adenomyosis?
Endometriosis
Fibroids
Endometrial hyperplasia/carcinoma
Endometrial polyps (not associated with dysmenorrhea)
PID (not cyclical pain)
Hypothyroidism and coagulation disorders (menorrhagia)
What are the investigations for adenomyosis?
Definitive diagnosis - histological after hysterectomy/hysteroscopic biopsy
Transvaginal USS
MRI
What are the signs of adenomyosis on transvaginal USS?
Globular uterine configuration Poor definition of the endometrial-myometrial surface Myometrium anterior-posterior asymmetry Intramyometrial cysts Heterogenous myometrium echo texture
What are the signs of adenomyosis that can be seen on MRI?
Endo-myometrium junctional zone distinguished from endometrium and outer myometrium
An irregular thickening of this one
What is the main aim in the management of adenomyosis?
To control the dysmenorrhea and the menorrhagia
What is the only curative therapy for adenomyosis?
Hysterectomy
What are the hormonal therapies for adenomyosis?
COCP
Progestogens (oral/IUS)
GnRH agonists
Aromatase inhibitors
How do the hormonal treatments for adenomyosis work?
Reduce proliferation of ectopic endometrial cells
This decreases uterine size and volume of blood lost
Continuous use may temporarily induce the regression of adenomyosis
What are the non-hormonal treatments for adenomyosis?
Analgesia Hysterectomy (only definitive management) Uterine artery embolisation Endometrial ablation and resection Laparoscopic excision Magnetic resonance-guided focused US
How does uterine artery embolisation work to treat adenomyosis and when might it be used?
In the short-medium term for women waning to avoid hysterectomy and/or preserve fertility
Blocks the blood supply to the adenomyosis causing it to shrink
