Uterine Disorders Flashcards
What is the muscular wall of the uterus called?
Myometrium
What is the inner layer of the uterus called?
Endometrium
What is the name for inflammation of the endometrium?
Endometritis
https://www.youtube.com/watch?v=LAqMrrtlPWA
What is the usual cause of endometritis?
The normal bacterial organisms of the lower genital tract ascending up into the endometrium
What are some causes of endometritis?
Retention of products of conception- fetal or placental tissues following delivery or abortion
Foreign body- e.g. IUCD, hysteroscopy
Ascending STIs
Surgery- C-Sections
Note- it is uncommon unless the barrier to the endometrium is shed (acid vaginal pH and cervical mucus plug) e.g. during childbirth, TOP, IUCD, hysteroscopy and surgery.
How are the sub-types of endometritis divided?
Acute
Chronic
How might someone with acute endometritis present?
Fever Lower abdominal plain Abnormal uterine bleeding Dyspareunia Dysuria
How might chronic endometritis present?
Often asymptomatic
Or milder symptoms of those with acute endometritis- fever, lower abdominal pain, abnormal bleeding, dyspareunia
What would an endometrial biopsy show in acute endometritis?
Neutrophils in the endometrium- this is the hallmark of acute inflammation
What would an endometrial biopsy show in chronic endometritis?
Lymphocytes in the endometrium- a marker of long standing inflammation
What findings might there be for someone with endometritis on examination?
Tenderness on bimanual examination
Foul smelling discharge
What is seen on biopsy for endometrial tuberculosis?
Granulomas- another name is chronic granulomatous endometritis
What is the treatment for endometritis?
Antibiotics e.g. cefalexin or metronidazole
Remove IUCD if not responding to antibiotics
What are two STIs that can cause endometritis?
Gonorrhoea
Chlamydia
What bacterium causes granulomatous endometritis?
Tuberculosis
What is an important complication of chronic endometritis? What happens?
Asherman’s syndrome-
Intrauterine adhesions occur due to the inflammations of the endometrium. The basal layer is unable to regenerate the functional layer and leads to fibrosis and adhesions.
What are some of the complications of asherman’s syndrome? What causes it?
Amenorrhoea- fibrosis of the basal layer and inability to regenerate the functional layer
Infertility/ Recurrent Miscarriage- due to fibrotic bands in the endometrium
What is the treatment for endometritis caused by retention of products?
Dilation and curettage to remove the retained tissues
Why might someone develop amenorrhoea as a complication of endometritis?
Due to fibrosis of the basal layer meaning the functional layer cannot regenerate. Intrauterine adhesions also form leading to recurrent miscarriage or infertility.
This is called Asherman’s syndrome
What aspect of the history is typical of a woman with features of Asherman’s syndrome?
Intrauterine instrumentation in the past- e.g. dilation and curettage for retention of products
What is the normal thickness of the endometrium early in the cycle?
<5mm
What is the normal thickness of the endometrium during the proliferative phase of the cycle?
7-16mm
Above what endometrial thickness should a biopsy or endometrial sample be taken to rule out hyperplasia/cancer?
Answer both menopausal and post-menopausal
> 20mm if menopausal
> 4mm if post menopausal
What is endometrial hyperplasia?
Increase growth of the endometrial layer of the uterus
What stimulates endometrial proliferation?
Oestrogen
What causes endometrial hyperplasia?
Exposure to high levels of oestrogen for a prolonged period of time
What are some causes of excess oestrogen?
Obesity PCOS- chronic anovulation Oestrogen secreting tumour Oestrogen only HRT (not to be given to women with a uterus ) Early menarche Late menopause No pregnancies
What is the name of the pre-cancerous lesion of endometrial carcinoma?
Endometrial hyperplasia
What breast cancer medication is associated with an increased risk of endometrial cancer?
Tamoxifen- whilst it blocks oestrogen receptors in the breast it stimulates them in to uterus increasing the risk of endometrial cancer
What symptoms might a pre-menopausal woman present with if she has developed endometrial cancer?
Abnormal vaginal bleeding
IMB
Heavier or irregular periods
What symptoms might a menopausal woman present with if she has developed endometrial cancer?
IMB
Heavier periods than normal
What symptoms might a post menopausal woman present with if she has developed endometrial cancer?
PMB- any post menopausal bleeding requires further investigation as to the cause
What is the most common cause of PMB?
Atrophic vaginitis- due to low oestrogen stats and small bleeds that occur. PMB always requires further assessment as to the cause as it may be due to malignancy
What initial investigation should be done for PMB?
Transabdominal or transvaginal USS
What endometrial thickness on USS in a post-menopausal woman indicates that endometrial sampling is needed?
> 4mm
<4mm has a 96% negative predictive value with no requirement for biopsy
What are the two ways a biopsy sample may be obtained of the endometrium?
Endometrial sampling using a pipelle
Via hysteroscopy
What information is required to stage a cancer?
Staging is done in order to assess the extent of spread of a cancer- therefore imaging is required either CT or MRI
What is seen in stage 1 endometrial cancer?
Confined to the body of the uterus only
What is seen in stage 2 endometrial cancer?
Spread to the cervix
What is seen in stage 3 endometrial cancer?
Advancing beyond the uterus into surrounding structures but still within the lesser/true pelvis
What is seen in stage 4 endometrial cancer?
Extending outside the pelvis with distant metastases
What treatment options exist for the treatment of endometrial cancer?
Surgery- hysterectomy, bilateral salpingo-oophorectomy (BSO), pelvic lymphadenectomy
Radiotherapy
Chemotherapy- e.g. paclitaxel, doxorubicin, cisplatin
Treatment is carried out within specialist cancer centres according to stage and grade of the cancer
https://www.youtube.com/watch?v=wJ5WHwq5e7g
Why does PMB always require further assessment?
May be due to endometrial carcinoma
Lecture on endometrial cancer
https://www.youtube.com/watch?v=3BuVJCtds4g
Why should oestrogen only HRT not be given to women with a uterus?
The exposure to unopposed oestrogen increase the risk of endometrial cancer developing
What cancer syndrome is endometrial cancer associated with?
Lynch Syndrome of HNPCC
Others- Ovarian, colon, other GI cancers
What might be done to manage endometrial hyperplasia?
Remove the excess oestrogen source that is stimulating the hyperplasia- weight loss, HRT, PCOS
Progestogens- Mirena coil but this is a contraceptive and so oral progesterone may be taken for a short period of time instead (medroxyprogresterone acetate)
Re-biopsy in 6-12 months to check for response/investigate for cancerous change
What are endometrial polyps?
Benign growth of the endometrium that protrude into the endometrial cavity
What breast cancer medication is associated with an increased risk of endometrial polyps?
Tamoxifen- whilst it blocks oestrogen receptors at the breast it stimulates that endometrium
What is pyometra? What is important to remember about it?
Pyometra is pus in the uterus
It is important to remember that 50% have underlying outflow obstruction due to cancer
What is endometriosis?
Presence of endometrial tissue outside of the uterus
What is adenomyosis?
Endometrial tissue within the myometrium
What are some of the theories about the cause of endometriosis?
1) Retrograde Menstruation- leading to adherence, invasion and growth of tissue elsewhere
2) Impaired immunity following retrograde mensuration meaning the cells aren’t cleared by the immune response
3) Metaplasia of mesothelial cells that line the peritoneum
4) Metastasis of endometrial cells- travel to distant organs
5) Extrauterine stem cell theory- differentiate to endometrial cells within the bone marrow and travel to distal site
Exact cause isn’t known
What is the mesothelium?
The epithelial lining of the pleura, peritoneum and pericardium
What are some risk factors for endometriosis?
Family history
No pregnancy
Early menarche/Late menopause
(think more oestrogen and menstrual cycles)
What causes the pain in endometriosis?
Like the endometrium the endometrial deposits bleed during the menstrual cycle. Bleeding into the abdomen generates an immune response and there is resulting pain that is cyclical in nature- prolonged inflammation leads to adhesions which can cause chronic pain
What is an endometrioma?
This is also called a chocolate cyst- due to endometrial tissue within the ovaries causing dark collections of blood
How might someone with endometriosis present?
Pelvic/lower abdominal pain
Cyclical pain that is worse with periods
Chronic pain if adhesions have formed
Severe dysmenorrhoea
Deep Dyspareunia- due to inflammation of uterosacral ligaments
Pain on defecation (dychezia)
May experience cyclical rectal bleeding if endometrial deposits present there
Sub-fertility due to prolonged inflammation
Symptoms depend upon the location of the endometrial cells
Why might endometriosis cause cyclical rectal bleeding?
Due to endometrial deposits in the rectum
What area of the pelvic may be involved to cause dyschezia in patients with endometriosis?
Pouch of Douglas- recto-vaginal pouch
What is the gold-standard investigation for endometriosis?
Laparoscopy- with biopsy for histological confirmation
The extent of disease should be documented with photographs.
What are the treatment options for endometriosis?
Medical- Stopping periods prevents the inflammatory process. COCP, Mirena Coil, GnRH Analogues (e.g. Gosrhelin with Tibolone HRT), NSAIDs for analgesia (e.g. Mefanamic acid)
Surgical Treatment- only if medical treatment has failed. Laparoscopy using ablation, excision of coagulation to destroy to deposits. Excision of endometriomas. Hysterectomy may be considered if completed family.
What medical options are used to treat endometriosis?
Combined oral contraceptive
Mirema coil
GnRH analogues- Gosrhelin
NSAIDs for pain relief-
What surgical options are available for the treatment of endometriosis?
Surgery is only considered for patients with endometriosis that has not responded to medical therapy
Excision, ablation or coagulation of the endometrial deposits
If completed family- hysterectomy may be considered
What is a leiomyoma?
Also called a uterine fibroid- it is a benign tumour of the smooth muscle of the uterus
Their the most common type of intra-mural fibroids
How can uterine fibroids be classified?
According to their location in the uterus
Subserosal- smooth muscle cells at the perimetrium
Submucosal- just below the endometrium
Intramural- within the myometrium
Pedunculated- submucosal fibroids that grow into the uterine cavity or extend into the abdominal cavity. They’re connected to the myometrium via a stalk.
What ethnicity is most commonly affected by fibroids?
Afro-Caribean
What is the relationship between fibroids and oestrogen levels?
Fibroids are oestrogen dependent and their growth rate increases when there is increased oestrogen levels, especially during pregnancy. Additionally the atrophy after menopause.
What triggers large increases in fibroid size?
Pregnancy due to the increased levels of oestrogen
What are some risk factors for fibroid development?
Afro-Caribbean
No pregnancies
Early menarche
Late menopause
(Similar risk factors for endometrial hyperplasia)
How might fibroids present?
Menorrhagia- heavy periods due to increased SA of endometrium. Especially submucosal and pedunculated.
Fertility issues- due to difficulty with implantation and distortion of uterine cavity with submucosal fibroids.
Pain- torsion and red degeneration
Sx due to mass effect- varicose veins, DVT, urinary frequency
What syndrome are fibroids associated with?
Reed’s syndrome
Skin and uterine fibroids
Aggressive papillary renal cell cancer
What investigations might be done to investigate for fibroids?
Trans vaginal scan
Trans abdominal scan
Rarely biopsy if suspicious features
What are the treatment options for fibroids?
Conservative- if small and asymptomatic the can be left alone
Medical- Mainly to shrink fibroids prior to surgery, GnRH Analogues (e.g. Gosrhelin), Ullipristal Acetate (progesterone receptor modulator)
Surgical- Myomectomy, Hysterectomy, Uterine artery embolisation by interventional radiologist
What is the macro and microscopic appearance of fibroids?
Macro- round, firm and grayish white
Micro- whorled pattern of smooth muscle bundles with well defined borders
What are some concerning features that might suggest leiomyosarcoma over leiomyoa?
Haemorrhage or necrosis
A single lesion- fibroids are typically multiple
Biopsy would show atypical cells with a high mitotic index
