Uterine Disorders Flashcards
Endometrial cancer incidence
Incidence 33 in 100,000
Peak incidence between 65 and 75
Endometrial cancer pathophysiology
Most commonly adenocarcinoma – due to stimulation of endometrium by oestrogen without protective effects of progesterone
Endometrial hyperplasia can predispose to atypia, a precancerous state
Endometrial cancer risk factors
- Anovulation – early menarche/later menopause, low parity, PCOS, HRT, tamoxifen
- Increasing age
- Obesity – faster rate of peripheral aromatisation of androgens to oestrogen
- Heredity factors – lynch syndrome
Endometrial cancer presentation
Main clinical feature is postmenopausal bleeding
- 75-90% of women with endometrial cancer present with PMB
- 90% of women with PMB do have endometrial cancer
- Younger women may present with irregular or intermenstrual bleeding
Endometrial cancer investigations
1st line investigation is a TV USS – endometrial thickness > 5mm
- If thickness of > 4mm in postmenopausal women -> endometrial biopsy
- Can be performed in outpatients with a pipelle biopsy
- If high risk then hysteroscopy with biopsy performed – outpatient or under GA
- If malignancy confirmed then MRI/CT may be used for staging
Endometrial cancer staging
Stage 1 – confined within uterine body
- A – endometrium
- B – myometrium
Stage 2 – into cervix but not beyond uterus
Stage 3 – carcinoma extends beyond uterus but in confined to pelvis
- Ovaries, vagina, lymph nodes
Stage 4 – Involves bladder or bowel or metastasized to distant sites
Endometrial cancer management
Stage 1 – total hysterectomy and bilateral salpingo-oophorectomy
- Peritoneal washings also taken
- 75% women present with stage 1 and 5 year survival rate of 90%
Stage 2 – radical hysterectomy – vaginal tissues surrounding cervix and supporting ligaments removed
- May be offered adjuvant radiotherapy
Stage 3/4 – maximal de-bulking surgery
- Additional chemotherapy and radiotherapy
- Palliative approach may be preferred – low dose radiotherapy or high dose oral progestogens
Define adenomyosis
Presence of functional endometrial tissue within the myometrium of the uterus
Pathophysiology of adenomyosis
Endometrial stroma allowed to communicate with underlying myometrium after uterine damage
Oestrogen, progesterone and androgen receptors found in ectopic endometrial tissue making it responsive to hormones
Invasion can be focal or diffuse - commonly found in posterior wall
Adenomyoma - collection of endometrial glands form grossly visible nodule
Risk factors for adenomyosis
Pregnancy and childbirth
High parity
Caesarean section
Uterine surgery - endometrial curettage, endometrial ablation
Surgical management of miscarriage or TOP
Hereditary occurrence
Clinical features of adenomyosis
Menorrhagia
Dysmenorrhoea - begins as cyclical pain but can worsen to daily pain
Deep dyspareunia
Irregular bleeding
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 for adenomyosis
Definitive diagnosis is histological after hysterectomy
Imaging
- TV USS - globular uterine configuration, poor definition of endometrial-myometrial interface, myometrial AP asymmetry, intramyometrial cysts and heterogeneous myometrial echo texture
- MRI - endo-myometrial junctional zone, irregular thickening
Management of adenomyosis
Symptom control
- hormone therapy - reduced proliferation of ectopic endometrial cells
- COCP
- progestogens - oral or intrauterine system
- gonadotropin-releasing hormone agonists
- aromatase inhibitors
- non hormonal
- hysterectomy - only definitive treatment
- uterine artery embolisation - block blood supply to adenomyosis causing it to shrink
Define endometriosis
Endometrial tissue located in other sites than the uterine cavity
Risk factors for endometriosis
Early menarche FH Short menstrual cycles Long duration of menstrual bleeding Heavy menstrual bleeding Defects in uterus of fallopian tubes
Clinical features of endometriosis
Cyclical pelvic pain - occurs at time of menstruation - may be constant if adhesions have formed Dysmenorrhoea Dyspareunia Dysuria Dyschezia Subfertility
Differential diagnosis of endometriosis
PID - dyspareunia, pelvic pain and abnormal and/or heavy bleeding
Ectopic pregnancy - dyspareunia, pelvic pain and abnormal and/or heavy bleeding, and sometimes collapse
Fibroids - pelvic pain, long duration of menstrual bleedings, heavy menstrual bleeding, a feeling of a mass or bloating
IBS - abdominal pain, dyspareunia and bloating
Investigations for endometriosis
Gold standard = laparoscopy
- chocolate cysts
- adhesions
- peritoneal deposits
Management of endometriosis
Pain - analgesia or NSAIDs Ovulation - COCP or norethisterone - suppressing ovulation for 6-12 months can cause atrophy of endometriosis lesions Surgery - excision - fulgaration - laser ablation
Define uterine fibroids
Leiomyomas
Benign smooth muscle tumours of the uterus
Classification of fibroids
Intramural - most common
- confined to myometrium of the uterus
Submucosal
- develops immediately underneath the endometrium of the uterus and protrudes into uterine cavity
Subserosal
- protrudes into and distorts serosal surface of uterus
Risk factors for fibroids
Obesity Early menarche Increasing age FH Ethnicity - African-Americans 3x more likely
Clinical features of fibroids
Majority of women are asymptomatic
History of
- Pressure symptoms +/- abdominal distention - urinary frequency or chronic retention
- Heavy menstrual bleeding
- Subfertility – due to the obstructive effect of the fibroid
- Acute pelvic pain (rare) - in pregnancy due to red degeneration. This is where the rapidly growing fibroid undergoes necrosis and haemorrhage
Differential diagnosis of fibroids
Endometrial polyp
Ovarian tumours
Leiomyosarcoma – malignancy of the myometrium
Adenomyosis – presence of functional endometrial tissue within the myometrium
Investigations for fibroids
Pelvic USS
MRI - if sarcoma suspected
Management of fibroids
Medical
- Tranexamic or mefanamic acid
- Hormonal contraceptives - control menorrhagia
- GnRH analogues (Zolidex) - 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 (Ulipristal / Esmya) - reduces size of fibroid and menorrhagia
- useful pre-operatively or as an alternative to surgery
Surgical
- Hysteroscopy and Transcervical Resection of Fibroid (TCRF) - submucosal fibroids
- Myomectomy - preserves uterus
- Uterine Artery Embolization (UAE) - performed by a radiologist via the femoral artery but commonly causes pain and fever post-operatively
- Hysterectomy
