Uterine Disorders

Question 1

Endometrial cancer incidence

Answer 1

Incidence 33 in 100,000

Peak incidence between 65 and 75

Question 2

Endometrial cancer pathophysiology

Answer 2

Most commonly adenocarcinoma – due to stimulation of endometrium by oestrogen without protective effects of progesterone
Endometrial hyperplasia can predispose to atypia, a precancerous state

Question 3

Endometrial cancer risk factors

Answer 3

• 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

Question 4

Endometrial cancer presentation

Answer 4

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

Question 5

Endometrial cancer investigations

Answer 5

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

Question 6

Endometrial cancer staging

Answer 6

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

Question 7

Endometrial cancer management

Answer 7

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

Question 8

Define adenomyosis

Answer 8

Presence of functional endometrial tissue within the myometrium of the uterus

Question 9

Pathophysiology of adenomyosis

Answer 9

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

Question 10

Risk factors for adenomyosis

Answer 10

Pregnancy and childbirth
High parity
Caesarean section
Uterine surgery - endometrial curettage, endometrial ablation
Surgical management of miscarriage or TOP
Hereditary occurrence

Question 11

Clinical features of adenomyosis

Answer 11

Menorrhagia
Dysmenorrhoea - begins as cyclical pain but can worsen to daily pain
Deep dyspareunia
Irregular bleeding

Question 12

Differential diagnosis of adenomyosis

Answer 12

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

Question 13

Investigations for adenomyosis

Answer 13

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

Question 14

Management of adenomyosis

Answer 14

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

Question 15

Define endometriosis

Answer 15

Endometrial tissue located in other sites than the uterine cavity

Question 16

Risk factors for endometriosis

Answer 16

Early menarche
FH
Short menstrual cycles
Long duration of menstrual bleeding
Heavy menstrual bleeding
Defects in uterus of fallopian tubes

Question 17

Clinical features of endometriosis

Answer 17

Cyclical pelvic pain 
- occurs at time of menstruation
- may be constant if adhesions have formed
Dysmenorrhoea
Dyspareunia
Dysuria
Dyschezia
Subfertility

Question 18

Differential diagnosis of endometriosis

Answer 18

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

Question 19

Investigations for endometriosis

Answer 19

Gold standard = laparoscopy

• chocolate cysts
• adhesions
• peritoneal deposits

Question 20

Management of endometriosis

Answer 20

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

Question 21

Define uterine fibroids

Answer 21

Leiomyomas

Benign smooth muscle tumours of the uterus

Question 22

Classification of fibroids

Answer 22

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

Question 23

Risk factors for fibroids

Answer 23

Obesity
Early menarche
Increasing age
FH
Ethnicity - African-Americans 3x more likely

Question 24

Clinical features of fibroids

Answer 24

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

Question 25

Differential diagnosis of fibroids

Answer 25

Endometrial polyp
Ovarian tumours
Leiomyosarcoma – malignancy of the myometrium
Adenomyosis – presence of functional endometrial tissue within the myometrium

Question 26

Investigations for fibroids

Answer 26

Pelvic USS

MRI - if sarcoma suspected

Question 27

Management of fibroids

Answer 27

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