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Women's and Children's health Matrix > Uterine Disorders > Flashcards

Uterine Disorders Flashcards

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1
Q

Outline the PALM-COEIN classification for abnormal Uterine bleeding?

A
  • Polyps
  • Adenomyosis
  • Leiomyomas
  • Malignancy and hyperplasia
  • Coagulation disorders
  • Ovarulatory dysfunction
  • Eendometrial dysfunction
  • Iatrogenic (unapposed estrogen, herbal suppliments (ginseng, ginko, soya), anti-coags
  • Not yet classified (chronic endometritis, AVM, Myometrial hypertrophy)
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2
Q

What must be excluded as causes in a patient with Menorrhagia?

A
  • PID
  • Pap smears
  • Pregnancy
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3
Q

What are the primary causes of oligo / amenhorrhea?

A
  • Uterus
    • Congenital uterine malformations
  • Ovaries / pelvis
    • ​PCOS
    • Premature menopause
  • Other systems
    • ​Hypothyroid
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4
Q

What are the primary causes of post coital bleeding?

A
  • Cervix
    • ​Cervical cancer
    • Cervical ectropion
    • Acute and chronic cervicitis
    • Cervical polyps
  • Vulva + vagina
    • ​Vaginal cancer
  • Pelvic floor
    • ​Pelvic organ prolapse
  • Infections
    • ​PID
    • Chlamydia
    • Gonorrhea
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5
Q

What are the primary causes of intermenstrual bleeding?

A
  • Uterus
    • Endometrial cancer
    • Endometrial polyps
  • Cervix
    • ​Cervical cancer
    • Cervical ectropion
    • Acute and chronic cervicitis
    • Cervical polyps
  • Ovaries and pelvis
    • ​Ovarian cancer
  • Vulva + vagina
    • ​Vulval cancer
    • Vaginal cancer
  • Early pregnancy
    • ​Ectopic pregnacny
    • Gestational trophoblastic neoplasia
  • Iatrogenic
    • ​Contraception
    • OBGYN procedures
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6
Q

What are the primary causes of post-menopausal bleeding?

A
  • Uterus
    • ​Endometrial cancer
    • Endometrial polyps
    • Uterine sarcoma
  • Cervix
    • ​Cervical cancer
    • Acute and chronic cervicitis
    • Cervical polyps
  • Disorders of menopause
    • ​Vulvovaginal atrophy
    • Other conditions of peri-menopause
  • Iatrogenic
    • ​OBGYN procedures
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7
Q

What are the primary pharmacological treatments available for menorrhagia?

A
  • Tranexamic acid
  • NSAIDs (mefenamic acid)
  • Combined oral contraceptive pill
  • Oral progestogens
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8
Q

What is the MOA of tranexamic acid?

A
  • Anti-fibrinolyic.
  • prevents activation of plasminogen and plasmin.
  • Reduces clot breakdown

Is used for 3-5 days during period

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9
Q

What is the MOA of NSAIDS (medenamic acid) for treating menorrhagia?

A
  • Inhibits prostaglanding formation
  • Reduces dilation in the endometrial vessels
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10
Q

What are endometrial polyps?

A
  • Abnormal groeths containing glands, stroma, and blood vessels that project from the endometrium into the uterine cavity
  • Mostly located in the fundus
  • Appear smooth and spherical
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11
Q

What are the comlications of endometrial polyps?

A
  • Associated with endometrial cancer (1-3%)
  • Abnormal uterine bleeding
  • Infertility
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12
Q

What are the risk factors for endometrial polyps?

A
  • Obesity (increased aromatase)
  • HRT
  • Tamoxifen
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13
Q

What are typical history findings for Endometrial polyps?

A
  • Intermenstrual bleeding
  • Post-coital bleeding
  • Mostly asymptomatic
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14
Q

What investigations should be conducted and what findings are expected for Endometrial polyps?

A
  • Transvaginal US
    • Hyperechogenic lesion with regular contours with or without cystic glands
    • Should be done at day 10 of menstrual cycle (thinnest endometrium)
  • Dopler
    • Thickness >5cm in post menopausal women or hyperechogenic focal mass
  • Hysteroscopy + biopsy
    • Smooth spherical, tan/yellow sessile or pedunculated mass, mostly in the fundus
    • Normal or hyperplastic endometrium
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15
Q

What is the management for endometrial polyps?

A
  • Observation <10mm
    • High rate of spontaneous regression over 1y period
  • Removal (Definitely in post-menopausal, consider in pre-menopausal &<40)
    • Hysteroscopy and polypectomy
    • Dilatation and curettage
  • Pharmacological removal
    • Progesterone
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16
Q

What is adenomyosis?

A
  • Endometrial tissue within the myometrium
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17
Q

What is the presumed pathophysiology of adenomyosis?

A
  • Invasion of endometrium into myometrium with spiral vessels
  • Hyperplasia and hypertrophy of the adjacent muscles (dysfunctional)
  • AUB from lack of tamponading effect from muscles
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18
Q

What are the three types of adenomyosis?

A
  1. Diffuse adenomyosis (most common)
  2. Focal (adenomyoma)
  3. Cystic (adenomyotic cyst)
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19
Q

What are the risk factors for adenomyosis?

A
  • Histroy of uterine surgical procedures
  • Multiparous
  • 30-50yo
  • High estrogen exposure (early menarchy)
  • Endometriosis
  • Fibroids
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20
Q

What is the typical history for adenomyosis?

A
  • Mostly asymptomatic
  • Chronic pain
  • Dysmenorrhea
  • Irregular, heavy, or prolonged periods
  • Dyspareunia
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21
Q

What are the usual exam findings in adenomyosis?

A
  • Dense, boggy, enlarged uterus
  • Tender uterus
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22
Q

What are the relevant investigations for adenomyosis, and what are the typical findings?

A
  • Transvaginal US
  • MRI (preferred)
    • Vascular, distended endometrial gland (may be nodular)
  • Hysterosalpingogram
    • Diverticula into the myometrium
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23
Q

What are the key differentials for adenomyosis?

A
  • Endometriosis (needs US / laproscopy to distinguish, can co-occur)
  • Endometrial carcinoma or stromal sarcoma
  • Uterine fibroids (more well defined, some calcification)
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24
Q

What is the management for adenomyosis?

A
  • Anti-inflammatories
    • Ibuprofen 1-2 days before period
  • Contraception
    • Progesterone alone
    • Mirena
    • Depo-provera
    • GnRH agonist
  • Surgical
    • Adenomyomectomy
    • Hysterectomy
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25
Q

What are Leiomyoma (fibroids)?

A

Benign tumours of smooth muscle and connective tissue, morst commonly in and around the uterus, but can occur elsewhere in the abdominal cavity

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26
Q

What are the risk factors for Leiomyoma (fibroids)

A
  • MED12 genes
  • Long term COCP
  • African descent
  • HTN
  • Obesity
  • Nulliparity
  • Family history
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27
Q

What is the pertinent epi for Leiomyome (fibroids)?

A
  • Pre-menopausal
  • Most common benign uterine tumour
  • 20% of women >30
  • 50% at autopsy
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28
Q

What is the pathophys for leiomyoma (fibroids)?

A
  • Smooth muscle cells upregulate estrogen and progesterone receptors and produce aromatase
    • This has a mitogenic effect on myometrium
    • Results in fibroid growth with no atypia
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29
Q

What are the main pathology findings for leiomyoma (fibroids)?

A
  • Whorled appearance
  • Benign degeneration
    • Red: acute disruption of blood supply
      • 2nd trimester
      • sudden onset pain, localised tenderness, pyrexia, leukocytosis (NSAIDS)
    • Also cystic and hyaline (not important
  • Malignant transformation (atypia)
    • Sarcomatous (leiomyosarcoma)
      • Very rare, but poor prognosis
      • Rapidly increasing size in (mostly) post-menopausal women)
      • Treated as malignancy
30
Q

What are the main complications of leomyoma (fibroids)?

A
  • Tortion (pedunculated, 2nd trimester pregnancy)
  • Anaemia
  • Infertility (submucosal, intramural)
  • Urinary tract obstruction
  • Obstetric (abnormal lie, PPH, preterm labour)
31
Q

What are the common findings on HISTORY for leimoyoma (fibroids)?

A
  • Mostly asymptomatic
  • Mentrual irregularity
    • Menorrhagia
  • Mass effect
    • Abdo distention
    • Frequency
    • Constipation
  • Subfertility
  • Must ask about reproductive intentions
32
Q

What are the findings on EXAM for leiomyoma (fibroids)?

A
  • Large mobile mass with an irregular contour
  • What to note in exam
    • Level of fundus
    • Palpable bladder
    • Uterine irregularity
    • Mobility
    • Scars
33
Q

What are the main differentials for a MASS or ENLARGED UTERUS?

A
  • Leiomyoma
  • Pregnancy
  • Uterine sarcoma
  • Endometrial carcinoma
  • Massive ovarian cyst
34
Q

What is the management for Leiomyoma (fibroids)?

A
  • Expectant
    • Small and asymptomatic
      • repeat US every 6-12 months
  • Fertility desired
    • ​MED:
      • TXA
      • Mefenamic acid (NSAID)
    • Surg
      • Myomectomy
      • Hysteroscopy and resection
  • Fertility NOT desired
    • ​MED:
      • Levonorgestes IUD (Mirena)
        • Higher risk of expulsion
        • Better in submucosal fibroids
    • Surg:
      • Uterine artery embolisation
      • Causes ischemia
35
Q

What are the tradional classification for endometrial carcinoma?

A

Type 1: Endometioid Adenocarcinoma

Type 2: Serous papillary carcinoma

36
Q

What is the epi of endometriod carcinoma?

A
  • 90% of ECs
  • Appears in younger women
37
Q

What are the risk factors for endometriod carcinoma?

A
  • Estrogen driven
38
Q

What is the pertinent HISTOLOGY for endometriod carcinoma?

A
  • Precursor lesion: Atypical endometrial hyperplasia / Endometriod intrarpithelial neoplasia (EIN)
    • Clonal proliferation of glandular epithelial cells
    • Mild or moderate cytologic atypia
    • Nuclear stratification and enlargement with prominent nucleoli
  • Associated with PTEN mutation
39
Q

What is the epi for serous papillary carcinoma?

A
  • 10% of EC
  • Older women
40
Q

What is the pertinent histology for serous papillary carcinoma?

A
  • Precursor lesion: Serous endometrial intraepithelial carcinoma (SEIC)
    • Nucleomegaly
    • Atypical nuclei
    • Psammoma bodies
    • High proliferative index
    • ****clear cellls with high glycaemic content + eosinophilic globules = clear cell morphology
  • Associated with TP53 mutations
41
Q

What aret the KEY DIFFERENCES between Endometriod adenocarcinoma and serous papillary carcinoma?

A
  • EC is more common and associated with younger women
  • SPC IS ESTROGEN INDEPENDENT!
  • SPC is more serious (poor prognosis)
  • EC precursor is EIN, SPC precursor is SEIC
  • EC is associated with PTEN mutations, SPC is associated with TP53 mutations
42
Q

What are the FIGO staging levels and associated 5-year survival rates?

A
  • Stage 1
    • Confined to the uterus
    • 88%
      • 1A = less than 50% invasion
      • 1B = more than 50% invasion
  • Stage 2
    • ​Spread to the cervix
    • 75%
  • Stage 3
    • ​Spread to ovaries, fallopian tubes, vagina or regional lymph nodes
    • 55%
      • 3A = Invdes serosa of uterus
      • 3B = Invdes vagina and/or parametrium
      • 3C = Metastasies to pelvis and/or paraaortic lymphnodes
  • Stage 4
    • ​Spread to bladder / rectum / distant mets
    • 16%
43
Q

What are poor prognostic indicators for endometrial cancer

A
  • >70yo
  • High BMI
  • >grade 3
  • Papillary serous or clear cell histology
  • Lymphovascular space involvement
  • Nodal mets
  • Distant mets
44
Q

What are the risk factors for endometrial hyperplasia / endometrial cancer?

A

AN OLD CUNT

  • Age
  • Next of kin
  • Obesity
  • Late menopause / early menarche
  • Diabetes
  • Cancer (HNPCC)
  • Unopposed estrogen (PCOS, HRT)
  • Nulliparity
  • Tampxifen
45
Q

What are the protective factors for Endometrial hyperplasia / Endometrial Cancer?

A
  • COCP
  • Progestrone only contraception
  • Smoking
46
Q

What is the pertinent HISTORY for endometrial cancer?

A
  • Premenopausal
    • Intermentrual bleeding
    • Blood-stained vaginal discharge
    • Heavy period
    • Lower abdo pain
    • Dyspareunia
  • Postmenopausal
    • Irregular bleeding
      • 10% Post-menopausal bleeding = cancer
  • Advanced disease
    • ​Bony pain
    • Respiratory symtoms
47
Q

What are the pertinent EXAM FINDINGS for endometrial cancer?

A
  • Anaemia signs
  • Blood on speculum
  • Enlarged uterus
  • Advanced signs
    • ​Fistula
    • Bone tenderness
    • Resp findings
48
Q

What are the investigations for endometrial cancer?

A
  • Transvaginal ultrasound
    • Endometrial thickening (>12mm for premenopausal, >5mm for peri/post menopausal)
  • Biopsy to differentiate from hyperplasia is needed
49
Q

When is a biopsy necessary to differentiate between endomtrial hyperplasia and endometrial cancer?

A
  • +radiological findings (endometrial thickening 12mm in premenopausal, 5mm in peri/postmenopausal)
  • Unresponsive to medical therapy
  • Risk factors for endometrial cancer
50
Q

What are the indications for early specialist referral <6months in endometrial hyperplasia symptoms?

A
  • Oligomenorrhoea
  • PCOS
  • Fhx/ PMhx of endometrial or colon cancer
  • Unopposed estrogen therapy
  • Tamoxifen
  • Obesity
  • >45yo
  • +radiological findings
51
Q

What are some other investigations for AUB / suspected endometrial hyperplasia / cancer?

A
  • SIS (Saline infusion sonohysterography)
    • Saline + TVUS
  • Hysteroscopy
    • Direct observation
  • MRI / CTCAP
    • For mets
52
Q

What is the main CONTRAINDICATION for women with suspected endometrial cancer?

A

Mirena (LNG-IUD)

  • Increased risk of infection and bleeding on insertion
  • Risk of uterine perforation
53
Q

What is the main surgical management for endometrial cancer?

A
  • Hysterectomy +/- bilateral salpingo-oophorectomy
        • Pelvic lymph node dissection
      • +Oara-aortic lymph node dissection
    • High grade / papillary serous
54
Q

What is endometriosis?

A

Endometriosis is a chronic inflammatory condition caused by the growth of endometrial tissue OUTSIDE the uterus

55
Q

What are the common sites of endometrial tissue growth in Endometriosis?

A
  • Most common
    • Pelvic cavity
    • Uterosacral ligaments
    • Ovaries
  • Rare
    • Umbilicus
    • Abdominal scars
    • Rectum
    • Pleural cavity
    • Nasal passages
56
Q

What are the two main hypotheses regarding the development of Endometriosis?

A
  • Sampson’s retrograde transplantation theory
    • ​Endometrial glands leaked into the peritoneal cavity
  • Embryological mullerianosis theory
    • ​Some endometrial tissue became misplaced outside the uterine cavity during embruological organogenesis
57
Q

What is the pathophys of Endometriosis?

A
  • Deposition of endometrial tissue outside of the uterine cavity
    • Can be superficial or infiltrating
  • Extopic endometrial tissue responds to estrogen
    • Inflammation, bleeding, fibrosis
    • Leads to endometriotic nodules and adhesions
    • Can cause pain and infertility
58
Q

What is the pertinent epi of Endometriosis?

A
  • 2-10% of women of reproductive age
  • Peak incidence 25-35
  • Estrogen dependent - resolves post menopause
  • Most common benign gynecological condition
59
Q

What are the main risk factors for Endometriosis?

A
  • First degree relative with the condition (3-10x risk)
  • Early age menarche
  • Short mentrual cycle
60
Q

What are the complications of Endometriosis?

A
  • Infertility
  • Chronic pain
  • Adhesions
61
Q

What are the primary differentials for endometriosis?

A
  • Restricted uterine mobility
    • Chronic PID
    • Malignacy
  • Pain
    • Ectopic pregnancy
    • Appendicity
    • Diverticulitis
    • IBS
    • Primary dysmenorrhea
    • Fibroids
    • PID
    • Ovarian cyst
    • Interstitial cystitis
62
Q

What is the pertinent hystory for Endometriosis?

A
  • Dysmenorrhea
  • Chronic pelvic pain
    • Severe, chronic (>3-6months)
    • Mostly cyclic (can be acyclic in adolescence)
    • Sharp or throbbing
  • Deep dyspareunia (endometriosis in pouch of douglas)
  • Dysuria
  • Dyschezia
  • Heavy mentrual bleeding
  • Bowel and bladder symptoms
  • Infertility
  • Rare
    • Cyclic epistaxis, cyclical rectal bleeding
  • MUST ASSESS REPRODUCTIVE GOALS
63
Q

What are the pertinent exam findings in endometriosis?

A
  • Abdo
    • Lower quadrant tenderness
    • Masses
  • Pelvic / PV
    • Motion tenderness
    • Tenderness in pouch of douglas
    • Thickening / nodularity of the uterosacral ligaments
    • Tender adnexal mass
    • Fixed retroverted / leterally displaced uterus
  • Speculum
    • Visible nodules
64
Q

What are the investigations for Endometriosis?

A
  • US
    • Deposits on ovary / pelvic cavity / peritoneum (TV>TA)
    • Normal results do not rule endometriosis out
  • Laproscopy and histopathology
    • Normal results do not exclude diagnosis
  • Treatment can be started with presumed diagnosis (history and exam)
65
Q

What are the indications for referral to specialist for endometriosis?

A
  • Not responding to first-line meds
  • Mass/nodule detected
  • Suspicious of bladder / bowel involvement
  • refer to fertility clinic if >35 or not able to conceive after 6 months of trying
66
Q

What is the management for endometriosis?

A

Symptom diary to establish cyclical v acyclical

First line is analgeia +/- hormonal therapy

Analgesia

  • NSAIDS 3 per day for first 2-3 days of menses
  • +/- Paracetamol

Analgesia (neuropathic)

  • Gabapentinoids
  • TCAs
  • SNRIs
  • Review in 3 months

Hormonal

  • COCP or
  • Long acting progrestogens (LNG-IUD, implanon, Depo-provera)
  • Specialist drugs (Danazol, GnRH inhibitors, aromatase inhibitors + ovulation supression)

Surgical

  • Laproscopic removal / ablation of deposits
  • Hysterectomy (if adenomyosis is detected, or heavy bleeding which is not responding to Tx)
67
Q

What are the main types of congenital uterine malformations?

A
  • Didelphus
  • Arcuate
  • Unicornate
  • Bicornate
  • Septate
68
Q

Which congential uterine malformations arrise from errors in fusion?

A
  • Bicornate
    • Partial fusion results in indent in fundus
  • Unicornate
    • Asymetrical fusion. One normal and one underdeveloped side
  • Didelphus
    • Ducts dont fuse, resulting in two distinct reproductive structures
69
Q

What types of congenital uterine malformations arrise from errors in septal reabsorbtion?

A
  • Septate
    • Septa (fibrous and muscular) exists between ducts
  • Arcuate
    • ‘little septum’. Broad indentation into the fundal cavity
70
Q

What are the complications of congenital uterine malformations?

A
  • Abnormalities in renal structures
  • Infertility

Women's and Children's health Matrix (34 decks)

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