Uterine Disorders Flashcards
Outline the PALM-COEIN classification for abnormal Uterine bleeding?
- 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)
What must be excluded as causes in a patient with Menorrhagia?
- PID
- Pap smears
- Pregnancy
What are the primary causes of oligo / amenhorrhea?
-
Uterus
- Congenital uterine malformations
-
Ovaries / pelvis
- PCOS
- Premature menopause
-
Other systems
- Hypothyroid
What are the primary causes of post coital bleeding?
-
Cervix
- Cervical cancer
- Cervical ectropion
- Acute and chronic cervicitis
- Cervical polyps
-
Vulva + vagina
- Vaginal cancer
-
Pelvic floor
- Pelvic organ prolapse
-
Infections
- PID
- Chlamydia
- Gonorrhea
What are the primary causes of intermenstrual bleeding?
-
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
What are the primary causes of post-menopausal bleeding?
-
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
What are the primary pharmacological treatments available for menorrhagia?
- Tranexamic acid
- NSAIDs (mefenamic acid)
- Combined oral contraceptive pill
- Oral progestogens
What is the MOA of tranexamic acid?
- Anti-fibrinolyic.
- prevents activation of plasminogen and plasmin.
- Reduces clot breakdown
Is used for 3-5 days during period
What is the MOA of NSAIDS (medenamic acid) for treating menorrhagia?
- Inhibits prostaglanding formation
- Reduces dilation in the endometrial vessels
What are endometrial polyps?
- 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
What are the comlications of endometrial polyps?
- Associated with endometrial cancer (1-3%)
- Abnormal uterine bleeding
- Infertility
What are the risk factors for endometrial polyps?
- Obesity (increased aromatase)
- HRT
- Tamoxifen
What are typical history findings for Endometrial polyps?
- Intermenstrual bleeding
- Post-coital bleeding
- Mostly asymptomatic
What investigations should be conducted and what findings are expected for Endometrial polyps?
- 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
What is the management for endometrial polyps?
- 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
What is adenomyosis?
- Endometrial tissue within the myometrium
What is the presumed pathophysiology of adenomyosis?
- Invasion of endometrium into myometrium with spiral vessels
- Hyperplasia and hypertrophy of the adjacent muscles (dysfunctional)
- AUB from lack of tamponading effect from muscles
What are the three types of adenomyosis?
- Diffuse adenomyosis (most common)
- Focal (adenomyoma)
- Cystic (adenomyotic cyst)
What are the risk factors for adenomyosis?
- Histroy of uterine surgical procedures
- Multiparous
- 30-50yo
- High estrogen exposure (early menarchy)
- Endometriosis
- Fibroids
What is the typical history for adenomyosis?
- Mostly asymptomatic
- Chronic pain
- Dysmenorrhea
- Irregular, heavy, or prolonged periods
- Dyspareunia
What are the usual exam findings in adenomyosis?
- Dense, boggy, enlarged uterus
- Tender uterus
What are the relevant investigations for adenomyosis, and what are the typical findings?
- Transvaginal US
- MRI (preferred)
- Vascular, distended endometrial gland (may be nodular)
- Hysterosalpingogram
- Diverticula into the myometrium
What are the key differentials for adenomyosis?
- Endometriosis (needs US / laproscopy to distinguish, can co-occur)
- Endometrial carcinoma or stromal sarcoma
- Uterine fibroids (more well defined, some calcification)
What is the management for adenomyosis?
- Anti-inflammatories
- Ibuprofen 1-2 days before period
- Contraception
- Progesterone alone
- Mirena
- Depo-provera
- GnRH agonist
- Surgical
- Adenomyomectomy
- Hysterectomy
What are Leiomyoma (fibroids)?
Benign tumours of smooth muscle and connective tissue, morst commonly in and around the uterus, but can occur elsewhere in the abdominal cavity
What are the risk factors for Leiomyoma (fibroids)
- MED12 genes
- Long term COCP
- African descent
- HTN
- Obesity
- Nulliparity
- Family history
What is the pertinent epi for Leiomyome (fibroids)?
- Pre-menopausal
- Most common benign uterine tumour
- 20% of women >30
- 50% at autopsy
What is the pathophys for leiomyoma (fibroids)?
- 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
What are the main pathology findings for leiomyoma (fibroids)?
- 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
- Red: acute disruption of blood supply
- Malignant transformation (atypia)
- Sarcomatous (leiomyosarcoma)
- Very rare, but poor prognosis
- Rapidly increasing size in (mostly) post-menopausal women)
- Treated as malignancy
- Sarcomatous (leiomyosarcoma)
What are the main complications of leomyoma (fibroids)?
- Tortion (pedunculated, 2nd trimester pregnancy)
- Anaemia
- Infertility (submucosal, intramural)
- Urinary tract obstruction
- Obstetric (abnormal lie, PPH, preterm labour)
What are the common findings on HISTORY for leimoyoma (fibroids)?
- Mostly asymptomatic
- Mentrual irregularity
- Menorrhagia
- Mass effect
- Abdo distention
- Frequency
- Constipation
- Subfertility
- Must ask about reproductive intentions
What are the findings on EXAM for leiomyoma (fibroids)?
- Large mobile mass with an irregular contour
- What to note in exam
- Level of fundus
- Palpable bladder
- Uterine irregularity
- Mobility
- Scars
What are the main differentials for a MASS or ENLARGED UTERUS?
- Leiomyoma
- Pregnancy
- Uterine sarcoma
- Endometrial carcinoma
- Massive ovarian cyst
What is the management for Leiomyoma (fibroids)?
-
Expectant
- Small and asymptomatic
- repeat US every 6-12 months
- Small and asymptomatic
-
Fertility desired
-
MED:
- TXA
- Mefenamic acid (NSAID)
- Surg
- Myomectomy
- Hysteroscopy and resection
-
MED:
-
Fertility NOT desired
-
MED:
- Levonorgestes IUD (Mirena)
- Higher risk of expulsion
- Better in submucosal fibroids
- Levonorgestes IUD (Mirena)
- Surg:
- Uterine artery embolisation
- Causes ischemia
-
MED:
What are the tradional classification for endometrial carcinoma?
Type 1: Endometioid Adenocarcinoma
Type 2: Serous papillary carcinoma
What is the epi of endometriod carcinoma?
- 90% of ECs
- Appears in younger women
What are the risk factors for endometriod carcinoma?
- Estrogen driven
What is the pertinent HISTOLOGY for endometriod carcinoma?
- 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
What is the epi for serous papillary carcinoma?
- 10% of EC
- Older women
What is the pertinent histology for serous papillary carcinoma?
- 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
What aret the KEY DIFFERENCES between Endometriod adenocarcinoma and serous papillary carcinoma?
- 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
What are the FIGO staging levels and associated 5-year survival rates?
-
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%
What are poor prognostic indicators for endometrial cancer
- >70yo
- High BMI
- >grade 3
- Papillary serous or clear cell histology
- Lymphovascular space involvement
- Nodal mets
- Distant mets
What are the risk factors for endometrial hyperplasia / endometrial cancer?
AN OLD CUNT
- Age
- Next of kin
- Obesity
- Late menopause / early menarche
- Diabetes
- Cancer (HNPCC)
- Unopposed estrogen (PCOS, HRT)
- Nulliparity
- Tampxifen
What are the protective factors for Endometrial hyperplasia / Endometrial Cancer?
- COCP
- Progestrone only contraception
- Smoking
What is the pertinent HISTORY for endometrial cancer?
- Premenopausal
- Intermentrual bleeding
- Blood-stained vaginal discharge
- Heavy period
- Lower abdo pain
- Dyspareunia
- Postmenopausal
- Irregular bleeding
- 10% Post-menopausal bleeding = cancer
- Irregular bleeding
-
Advanced disease
- Bony pain
- Respiratory symtoms
What are the pertinent EXAM FINDINGS for endometrial cancer?
- Anaemia signs
- Blood on speculum
- Enlarged uterus
-
Advanced signs
- Fistula
- Bone tenderness
- Resp findings
What are the investigations for endometrial cancer?
- Transvaginal ultrasound
- Endometrial thickening (>12mm for premenopausal, >5mm for peri/post menopausal)
- Biopsy to differentiate from hyperplasia is needed
When is a biopsy necessary to differentiate between endomtrial hyperplasia and endometrial cancer?
- +radiological findings (endometrial thickening 12mm in premenopausal, 5mm in peri/postmenopausal)
- Unresponsive to medical therapy
- Risk factors for endometrial cancer
What are the indications for early specialist referral <6months in endometrial hyperplasia symptoms?
- Oligomenorrhoea
- PCOS
- Fhx/ PMhx of endometrial or colon cancer
- Unopposed estrogen therapy
- Tamoxifen
- Obesity
- >45yo
- +radiological findings
What are some other investigations for AUB / suspected endometrial hyperplasia / cancer?
- SIS (Saline infusion sonohysterography)
- Saline + TVUS
- Hysteroscopy
- Direct observation
- MRI / CTCAP
- For mets
What is the main CONTRAINDICATION for women with suspected endometrial cancer?
Mirena (LNG-IUD)
- Increased risk of infection and bleeding on insertion
- Risk of uterine perforation
What is the main surgical management for endometrial cancer?
- Hysterectomy +/- bilateral salpingo-oophorectomy
- Pelvic lymph node dissection
- +Oara-aortic lymph node dissection
- High grade / papillary serous
What is endometriosis?
Endometriosis is a chronic inflammatory condition caused by the growth of endometrial tissue OUTSIDE the uterus
What are the common sites of endometrial tissue growth in Endometriosis?
- Most common
- Pelvic cavity
- Uterosacral ligaments
- Ovaries
- Rare
- Umbilicus
- Abdominal scars
- Rectum
- Pleural cavity
- Nasal passages
What are the two main hypotheses regarding the development of Endometriosis?
-
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
What is the pathophys of Endometriosis?
- 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
What is the pertinent epi of Endometriosis?
- 2-10% of women of reproductive age
- Peak incidence 25-35
- Estrogen dependent - resolves post menopause
- Most common benign gynecological condition
What are the main risk factors for Endometriosis?
- First degree relative with the condition (3-10x risk)
- Early age menarche
- Short mentrual cycle
What are the complications of Endometriosis?
- Infertility
- Chronic pain
- Adhesions
What are the primary differentials for endometriosis?
- Restricted uterine mobility
- Chronic PID
- Malignacy
- Pain
- Ectopic pregnancy
- Appendicity
- Diverticulitis
- IBS
- Primary dysmenorrhea
- Fibroids
- PID
- Ovarian cyst
- Interstitial cystitis
What is the pertinent hystory for Endometriosis?
- 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
What are the pertinent exam findings in endometriosis?
- 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
What are the investigations for Endometriosis?
- 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)
What are the indications for referral to specialist for endometriosis?
- 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
What is the management for endometriosis?
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)
What are the main types of congenital uterine malformations?
- Didelphus
- Arcuate
- Unicornate
- Bicornate
- Septate
Which congential uterine malformations arrise from errors in fusion?
- 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
What types of congenital uterine malformations arrise from errors in septal reabsorbtion?
- Septate
- Septa (fibrous and muscular) exists between ducts
- Arcuate
- ‘little septum’. Broad indentation into the fundal cavity
What are the complications of congenital uterine malformations?
- Abnormalities in renal structures
- Infertility
