Uterine Pathology

Question 1

What is the normal position of the uterus?

Answer 1

Anteverted & Anteflexed (80%)

Retroverted and/or retroflexed (20%) increases likelihood of prolapse

Question 2

Describe the blood supply to the uterus

Answer 2

I - iliolumbar
Love - lateral sacral
Going - gluteal (superior & inferior)
Places - pudendal
In - inferior vesicle/uterine
My - middle rectal
Very - vaginal/prostatic
Own - obturator
Underwear - umbilical

Question 3

Describe position of the uterine artery

Answer 3

1. Forms rich anastomoses with ovarian artery (which arises from aorta at L2)
2. Uterine artery travels over the ureter (bridge over water)

Question 4

Describe the structures that maintain the position of the uterus

Answer 4

1. Broad ligament - subdivides into mesosalpinx, mesovarium and mesometrium
2. Suspensory ligament - contains all ovarian vessels
3. Uterus is anchored by the cervix. Anchoring ligaments form from endopelvic fascia (transverse cervical and pubocervical)
4. Space posterior to the uterus into the lower pelvis = pouch of Douglas or rectouterine pouch.

Question 5

Describe the pathophysiology of uterine fibroids

Answer 5

• Benign tumours of the myometrium
• Oestrogen & progesterone dependent (usually regress after menopause)
• Can be intramural, subserosal, or submucosal

Question 6

What are the signs & symptoms of fibroids?

Answer 6

50% are asymptomatic

Symptoms largely related to size:

• Menorrhagia (30%)
• Intermenstrual bleeding (submucosal)
• Dysmenorrhea (only if torsion/red degeneration/sacromatous changes)
• Bladder problems (increased frequency, retention, hydronephrosis)
• Fertility (compression of structures)

Signs:
- Solid mass palpable on examination (will arise from pelvis and be continuous with uterus)

Question 7

Complications of fibroids?

Answer 7

• Enlargement causing problems with pressure on surrounding structures
• Degeneration (due to inadequate blood supply) = pain, tenderness
• Malignancy (<0.1% of fibroids may have malignant potential)
• Problems with pregnancy & labour (pain, preterm labour, transverse lie, PPH, obstructed labour)

Question 8

Investigations for fibroids

Answer 8

1. USS
2. MRI
3. Laparoscopy
4. Hysteroscopy

Question 9

Treatment for fibroids

Answer 9

1. No treatment for asymptomatic/unproblematic fibroids
2. Medical management = TXA, NSAIDs, Progestogens as 1st line. GnRH agonists may be used
3. Surgical management = hysteroscopic removal or hysterectomy

Question 10

What is adenomyosis?

Answer 10

Presence of endometrium + underlying stroma within the myometrium

Question 11

What causes adenomyosis?

Answer 11

Condition is oestrogen dependent but why it happens is unknown

Question 12

What are the signs + symptoms of adenomyosis?

Answer 12

Largely asymptomatic but can cause heavy, painful periods.

Uterus may be mildly enlarged and/or tender on examination.

Question 13

What is the diagnostic process and management for adenomyosis?

Answer 13

Diagnosis:
- MRI (difficult to see on USS)

Treatment:

• IUD or COCP
• NSAIDS to manage pain
• Hysterectomy

Question 14

What is endometriosis?

Answer 14

Presence of endometrial tissue outside of the uterus, such as the fallopian tubes. Can be found in distant sites such as lungs.

Question 15

What is the aetiology of endometriosis?

Answer 15

Believed to be due to retrograde menstruation

Question 16

Signs + symptoms of endometriosis?

Answer 16

• Extremely painful periods
• Chronic pelvic pain
• Dyspareunia
• Dysuria

Question 17

Diagnosis of endometriosis?

Answer 17

• Only definitively diagnosed via laparoscopy

- USS may show endometriomas

Question 18

Treatment of endometriosis?

Answer 18

• Pain management (i.e. NSAIDS + analgesic ladder)
• GnRH modulators
• COCP/IUD
• Surgical resection of endometrial tissue

Question 19

Sequelae of endometriosis?

Answer 19

• Subfertility

- Major disruption to daily life