Uterine Pathology Flashcards
Fibroids are benign smooth muscle tumours of the Uterus. Describe the pathophysiology.
Growth is stimulated by oestrogen
Rarely become malignant
Describe the classification of Fibroids
Intramural: Most common, confined to myometrium
Submucosal: Develops underneath endometrium and protrudes into cavity
Subserosal: protrudes into and distends Serosal surface of Uterus
Give three risk factors for Fibroids
Obesity
Early Menarche
Increased Age
How do Fibroids present?
Most are asymptomatic
Pressure Symptoms
Heavy Menstrual Bleeding
Subfertility
Normally a non tender mass OE
What does acute pelvic pain on the background of Fibroids suggest?
Torsion
How are Fibroids normally imaged?
TV USS
Give three differentials for Fibroids
Endometrial Polyp
Ovarian Tumour
Leiomyosarcoma
When do Fibroids require management?
When symptomatic
Give three medical managements of Fibroids
Tranexamic Acid
Hormonal Contraceptives
GnRH Analogues (only used for 6 months due to Osteopenia risk - oestrogen deficient state causes regression)
State four possible surgical managements of Fibroids
Hysteroscopy and Transcervical Resection of Fibroid
Myectomy
Hysterectomy
Uterine Artery Embolisation
Define Endometriosis
Where Endometrial tissue is located at sites other than Uterine Cavity (such as Ovaries, PoD, Pelvic Peritoneum, Lungs)
Describe the pathophysiology of Endometriosis
Retrograde Menstruation - Endometrial cells travel backwards from Uterine Cavity through Fallopian tubes and deposit
Sensitive to Oestrogen so do bleed
Give four clinical features of Endometriosis
Dysmenorrhoea (Cyclical but constant if adhesions)
Dysuria
Dyspareunia
Subfertility
Describe the investigations for Endometriosis and what you would expect to find
Laparoscopy - Adhesions, Peritoneal Deposits, Chocolate Cysts
Pelvic USS
Describe the medical management of Endometriosis
If no symptoms - no treatment required
Pain: WHO analgesic ladder
Suppressing Ovulation: COCP/Mirena Coil (may cause regression)
Describe the surgical management of Endometriosis
Ablation/Excision (both may require repeated procedures)
Hysterectomy (+/- HRT)
Define Adenomyosis
Presence of functional endometrial tissue within the myometrium
A variant of endometriosis but they can occur together
Describe the pathophysiology of Adenomyosis
Endometrial stroma communicates with myometrium after Uterine Damage
Commonly in posterior wall
Give four causes of Adenomyosis
Childbirth
Caesarean Section
Pelvic Surgery
Surgical Management of Miscarriage
Give four clinical features of Adenomyosis
Menorrhagia
Deep Dyspareunia
Dysmenorrhoea (Cyclical worsening to Daily)
Irregular Bleeding
What three investigations can be done for Adenomyosis? What would they show?
MRI - endomyometrial junction zone thickened irregularly
Only definitive is histological examination post hysterectomy
Describe the short term management of Adenomyosis
Uterine Artery Embolisation
How can the symptoms of Adenomyosis be controlled?
NSAIDS
COCP/Mirena
What is the definitive management of Adenomyosis?
Hysterectomy
Endometrial Cancer is the most common gynaecological cancer of the developed world. Describe the pathophysiology
Most commonly adenocarcinoma
Often preceded by Endometrial Hyperplasia
Give four risk factors for Endometrial Cancer
High Oestrogen Exposure
Age
Obesity
Genetic (Lynch)
Give three clinical features of Endometrial Cancer
Post Menopausal Bleeding (or intermenstrual if pre menopausal)
Abdominal pain
Weight Loss
Give three differentials for Endometrial Cancer
Vulval Atrophy
Cervical Cancer
Endometrial Hyperplasia
How is Endometrial Cancer investigated?
1) Transvaginal USS (of if high risk then skip to 2)
2) If thickness >4mm then referred for Hysteroscopy with Pipelle Biopsy
3) MRI/CT Staging if cancerous
Describe the FIGO staging of Endometrial Cancer
I- Confined to Uterine Body
II - May extend to cervix but not beyond uterus
III - Beyond Uterus but confined to Pelvis
IV - Bladder/Bowel/Distant Sites
How is Endometrial Hyperplasia managed?
With Progesterones such as Mirena
Any sign of atypical features then full hysterectomy and bilateral salpingo-oophorectomy
How is Stage 1 Endometrial Cancer managed?
Hysterectomy with Bilateral Oophorectomy
the most commons stage presentation and procedure
How is Stage 2 Endometrial Cancer managed?
Radical Hysterectomy (including parts of the vagina and lymph node dissection)
How is Stage 3 Endometrial Cancer managed?
Maximal Debulking
Chemoradiotherapy
How is Stage 4 Endometrial Cancer managed?
Maximal Debulking
Define Dysmenorrhoea
Pain associated with the onset of menstruation, can be Primary (no underlying pathology) or Secondary (underlying pathology)
Describe the proposed pathophysiology of Primary Dysmenorrhoea
When the corpus luteum regresses there is a drop in progesterone and rise in PG
PGs cause myometrial contractions and spiral artery vasospasm
An exaggerated response of the above is thought to be the cause of the pain
Give four clinical features of Dysmenorrhoea
Crampy abdominal pain
Radiating down anterior thighs
Lasting 48-72 hours
Dizziness and Nausea
Give three causes of Secondary Dysmenorrhoea
Adenomyosis
Endometriosis
Adhesions (PID)
How can a Primary Dysmenorrhoea be distinguished from Secondary?
- Onset of secondary is normally a few days before starting period
- Secondary typically starts many years after initial menarche
How would you manage Dysmenorrhoea non pharmacologically?
TENS
Local application of heat
How could you manage Dysmenorrhoea pharmacologically?
1) Mefanamic Acid (NSAID - PG antagonist - in theory reduces the physiological effects)
2) COCP
What is Mittleshmerz?
Unilateral ovarian pain associated with ovulation, on around day 14 of cycle
Define Primary Amenorrhoea
- Failed to start periods by age of 16 but has secondary sexual characteristics
- Failed to start periods by age of 14 but has no secondary sexual characteristics
Define Secondary Amenorrhoea
Cessation of periods for>6m when previously started (pregnancy excluded)
Give two Hypothalamic causes of Amenorrhoea
Eating disorders
Chronic illness
Give four pituitary causes of Amenorrhoea
Sheehans Syndrome
Hyperprolactinaemia
Depot - Provera
Radiation
Give an adrenal cause of Amenorrhoea
Late/Mild Congenital Adrenal Hyperplasia
Give three Ovarian causes of Amenorrhoea
PCOS
Turners Syndrome
Primary Ovarian Failure
Give three genital causes of Amenorrhoea
Imperforate Hymen
Ashermans Syndrome
MRKH
Define Oligomenorrhoea
Less than 9 periods a year, or >35d between periods
Give three causes of Oligomenorrhoea
Thyroid disease
PCOS
Medications (including anti epileptics)
Name 5 bloods you would do for Amenorrhoea/Oligomenorrhoea
FSH/LH Oestrogen/Progesterone/Testosterone Thyroid Function Prolactin Hydroxylase enzymes (CAH)
Other than bloods, name three investigations you would do for Oligo/Anovulation
Pregnancy Test!
Swabs/Smear
Transvaginal USS
What is the Progesterone challenge test in Oligo/Anovulation
Giving 5-10d Progesterone to aim to induce a withdrawal bleed
Bleed - the problem was with ovulation (PCOS, Thyroid)
No bleed - the problem is with lack of oestrogen priming OR structural issue (imperforate hymen, hypopituitarism, hyperprolactinaemia)
How would you manage Oligo/Anovulation?
COCP/POP
How to Thyroid Abnormalities affect menstruation?
Hypothyroidism - by feedback increases TRH, which also acts to increase prolactin (inhibiting FSH and LH)
\it also reduces SHBG - increasing free circulating oestrogen and therefore causes menorrhagia
Define Menorrhagia
Excess menstrual loss at a level enough to affect woman’s QoL
Give four structural causes of Menorrhagia
PALM
Polyps
Adenomyosis
Leiomyoma (Fibroid)
Malignancy
Give 5 non structural causes of Menorrhagia
COEIN
Coagulopathies Ovarian Pathology Endometrial Pathology Iatrogenic Not Specified
Give 2 associated symptoms with Menorrhagia
Dizziness
Fatigue
How is Menorrhagia investigated?
Bloods (FBC, Clotting, TFTs, Hormones)
Pregnancy Test!
Transvaginal USS
Swabs and smear where relevant
How is Menorrhagia managed medically?
1) IUS (Mirena)
2) Tranexamic Acid or COCP
3) POP
How is Menorrhagia managed surgically?
Endometrial Ablation
Hysterectomy (subtotal or total)
Give 5 causes of Post Coital Bleeding
Vaginal Atrophy STIs Polyps Cervical Ectropian Cervical Cancer
Give 5 causes of Intermenstrual Bleeding
Tamoxifen STIs Pregnancy related Missed Pill Perimenopause
Give 5 causes of Post Menopausal Bleeding
Endometrial Hyperplasia Endometrial Cancer HRT Vaginal Atrophy Cervical cancer
Who should be on 2WW for Post Menopausal Bleeding?
Anyone over 55
For Transvaginal USS
How would you manage PMB?
Treat underlying cause
Vaginal Atrophy - Topical Oestrogen, Lubrication, HRT
Endometrial Hyperplasia - Dilation and Curettage to remove excess tissue
How would you investigate PCB?
Full Menstrual and Gynae History
PV Exam and Swabs
Pregnancy Test
Transvaginal USS
When should you refer a patient with PCB?
Abnormal Cervix with Cancer Suspicion
Cervical Polyp that is not easily removed
Pelvic Mass/USS abnormality
Those at high risk of endometrial cancer
Give 5 causes of Chronic Pelvic Pain
Endometriosis Adenomyosis Adhesions IBS Interstitial Cystitis MSK/nerve
How is Chronic Pelvic Pain investigated?
STI screen
Transvaginal USS
Laparoscopy
