Uterine Pathology

Question 1

What is endometritis?

Answer 1

Inflammation of the endometrium

Question 2

What is the most common cause of endometritis?

Answer 2

Childbirth

Question 3

What is the aetiology of acute endometritis?

Answer 3

Usually bacterial

More common in caesarian section

Question 4

What does chronic endometritis cause?

Answer 4

Pelvic inflammatory disease

Question 5

What organisms can cause endometritis?

Answer 5

Neisseria gonorrhoea
Chlamydia
TB
CMV 
Anaerobes (clostridium)
Aerobic (strep, enterococci, staph, klebsiella, proteus, e coli)

Question 6

What are the causes of endometritis?

Answer 6

Post-partum
Post-abortion
Post-curretage
Intrauterine contraceptives
Granulomatous disease (sarcoidosis, foreign body post-ablation)
Leiomyomata or polyps

Question 7

What are risk factors for endometritis?

Answer 7

Caesarian section
Prolonged labour
Retained products of conception
Chorioamnionitis
Low socioeconomic status
Multiple cervical examinations
Young maternal age
Meconium stained amniotic fluid

Question 8

What are the symptoms of endometritis?

Answer 8

Lower abdomen pain
Fever
Abnormal discharge - foul smelling and purulent
Abnormal bleeding

Question 9

What are signs of endometritis?

Answer 9

Increased temperature
Tachycardia
Hypogastric tenderness
Signs of sepsis

Question 10

What is seen on histology in endometritis?

Answer 10

Abnormal pattern of inflammatory cells and plasma cells

Question 11

What is seen in blood tests in endometritis?

Answer 11

Leucocytosis

Question 12

What is the treatment for endometritis?

Answer 12

Broad spectrum antibiotics - co-amoxiclav and metronidazole for 7 days
Co-trimoxazole and metronidazole if pen allergic)

Question 13

What are the complications of endometritis?

Answer 13

Sepsis

Placenta praevia

Question 14

What are uterine polyps?

Answer 14

Benign growth of the endocevix

Question 15

Do uterine polyps have a risk of malignancy?

Answer 15

Yes - rarely

Question 16

What are risk factors for uterine polyps?

Answer 16

Increasing age
Hypertension
Obesity
Tamoxifen use

Question 17

What are symptoms of uterine polyps?

Answer 17

Abnormal uterine bleeding (intermenstrual, post-coital, post-menopausal)
Discharge - watery, non-smelly, non-itchy
Can be asymptomatic

Question 18

What investigations are done in uterine polyps, and what do they show?

Answer 18

Transvaginal USS - hyperechoic lesion, sometimes cystic spaces within
Colour doppler - may delineate the feeding vessel
Hysteroscopy and biopsy - diagnostic and can treat

Question 19

What is the management for uterine polyps?

Answer 19

Hysteroscopic polypectomy

Question 20

What is endometrial hyperplasia?

Answer 20

Proliferation of the endometrial layer of the uterus

Precursor for endometrial cancer

Question 21

What are risk factors for endometrial hyperplasia?

Answer 21

Increased oestrogen

• PCOS
• obesity
• oestrogen-only HRT
• tamoxifen

Question 22

What are the types of endometrial hyperplasia, and their chance of progression of cancer?

Answer 22

Simple - 0% risk of cancer
Complex - 1-2% risk of cancer
Atypical - 10-20% risk of cancer

Question 23

What are the symptoms of endometrial hyperplasia?

Answer 23

Abnormal bleeding (especially post-menopausal)

Question 24

What investigations are done for endometrial hyperplasia?

Answer 24

PV and speculum examination
TVUS
Hysterocopy and biopsy

Question 25

What does TVUS allow you to assess?

Answer 25

Endometrial thickness

Question 26

What size of endometrial thickness is suspicious in endometrial hyperplasia?

Answer 26

>4mm in post-menopausal women | >16mm in pre-menopausal women

Question 27

What is the management of endometrial hyperplasia if atypia are seen on hysteroscopy and biopsy?

Answer 27

Hysterectomy

Question 28

What is the management of endometrial hyperplasia if simple hyperplasia is seen on hysteroscopy and biopsy?

Answer 28

``` Monitor Mirena coil Progestin therapy Repeat sampling in 3/4 months Decrease oestrogen exposure ```

Question 29

What are the 2 types of endometrial cancer?

Answer 29

Endometroid (type 1) | Serous (type 2)

Question 30

What is the difference between the 2 types fo endometrial cancer?

Answer 30

``` Endometroid (type 1) - precursor is atypical endometrial hyperplasia - oestrogen driven - good prognosis - more common Serous (type 2) - atypical endometrial hyperplasia is not precursor - not oestrogen driven - worse prognosis - TP53 mutation ```

Question 31

What is the spread of serous endometrial carcinoma, and what implication does this have?

Answer 31

Spreads along fallopian tube mucosa and peritoneal surfaces | - Can present with extrauterine disease

Question 32

What are the risk factors for endometrial carcinoma?

Answer 32

``` Unopposed oestrogen or oestrogen excess - obesity - nulliparity - early menarche/late menopause - tamoxifen - PCOS - Lynch syndrome Increasing age (50-60) ```

Question 33

When should you consider Lynch syndrome?

Answer 33

Family history of endometrial or colorectal cancer, particularly when this ahs happened at a young age

Question 34

What factor is protective for endometrial carcinoma?

Answer 34

COCP

Question 35

What is the staging of endometrial carcinoma?

Answer 35

Stage 1 - confine two uterus Stage 2 - cervical involvement Stage 3 - ovaries/tubes involved Stage 4 - other organs involved

Question 36

What is the spread of endometrial carcinoma?

Answer 36

Direct into myometrium and cervix Lymphatic Haematogenous

Question 37

What are the symptoms of endometrial carcinoma?

Answer 37

Post-menopausal bleeding Late features - pain - discharge

Question 38

What is the examination finding in endometrial carcinoma?

Answer 38

Large uterus

Question 39

What investigations are done in endometrial carcinoma?

Answer 39

Transvaginal ultrasound scan Hysteroscopy and endometrial biopsy CT for mets and staging

Question 40

What is the treatment for endometrial carcinoma?

Answer 40

Hysterectomy and bilateral salpingo-oophorectomy | +/- radio/chemotherapy

Question 41

What is the other name for fibroids?

Answer 41

Leiomyoma

Question 42

What are fibroids?

Answer 42

Benign smooth muscle tumour in the myometrium of the uterus

Question 43

What stimulates the growth of fibroids?

Answer 43

Oestrogen

Question 44

What are the complications of fibroids?

Answer 44

Torsion of pedunculate fibroid | Red degeneration

Question 45

What is red degeneration?

Answer 45

Haemorrhagic infarction of fibroids causing ischaemia and necrosis

Question 46

What causes red degeneration?

Answer 46

Fibroid growth increases in the 3rd trimester, outgrowing its blood supply causing ischaemia The blood supply to the fibroid can be kinked due to increasing size of baby

Question 47

What factors predispose to red degeneration of fibroids?

Answer 47

Pregnancy COCP Atrophy after menopause

Question 48

How is red degeneration of fibroids managed?

Answer 48

Bed rest and analgesia | Resolves in 4-7 days

Question 49

Who are fibroids more common in?

Answer 49

Afro-Caribbean women Later reproductive years Rare before puberty

Question 50

What is the presentation of fibroids?

Answer 50

Menorrhagia Bulky uterus Subfertility Pain - lower abdominal cramping, often worse in menstruation Bloating, pressure symptoms on bowel, bladder May be asymptomatic

Question 51

What is the presentation of red degeneration of fibroids?

Answer 51

Low grade fever Abdo pain Vomiting

Question 52

What investigation is done for fibroids?

Answer 52

Transvaginal ultrasound

Question 53

What is the medical management for fibroids?

Answer 53

Mirena USS Tranexamic acid COCP GnRH agonists

Question 54

What are examples of GnRH agonists?

Answer 54

Goserelin | Leuprolide

Question 55

What effect do GnRH agonists have on fibroids, and when are they used?

Answer 55

May reduce size | Used for short-term management pre-op

Question 56

What is a complication of using GnRH agonists for fibroids?

Answer 56

Red degeneration

Question 57

What are the surgical options for fibroids?

Answer 57

Myomectomy Hysterectomy Hysteroscopic endometrial ablation

Question 58

When is a myomectomy done for fibroids?

Answer 58

If desire to conceive in the future

Question 59

What are the complications of surgical management of fibroids?

Answer 59

Myomectomy - adhesions, uterine perforation, bladder injury | Hysterectomy - urinary retenttion, enterocoele, vaginal vault prolapse

Question 60

What is adenomyosis?

Answer 60

Outpouches of endometrium growing into the myometrium

Question 61

What is the pathophysiology of adenomyositis?

Answer 61

Blood produced during the menstrual cycle saturates surrounding tissue causing swelling and intense pain

Question 62

Who most commonly present with adenomyositis?

Answer 62

Multiparous women | End of reproductive years

Question 63

What is the presentation of adenomyosis?

Answer 63

Enlarged, boggy and tender uterus Menorrhagia Dysmenorrhoea

Question 64

What is the diagnostic investigation for adenomyositis?

Answer 64

MRI

Question 65

What is the management of adenomyositis?

Answer 65

Mirena coil COCP GnRH agonists Hysterectomy (only curative option)