Uterine physiology and abnormalities

Question 1

What are fibroids? How common are they?

Answer 1

Benign tumours of the myometrium - leiomyomata.

25% of women affected.

Question 2

What are the three types of fibroid (i.e. sites)?

Answer 2

Submucosal, intramural, subserosal.

Submucosal and subserosal can form polyps (inside / outside the uterus respectively)

Question 3

What fibroids to grow?

Answer 3

Growth is oestrogen (and progesterone) dependent.

Question 4

How do fibroids present?

Answer 4

Asymptomatic - 50%

Menorrhagia - 30%

Irregular bleeding if submucosal / polypoid.

Pain - rare unless torted / sarcomatous change.

Pressure symptoms - frequency, retention, hydronephrosis

Question 5

What would you find on examination of a fibroid PT?

Answer 5

Solid, palpable mass on pelvic / abdo exam.

Arises from the pelvis and is continuous with the uterus.

Question 6

What are the complications of fibroids?

Answer 6

Degeneration of fibroids due to inadequate blood supply - red (painful, necrotic), hyaline (soft), cystic (soft) or calcification (postmenopausal, asymptomatic).

Malignancy in 0.1% (leiomyosarcoma).

Torsion of pedunculated fibroid.

Question 7

What are the complications of fibroids in pregnancy?

Answer 7

Premature labour, malpresentation, transverse lie, obstructed labour, PPH, red degeneration.

Question 8

How would you investigate fibroids?

Answer 8

USS! MRI if needed to differentiate from adenomyosis / ovarian mass.

Hysteroscopy to establish distortion or the uterus.

If fertility an issue - hysterosalpingogram.

Hb - can be low due to menorrhagia, or high due to fibroids secreting EPO.

Question 9

How would you medically treat fibroids?

Answer 9

Asymptomatic small fibroids - no treatment needed.

Asymptomatic larger fibroids - monitor for growth.

If menorrhagia - tranexamic acid, mefanamic acid and progestogens may / not help. GnRH analogues cause temporary amenorrhoea and fibroid shrinkage, but can only be used for 6m. You can add back in HRT with little fibroid growth for longer term control.

Question 10

How would you surgically treat fibroids?

Answer 10

Hysteroscopy and resection for polyps or small submucosal (<3cm) after GnRH treatment to shrink and devascularise.

Myomectomy if fertility required. Preceded by GnRH treatment.

Hysterectomy with GnRH pretreatment.

Other: Uterine artery embolisation has an 80% success rate, but more complications.

Question 11

What is adenomyosis?

Answer 11

Presence of endometrial tissue within the myometrium. It is associated with fibroids and endometriosis.

Question 12

What are the clinical features of adenomyosis?

Answer 12

Painful, heavy, regular menses.

O/E mildly enlarged tender uterus.

Question 13

How would you investigate adenomyosis?

Answer 13

MRI, because USS isn’t great.

Question 14

How would you treat adenomyosis?

Answer 14

IUS.

COCP +- NSAIDs.

Hysterectomy may be required.

Question 15

How would you treat a benign intrauterine polyp?

Answer 15

Resection with diathermy or avulsion.

Question 16

What is the most common type of endometrial carcinoma?

Answer 16

Adenocarcinoma of the endometrial glands - >90%.

Then adensquamous carcinoma.

Question 17

What is the main risk for endometrial carcinoma?

Answer 17

Oestrogen unnoposed by progesterone. This occurs due to excess production or iatrogenically.

Endogenous causes: obesity, PCOS (prolonged amenorrhoea), nulliparity, late menopause, oestrogen secreting tumours.

Iatrogenic: Tamoxifen.

Question 18

What are cystic hyperplasia and atypical hyperplasia?

Answer 18

Endometrial pre-malignant states.

Question 19

What are the clinical features of endometrial carcinoma?

Answer 19

Postmenopausal bleeding is the most common.

Pre-menopausal PTs may have irregular bleeding or rarely menorrhagia.

O/E - the pelvis often appears normal.

Question 20

How would you investigate ?endometrial carcinoma?

Answer 20

USS. Sometimes MRI.

Endometrial biopsy.

CXR to exclude pulmonary spread.

Question 21

How would you treat endometrial carcinoma?

Answer 21

Surgery! 75% have BSO.

Radiotherapy follow up in high risk PTs.

Question 22

What are the three categories of uterine sarcoma?

Answer 22

Leiomyosarcoma (uterine fibroids).

Endometrial stromal tumours (occur below the endometrium, commonest perimenopause).

Mixed mullerian tumours (commoner in old age).

Question 23

How do uterine sarcomas present?

Answer 23

Irregular / post-menopausal bleeding.

Or, rapid, painful enlargement of a fibroid.

Question 24

How do you treat uterine sarcomas?

Answer 24

Hysterectomy! +- radio and chemo.

Survival 30% at 5y.