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Gynae > Uterus > Flashcards

Uterus Flashcards

1
Q

What are the ligaments of the uterus?

A

Pubocervical, transverse, uterosacral ligaments (superior to anterior).
Round/broad/ovarian.

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2
Q

Describe the blood supply of the uterus:

A

Uterine arteries - supply myometrium + endometrium

Ovarian arteries - anastomose inferiorly with the uterine arteries to supply fundus of uteter as well

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3
Q

Where is the lymph drainage of the uterus/ovaries?

A

Internal and external ilian nodes.

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4
Q

Where is the symphathetic and parasympathetic nerve supply of the uterus?

A

Sympathetic (T12-L2) -> contraction and vasoconstriction

Parasympathetic (S2-4) -> Inhibit muscle spasp and cause vasodilation

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5
Q

What are the arteries which supply the proliferated endometrium called?

A

Spiral arterioles (shed each month)

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6
Q

What are leiomyomas?

A

Fibroids. Smooth muscle (myometrium) benign tumour

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7
Q

List 3 risk factors for fibroids:

A
  • Black & asian
  • Obese
  • Higher amount of oestrogen exposure (e.g. early menarche, late menopause) parity and COCs are protective factors.
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8
Q

Where do fibroids form?

A
  • Submucosal (intrauterine polyps)

- Intramural or subserosal (polyps on the outside, pushing in)

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9
Q

What do fibroids look like in cross section?

A

Whirled appearance

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10
Q

When and why can fibroids regress?

A

Can regress during pregnancy and after menopause as they are oestrogen-dependent.

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11
Q

On examination what would feel?

A

Solid mass palpable on pelvic examination

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12
Q

What are the main features of fibroids (symptoms)?

A
  • Asymptomatic (50%)
  • Heavy menstrual bleeding (HMB) (30%)
  • IMB (especially if submucosal
    pressure effects: on bladder, on ureter (hydronephrosis), sub-fertility
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13
Q

Identify 4 areas in which complication can develop in fibroids:

A

1) Enlargement - slow, stops at menopause unless HRT, pedunculated can undergo torsion -> pain.
2) Degeneration - red degeneration: decreased blood supply; haemorrhage + necrosis (usually in pregnancy)
3) Malignancy - uncommon but: pain + rapid growth + PMH + poor response to GnRH-agonist -> leiomyosarcoma
4) Pregnancy - premature labour, malpresentation, transverse lie, obstructed labour, postpartum haemorrhage

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14
Q

List 3 investigations which can be performed to assess someone with suspected fibroids:

A

1) USS - initial screening (size, number, position on fibroids)
2) MRI - greater accuracy. Can differentiate between fibroids and adenomyosis (endometrium in myometrium)
3) Hysteroscopy - used to assess distortion of uterine cavity (fertility Ix).

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15
Q

When would you treat fibroids?

A

Only if symptomatic or fertility problems

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16
Q

Outline medical treatment of fibroids:

A
  • GnRH-agonist +/- HRT (overstilulation & subsequent decrease in GnRH-receptors= temporary amenorrhoea + fibroid shrinkage. Restricted to 6months Rx due to decrease in bone density)
  • Ulipristal acetate (selective progesterone receptor modulator): decrease in HMB, shrink fibroids, reversible amenorrhoea -> there is no bone density loss
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17
Q

What common treatment is ineffective in the treatment of fibroids?

A

Transexamic acid and NSAIDs no goof for HMB in fibroids.

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18
Q

Outline the surgical Rx for fibroids:

A
  • Smaller polyp & submucosal fibroids -> Trans-cervical resaection of fibroid (TCRF) at hysteroscopy
  • Larger fibroids -> myomectomy (preceded with 2-3months Rx with GnRH-a)
  • For women with complete families - radical hysterectomy
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19
Q

What is Adenomyosis?

A

Endometrium within myometrium (Endometriosis interna)

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20
Q

Who is typically affected by adenomyosis and when does it typically get better?

A

Women >40, associated with endometriosis and fibroids, gets better after menopause.

21
Q

What are the features of adenomyosis (including O/E)?

A
  • Asymptomatic
  • HMB, dysmenorrhoea (menstruation regular however)
  • O/E: Uterus tender and mildly enlarged
22
Q

What investigation confirms adenomyosis?

A

MRI - Pockets of blood seen

USS can provide suspected adenomyosis but MRI confirms

23
Q

What is the treatment for Adenomyosis?

A
  • Progesterone IUS/COCs - can be used to help control HMB and dysmenorrhoea
  • Hysterectomy - usually needed
24
Q

What are endometritis, intrauterine polyps, haematometra and congenital uterine malformations examples of?

A

Benign uterine pathologies

25
Q

What is endometritis? List 3 causes

A

Infection or inflammation of the endometrium. Causes:

  • 2ndry to STIs
  • Surgical complications (C-section/termination)
  • Foreign tissue (IUD, retained products of contraception)
26
Q

List 3 features of endometritis:

A
  • tenderness
  • systemic infection
  • pyometra (infection of uterus)
27
Q

Rx for endometritis:

A

Abx +/- ERPC (Evacuation of Retained Products of Contraception)

28
Q

What is the difference between endometriOSIS and endometITIS?

A
  • Endometritis is inflammation or infection of the endometrium
  • Endometriosis is oestrogen-dependent growth of endometrium in extra-uterine locations (usually in pelvic cavity i.e. ovaries, pouch of douglas, uterosacral ligaments)
29
Q

From where do most intruterine polyps originate?

A

Endometrium. Others usually = myometrial (submucosal fibroids)

30
Q

What does Tamoxifen do and when is it used?

A

Anti-oestrogen medication - induced gonadotrophin release by occupying oestrogen receptors in the hypothalamus, thereby interfering with feedback mechanisms.

Used in Oestrogen receptor positive breast cancer (ER+).

31
Q

What are intrauterine polyps categorised as if they present before menopause?

A

Oestrogen-dependent (unless patient is on Tamoxifen)

32
Q

What are the features of intrauterine polyps and what Ix & Rx can be done?

A 
Features:
- Asymptomatic
- OR, HMB & IMB
Ix - 
- USS or hysteroscopy
Rx - 
- Resection with cutting diathermy
33
Q

What is haematometra?

A

Collection/retention of blood in the uterus.

34
Q

List 3 common causes of haematometra:

A
  • Imperforated hymen -> primary amenorrhoea
  • transverse vaginal septum
  • Acquired cervical stenosis (fibrosis, post-cone biopsy, carcinoma)
35
Q

What is a common congenital uterine malformation and what is it typically associated with?

A

Faulty fusion of Mullerian ducts at 9th week. (total failure = 2 of everything. If one duct develops better= rudimentary horn). Associated with renal anomalies -> Renal USS screen

36
Q

In terms of pregnancy, what is Faulty fusion of Mullerian duct associated with?

A
  • Malpresentation
  • Preterm labour
  • Transverse lie
  • Miscarriage
37
Q

What are the 3 most common gynaecological cancers in order?

A

1) Endometrial Carcinoma
2) Ovarian
3) Cervical

38
Q

When does endometrial carcinoma typically present?

A
  • 85% postmenopausal
  • Peak at 60years
  • Usually presents early
39
Q

Describe the pathology of endometrial carcinoma:

A

Subtypes:

  • Type 1: low-grade (oestrogen sensitive, majority of cases, related to obesity)
  • Type 2: High-grade (clear cell carcino-sarcoma, more aggressive, not (E) sensitive)

Spread:

  • Direct - myometrium,cervix, upper vagina
  • Lymphatic - pelvic LN, para-aortic LN
40
Q

What is Lynch syndrome type II?

A

(also known as HNPCC: Hereditary non-polyposis colorectal cancer):

  • Colon cancer
  • Ovarian cancer
  • endometrial cancer
41
Q

List 3 risk factors for endometrial cancer:

A
  • ^Exposure to oestrogens (endogenous and exogenous [unopposed HRT, Tamoxifen])
  • Diabetes (obesity)
  • Lynch syndrome type II
42
Q

List 2 protective factors against endometrial cancer:

A
  • Pregnancy
  • COC
    (anything which reduced oestrogen exposure)
43
Q

List 2 features of endometrial cancer:

A
  • PMB (post-menopausal bleeding) - 10% risk of cancer, most common presentation
  • IMB or new-onset-HMB in premenopausal patients
44
Q

What is the staging criteria called for endometrial cancer and what is the overall 5-yr-survival rates?

A

FIGO staging.

75%

45
Q

Outline the stages of endometrial cancer and the relative 5yr survival at each stage:

A

Stage 1 - confined to uterus (90%)
Stage 2 - Confined to uterus and cervix (75%)
Stage 3 - Tumour invades through uterus (60%)
Stage 4 - further spread (25%)

46
Q

What Ix can be performed for endometrial carcinoma? Which is diagnostic?

A
  • USS
  • Endometrial biopsy with pipelle (DIAGNOSTIC)
  • MRI: can assess the degree of myometrial invasion
47
Q

What is the Rx for endometrial carcinoma?

A

Total laparoscopic hysterectomy + BSO (bilateral salpingo-oophorectomy).

Additional external beam radiotherapy for high-risk patients -> reduced risk of LN spread (stage 2 or higher)

48
Q

What are uterine sarcomas ? What is the overall survival at 5years?

A

Rare tumours of myometrium: malignant fibroids (leiomyosarcomas)

Rapid and painful fibroid enlargement.

30%

Gynae (8 decks)

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