Uterus Flashcards
What are the ligaments of the uterus?
Pubocervical, transverse, uterosacral ligaments (superior to anterior).
Round/broad/ovarian.
Describe the blood supply of the uterus:
Uterine arteries - supply myometrium + endometrium
Ovarian arteries - anastomose inferiorly with the uterine arteries to supply fundus of uteter as well
Where is the lymph drainage of the uterus/ovaries?
Internal and external ilian nodes.
Where is the symphathetic and parasympathetic nerve supply of the uterus?
Sympathetic (T12-L2) -> contraction and vasoconstriction
Parasympathetic (S2-4) -> Inhibit muscle spasp and cause vasodilation
What are the arteries which supply the proliferated endometrium called?
Spiral arterioles (shed each month)
What are leiomyomas?
Fibroids. Smooth muscle (myometrium) benign tumour
List 3 risk factors for fibroids:
- Black & asian
- Obese
- Higher amount of oestrogen exposure (e.g. early menarche, late menopause) parity and COCs are protective factors.
Where do fibroids form?
- Submucosal (intrauterine polyps)
- Intramural or subserosal (polyps on the outside, pushing in)
What do fibroids look like in cross section?
Whirled appearance
When and why can fibroids regress?
Can regress during pregnancy and after menopause as they are oestrogen-dependent.
On examination what would feel?
Solid mass palpable on pelvic examination
What are the main features of fibroids (symptoms)?
- Asymptomatic (50%)
- Heavy menstrual bleeding (HMB) (30%)
- IMB (especially if submucosal
pressure effects: on bladder, on ureter (hydronephrosis), sub-fertility
Identify 4 areas in which complication can develop in fibroids:
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
List 3 investigations which can be performed to assess someone with suspected fibroids:
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).
When would you treat fibroids?
Only if symptomatic or fertility problems
Outline medical treatment of fibroids:
- 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
What common treatment is ineffective in the treatment of fibroids?
Transexamic acid and NSAIDs no goof for HMB in fibroids.
Outline the surgical Rx for fibroids:
- 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
What is Adenomyosis?
Endometrium within myometrium (Endometriosis interna)
Who is typically affected by adenomyosis and when does it typically get better?
Women >40, associated with endometriosis and fibroids, gets better after menopause.
What are the features of adenomyosis (including O/E)?
- Asymptomatic
- HMB, dysmenorrhoea (menstruation regular however)
- O/E: Uterus tender and mildly enlarged
What investigation confirms adenomyosis?
MRI - Pockets of blood seen
USS can provide suspected adenomyosis but MRI confirms
What is the treatment for Adenomyosis?
- Progesterone IUS/COCs - can be used to help control HMB and dysmenorrhoea
- Hysterectomy - usually needed
What are endometritis, intrauterine polyps, haematometra and congenital uterine malformations examples of?
Benign uterine pathologies
What is endometritis? List 3 causes
Infection or inflammation of the endometrium. Causes:
- 2ndry to STIs
- Surgical complications (C-section/termination)
- Foreign tissue (IUD, retained products of contraception)
List 3 features of endometritis:
- tenderness
- systemic infection
- pyometra (infection of uterus)
Rx for endometritis:
Abx +/- ERPC (Evacuation of Retained Products of Contraception)
What is the difference between endometriOSIS and endometITIS?
- 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)
From where do most intruterine polyps originate?
Endometrium. Others usually = myometrial (submucosal fibroids)
What does Tamoxifen do and when is it used?
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+).
What are intrauterine polyps categorised as if they present before menopause?
Oestrogen-dependent (unless patient is on Tamoxifen)
What are the features of intrauterine polyps and what Ix & Rx can be done?
Features: - Asymptomatic - OR, HMB & IMB Ix - - USS or hysteroscopy Rx - - Resection with cutting diathermy
What is haematometra?
Collection/retention of blood in the uterus.
List 3 common causes of haematometra:
- Imperforated hymen -> primary amenorrhoea
- transverse vaginal septum
- Acquired cervical stenosis (fibrosis, post-cone biopsy, carcinoma)
What is a common congenital uterine malformation and what is it typically associated with?
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
In terms of pregnancy, what is Faulty fusion of Mullerian duct associated with?
- Malpresentation
- Preterm labour
- Transverse lie
- Miscarriage
What are the 3 most common gynaecological cancers in order?
1) Endometrial Carcinoma
2) Ovarian
3) Cervical
When does endometrial carcinoma typically present?
- 85% postmenopausal
- Peak at 60years
- Usually presents early
Describe the pathology of endometrial carcinoma:
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
What is Lynch syndrome type II?
(also known as HNPCC: Hereditary non-polyposis colorectal cancer):
- Colon cancer
- Ovarian cancer
- endometrial cancer
List 3 risk factors for endometrial cancer:
- ^Exposure to oestrogens (endogenous and exogenous [unopposed HRT, Tamoxifen])
- Diabetes (obesity)
- Lynch syndrome type II
List 2 protective factors against endometrial cancer:
- Pregnancy
- COC
(anything which reduced oestrogen exposure)
List 2 features of endometrial cancer:
- PMB (post-menopausal bleeding) - 10% risk of cancer, most common presentation
- IMB or new-onset-HMB in premenopausal patients
What is the staging criteria called for endometrial cancer and what is the overall 5-yr-survival rates?
FIGO staging.
75%
Outline the stages of endometrial cancer and the relative 5yr survival at each stage:
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%)
What Ix can be performed for endometrial carcinoma? Which is diagnostic?
- USS
- Endometrial biopsy with pipelle (DIAGNOSTIC)
- MRI: can assess the degree of myometrial invasion
What is the Rx for endometrial carcinoma?
Total laparoscopic hysterectomy + BSO (bilateral salpingo-oophorectomy).
Additional external beam radiotherapy for high-risk patients -> reduced risk of LN spread (stage 2 or higher)
What are uterine sarcomas ? What is the overall survival at 5years?
Rare tumours of myometrium: malignant fibroids (leiomyosarcomas)
Rapid and painful fibroid enlargement.
30%
