Uterus Flashcards
What is the blood supply to the uterus?
Common iliac birfucates near the sacroiliac joint at L5/S1- the anterior branch supples the organs/viscera of the pelvis, whilst the posterior branch supplies muscles and nerves, they all have corresponding drainage o I: iliolumbar o Love: lacteral sacral o Going: gluteal – superior & inferior o Places: pudendal o In: inferior vesicle/uterine o My: middle rectal o Very: vaginal/prostatic o Own: obturator o Underwear: umbilical uterine artery forms rich anastomoses with ovarian artery, which comes off the aorta at L2- uterine artery travels over ureter ‘bridge over water’
What is the nerve supply to the uterus?
o Sympathetic: T12-l2- SHP via R&L hypogastric nerve
o Parasympathetic: S2-4 splanchnic nerve & visceral afferent
o Somatic: pudendal & distal 1/5 of vagina
What are fibroids?
leiomyomata- are benign tumours of the myometrium
Present in 25% of women
More common before menopause, Afro-caribbean and FH
Less common in parous women or those on COC or depo
• Size varies from mm to filling the abdomen, can be intramural, sub-erosal or submucosal, submucosal occasionally form intracavity polyps, smooth muscle and fibrous elements are always present
What are the symptoms associated with fibroids?
50% are asymptomatic
o Menstrual problems- menorrhagia (30%) and intermenstrual bleeding (submucosal)
o Pain- dysmenorrhoea, but seldom cause pain unless torsion, red degeneration or sarcomatous change occur
o Bladder- if pressing on bladder may cause frequency, urinary retention, hydronephrosis (ureters)
o Fertility- block the tubules or prevent implantation or unclear mechanism
• A solid mass may be palpable on examination- will arise from the pelvis and be continuous with the uterus, small fibroids cause irregular ‘knobbly’ enlargement of the uterus
What are the complications of fibroids?
o Enlargement- very slow, may stop growing & calcify after menopause. HRT may restimualte them again, enlarged in mid-pregnancy
o Degeneration- due to inadequate blood supply- red degeneration characterised by pain and uterine tenderness- hyaline/cystic degeneration leads to soft & liquefied fibroid
o Malignancy- 0.1% of fibroids are leimyosarcomata, may be result on malignant change or de novo
malignant transformation of normal smooth muscle
What are the complications of fibroids in pregnancy?
red degeneration is common in pregnancy and cause severe pain
pedunculated fibroids may tort postpartum
o Premature labour
o Malpresentations
o Transverse lie
o Obstructed labour
o Postpartum haemorrhage
How are fibroids diagnosed?
• Ultrasound is helpful in diagnosis, but MRI or laparoscopy may be required to distinguish from ovarian mass or adenomyosis- hysteroscopy or hysterosalpinogram (HSG) is used to assess distortion of the uterine cavity, particularly in fertility issues
What is the medical management for fibroids?
tranexamic acid, NSAIDs & progestogens may be ineffective when menorrhagia is also present, but worth trying as 1st line
GnRH cause temporary shrinkage and amenorrhoea, but can only be used for 6 months due to side effects (used pre-surgery) – may be given with HRT to allow longer use
surgery is used to manage women who want to conceive as hormone treatments can prevent ovulation
What is the surgical management for fibroids?
o Hysteroscopy- fibroid polyp or small submucosal fibroid (3-4mm), pretreatment with GnRH to shrink, reduce vascularity and thin endometrium
o Hysterectomy- scopically, vagianlly or abdominally
o Myomectomy- open or laproscopically, used in medical treatment failed, but preservation of reproductive function is required
o Embolisation- uterine artery embolization by radiologists, hospital stay is shorter, but pain may be higher requiring readmission
• NB – if open procedure is used to remove fibroids, then children must be delivered by C-section in the future to prevent uterine rupture
What is adenomyosis?
• Adenomyosis (endometriosis interna) is the presence of endometrium and its underlying stroma within the myometrium
most common around 40y/o- associated with endometriosis and fibroids
Oestrogen dependent
• Symptoms may be absent, but painful, regular, heavy menstruation is common- examination may show a mildly enlarged and tender uterus
• Adenomyosis is not easily diagnosed by US- but can be seen on MRI
What is the treatment for adenomyosis?
progesterone IUS or COCP +/- NSAIDs to control menorrhagia and dysmenorrhoea, but hysterectomy is often required
What os endometriosis?
- Often secondary to STI, a complication of surgery (C-section or intrauterine procedure) or because of foreign tissue (IUDs or retained products of conception)
- Infection in the post-menopausal uterus is commonly due to malignancy, the uterus is tender and pelvic/systemic infection may be evident
- Pyometra- when pus accumulates and is unable to escape
- Antibiotics and occasionally ERPC are required
What are intrauterine polyps?
Small, usually benign tumour that grow in the uterine cavity, most are endometrial in origin, but can be derived from submucosal fibroids- occasionally contain endometrial hyperplasia or carcinoma
• Common in women aged 40-50yrs and when oestrogen levels are high, but may be found in post- menopausal women on tamoxifen for breast cancer
• Sometimes asymptomatic, but often causes menorrhagia and intermenstrual bleeding, very occasionally prolapse
• Diagnosed using US or when a hysteroscopy is performed because of abnormal bleeding- resection of polyp with cutting diathermy or avulsion normally cures bleeding problems
What is a haematometroa?
• Accumulation of menstrual blood in the uterus due to outflow obstruction- cervical canal may be occluded by fibrosis or congenital abnormalitiy
What are congenital uterine malformations?
• Abnormalities result from differing degrees of failure of fusion of the two Muellerian ducts at 9 weeks-
these are common, but rarely clinical relevant
• 25% cause pregnancy related problems that lead to their discovery-including
o Malpresentations or transverse lie
o Premature labour
o Recurrent miscarriage (<5%)
o Retained placenta
• Women with a congenital uterine anomaly have an increased incidence of renal anomalies and should undergo renal tract imaging
