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Gynaecology > Uterus and its abnormalities > Flashcards

Uterus and its abnormalities Flashcards

1
Q

1st

A

1st

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2
Q

Where does lymph drainage of the uterus go to?

A

Internal and external iliac nodes

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3
Q

What happens to the endometrium in the first half of the menstrual cycle?

A

It proliferates, the glands elongate and it thickens - under the influence of oestrogen

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4
Q

What happens to the endometrium in the second half of the menstrual cycle?

A

The glands swell and blood supply increases - luteal/secretory phase - under influence of progesterone - then progesterone levels drop and secretory endometrium disintegrates

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5
Q

What are fibroids also known as?

A

Leiomyomata

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6
Q

What are fibroids?

A

Benign tumours of the myometrium (muscle of the uterus)

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7
Q

Incidence of fibroids?

A

At least 25% of women

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8
Q

Who are fibroids more common in? x3

A

Women near the menopause
In Afro-caribbean women
Those with family history

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9
Q

Who are fibroids less common in? x2

A

Parous women

Those who have taken COC or injectable progestogens

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10
Q

What different types of fibroids are there?

A

Intra-mural, subserosal (under external wall of uterus), submucosal (under internal wall of uterus)- submucosal can form intracavity polyps

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11
Q

What is the aetiology of fibroids?

A

Fibroid growth is oestrogen and probably progesterone dependent
During pregnancy, fibroids equally likely to grow, shrink or show no change
Fibroids regress after menopause because of reduction in circulating oestrogen

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12
Q

Symptoms of fibroids? x6

A

50% are asymptomatic
Menorrhagia - 30%
Dysmenorrhoea
Erratic bleeding (IMB)
Pressure effects - eg. pressing on bladder
Subfertility if tubal ostia are blocked or intramural can reduce fertility

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13
Q

Examination of fibroids

A

Solid mass may be palpable on pelvic or even abdominal examination
Multiple small fibroids can cause irregular knobbly enlargement of the uterus

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14
Q

What is degeneration of fibroid?

A

Normally the result of inadequate blood supply
‘Red degeneration’ is characterised by pain and uterine tenderness - haemorrhage and necrosis occur
Hyaline degeneration or cystic degeneration - fibroid is soft and partly liquefied

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15
Q

What % of fibroids are leiomyosarcomata? (malignant)

A

0.1% - may be as a result of malignant change or de novo malignant transformation of normal smooth muscle

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16
Q

What influence can fibroids have on pregnancy?x6

A 
Premature labour 
Malpresentations
Transverse lie
Obstructed labour 
PPH 
Red degeneration is common in pregnancy and can cause severe pain
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17
Q

What is the effect of HRT on fibroids?

A

Can cause continued fibroid growth

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18
Q

Investigations with fibroids

A

US
MRI or laparoscopy might be needed to distinguish fibroid from ovarian mass
Hb - anaemia due to bleeding or high as fibroids can secrete erythropoietin

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19
Q

When do no treatment for fibroids?

A

Asymptomatic if small or slow-growing then no treatment and no monitoring needed either as risk of malignancy is small
Larger need monitoring because remote possibility of malignancy

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20
Q

Medical treatment of fibroids

A

Tranxamic acid, NSAIDs or progestogens often ineffective for menorrhagia due to fibroids but worth trying first
GnRH agonists for 6 months or with “add-back” HRT to prevent side effects and bone density problems
Often used to shrink before surgery
GnRH agonists not good for trying to conceive because decreases ovulation
Also fibroids return to previous size after stopping GnRH

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21
Q

Surgical treatment of fibroids

A

Hysteroscopic surgery if less than 3cm
Myomectomy (open or laparoscopic)
Hysterectomy

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22
Q

Other treatment for fibroids

A

Uterine artery embolisation, 80% success rate

But readmission higher than myomectomy

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23
Q

What is adenomyosis?

A

Presence of endometrium and its underlying stroma within the myometrium

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24
Q

When is adenomyosis common, what other conditions is it associated with and prognosis?

A

Most common around age 40
Associated with endometriosis and fibroids
Symptoms subside after menopause (oestrogen dependent)

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25
Q

Clinical features of adenomyosis

A

Asymptomatic
Or painful, regular, heavy menstrual bleeding
Uterus is mildly enlarged and tender on examination

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26
Q

Investigation of adenomyosis

A

Not easily diagnosed by ultrasound but can be seen on MRI

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27
Q

Treatment of adenomyosis

A

IUS or COC without/with NSAIDs may control menorrhagia and dysmenorrhoea - but hysterectomy is often required

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28
Q

What is endometritis?

A

Infection confined to the cavity of the uterus alone

Spread to pelvis is common if untreated

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29
Q

Cause of endometritis?

A

Often secondary to sexually transmitted infections, as a complication of surgery (C-sections or intrauterine procedure) or foreign tissue (IUD or retained products of conception)

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30
Q

What is cause of endometritis in post-menopausal uterus commonly due to?

A

Malignancy

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31
Q

Presentation of endometriris?

A

Persistent and heavy vaginal bleeding with pain
Tender uterus
Cervical os open
Septicaemia/systemic infection can ensue

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32
Q

Investigations in endometritis?

A

Vaginal and cervical swab

FBC

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33
Q

Treatment of endometritis?

A

Antibiotics and occasionally evacuation of retained products of conception are required

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34
Q

What are intrauterine polyps?

A

Small, usually benign tumours that grow in the uterine cavity - most are endometrial in origin

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35
Q

When are polyps common? x2

A

Women aged 40-50 years and when oestrogen levels are high

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36
Q

In which post-menopausal women are polyps commonly found?

A

Those on tamoxifen for breast cancer

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37
Q

Presentation of polyps

A

Can be asymptomatic
Often cause menorrhagia and intermenstrual bleeding
Occasionally prolapse through the cervix

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38
Q

Diagnosis of polyps

A

Normally with US or hysteroscopy

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39
Q

Treatment of polyp

A

Resection with cutting diathermy or avulsion

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40
Q

What is didelphys?

A

Total failure of fusion of two Mullerian ducts leading to two uterine cavities and cervices - sometimes longitudinal vaginal septum

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41
Q

What do women with congenital uterine anomaly have increased incidence of?

A

Renal anomalies

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42
Q

What is the most common genital tract cancer?

A

Endometrial cancer

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43
Q

When is prevalence of endometrial cancer highest?

A

Age 60

Only 15% occur premenopausally

44
Q

Prognosis of endometrial cancer

A

Usually presents early therefore good prognosis but actually has same stage for stage prognosis as ovarian cancer

45
Q

What sort of cancer is endometrial cancer cellularly normally?

A

Adenocarcinoma of columnar epithelial gland cells - accounts for >90%

46
Q

What are the risk factors for endometrial cancer?

A

High ratio of oestrogen to progestogen

  • PCOS (unopposed oestrogens)
  • Obesity
  • Oestrogen secreting tumours
  • Nulliparity or late menopause
  • Tamoxifen
47
Q

What is protective against endometrial cancer? x2

A

COC or pregnancy

48
Q

What is the premalignant disease of endometrial cancer?

A

Endometrial hyperplasia with atypical hyperplasia

- can cause menstrual abnormalities or postmenopausal bleeding

49
Q

Management of premalignant endometrial hyperplasia

A

If uterus must be conserved then progestogens with 6-monthly endometrial biopsy - otherwise hysterectomy

50
Q

Clinical features of endometrial cancer?

A

Postmenopausal bleeding
IMB or irregular bleeding in premenopausal women
Occasionally recent onset menorrhagia

51
Q

Examination findings in endometrial cancer? x2

A

Pelvis appears normal and atrophic vaginitis may coexist

52
Q

Where does endometrial cancer directly spread to?

A

Through the myometrium to the cervix and upper vagina

Ovaries may be involved

53
Q

Where does endometrial cancer spread to lymphatically?

A

To pelvic and then para-aortic lymph nodes

54
Q

What is Stage 1 endometrial cancer?

A

Lesions confined to the uterus
1a - less than 1/2 myometrium invasion
1b - more than 1/2 myometrium invasion

55
Q

What is Stage 2 endometrial cancer?

A

Cervix involvement but not beyond uterus

56
Q

What is Stage 3 endometrial cancer?

A 
Tumour invades through uterus 
3A - serosa or adnexae
3B - vaginal or parametrial involvement 
3Ci - pelvic node involvement 
3Cii - para-aortic node involvement
57
Q

What is Stage 4 endometrial cancer?

A

Further spread
4A - bowel or bladder
4B - distant metastases

58
Q

What stage of endometrial cancer do most patients present with?

A

75% present with Stage 1 disease

59
Q

Treatment of endometrial cancer?

A

Hysterectomy and bilateral salpingophorectomy is first line treatment

60
Q

When is staging done in endometrial cancer

A

After hysterectomy - can see if lymph nodes were involved

61
Q

When is further treatment needed for endometrial cancer following hysterectomy?

A

Patients considered high risk for lymph node involvement - radiotherapy

62
Q

Prognosis of endometrial cancer post-surgery

A

Recurrence is common in vaginal vault in the first 3 years

63
Q

How common are uterine sarcomas?

A

Rare!! 150 cases in UK per year

64
Q

What is the blood supply to the cervix?

A

Upper vaginal branches and uterine artery

65
Q

Where do cervix lymphatics drain to?

A

Obturator and internal/external iliac nodes - then to the common iliac and para-aortic nodes

66
Q

What is cervical ectropion?

A

When the columnar epithelium of the endocervix is visible as a red area around the os of the cervix

67
Q

What causes cervical ectropion?

A

Due to eversion of cervix - normal finding in young women, esp. taking pill or who are pregnant

68
Q

Symptoms of cervical ectropion

A

Normally asymptomatic

Can cause vaginal discharge or PCB

69
Q

Treatment of symptomatic cervical ectropion

A

Freezing with cryotherapy - but only once smear has been done and carcinoma excluded

70
Q

Risk associated with cervical ectropion?

A

Exposed columnar epithelium is prone to infection

71
Q

Details of acute cervicitis

A

Rare - often results from STIs
Ulceration and infection occasionally found
Severe cases can have prolapse

72
Q

Details of chronic cervicitis?

A

Chronic inflammation or infection often of an ectropion
Common cause of vaginal discharge
Cryotherapy is used with or without antibiotics

73
Q

What is cervical intraepithelial neoplasia (CIN) also called?

A

Cervical dysplasia

74
Q

What is CIN?

A

Presence of atypical cells within squamous epithelium

75
Q

What is the grading for CIN?

A

CIN 1 - mild dysplasia - cells only found in lower 1/3 of epithelium
CIN 2 - moderate dysplasia - cels only found in lower 2/3 of epithelium
CIN 3 - severe dysplasia - cells occupy full thickness of epithelium

76
Q

What is CIN 3?

A

Cervical carcinoma in situ - cells are the same as those found in malignant lesions but there is no invasion

77
Q

How does CIN 3 or carcinoma in situ become cervical malignancy?

A

Invasion of the cells through the basement membrane

78
Q

Prognosis of untreated CIN II/III?

A

1/3 of women will develop cervical cancer over next 10 years

79
Q

Prognosis of CIN I?

A

Least malignant potential - CIN I can progress to CIN II/III but usually regresses spontaneously

80
Q

Peak incidence of CIN III

A

90% are under 45 years

Peak incidence in those 25-29years

81
Q

Most important risk factor for CIN

A

HPV which is sexually transmitted - therefore number of sexual partners

82
Q

What strains of HPV does the vaccine target?

A

Types 16 and 18 - responsible for 75% of cervical cancers in the UK

83
Q

What are other risk factors for CIN?

A

Oral contraceptive use
Smoking
Immunocompromised patients are also at increased risk and have increased risk of early progression to malignancy

84
Q

Symptoms of CIN

A

CIN causes no symptoms and is not visible on the cervix - therefore done with cervical smears

85
Q

Age and frequency of cervical smears in UK

A

25 (or after first intercourse) then repeated every 3 years until age 49
From 50-64 every 5 years

86
Q

Management of low-grade cellular abnormalities found on smear test

A

eg. dyskaryosis or borderline changes - Sample tested for HPV - if high-risk HPV type then colposcopy
If low-risk HPV then back to routine smear tests

87
Q

Management of abnormal columnar cells on smear

A

Colposcopy (speculum and operating microscope) with biopsy

88
Q

Management of CIN II and III

A

Transformation zone is excised with cutting diathermy - large loop excision of transformation zone (LLETZ)

89
Q

Consequence of LLETZ

A

May have postoperative haemorrhage rarely

Risk of subsequent preterm delivery is slightly higher

90
Q

Peak incidences of cervical carcinoma

A

During 30s and during 80s but majority of cases are in women aged 25-49

91
Q

Risk factors for cervical carcinoma

A

Same as for CIN - HPV, sexual partners

Not familial

92
Q

What is occult cervical carcinoma?

A

When there are no symptoms but diagnosis is made by biopsy or LLETZ

93
Q

Clinical features of cervical carcinoma x3

A

PCB
Offensive vaginal discharge
IMB or PMB
Pain is not an early feature

94
Q

Clinical features of late stage cervical cancer?

A

Involvement of ureters (uraemia), bladder (haematuria), rectum (rectal bleeding) and nerves (pain)

95
Q

Examination findings in cervical cancer

A

May see/palpate ulcer or mass on cervix

96
Q

What is an early feature of spread of cervical cancer?

A

Spread locally to parametrium and vagina

Lymphatic spread to pelvic nodes is early feature

97
Q

What is Stage 1 cervical cancer?

A

Lesions confined to cervix

98
Q

What is Stage 2 cervical cancer

A

Invasion into vagina but not lower vagina or pelvic side wall

99
Q

What is Stage 3 cervical cancer?

A

Invasion of lower vagina or pelvic wall or causing ureteric obstruction

100
Q

What is Stage 4 cervical cancer?

A

Invasion of bladder or rectal mucosa - or beyond true pelvis

101
Q

Investigations in cervical cancer?

A

Tumour biopsy for diagnosis
Vaginal and rectal exams to assess size and local invasion
Cystoscopy - bladder invovlement
MRI - tumour size spread and LN involvement

102
Q

Treatment of stage 1 a i cervical cancer

A

Small diagnosed microscopically - can do cone biopsy or simple hysterectomy

103
Q

Treatment of cervical cancer stage 1 a ii - 1 b i (clinically visible but less than 20mm)

A

Laparoscopic lymphadenectomy and radical trachelectomy (removal of 80% of cervix and upper vagina)

104
Q

Treatment of cervical cancer stage 1 b ii - 2a (up to invasion of vagina but not pelvic side wall)

A

Radical hysterectomy or chemo-radiotherapy

105
Q

Treatment of stage 2b cervical cancer (invasion of parametrium) and worse or positive lymph nodes at any stage

A

Chemo-radiotherapy

Gynaecology (8 decks)

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