Uterus & its abnormalities Flashcards
what is the lymph drainage of the uterus?
fundus - paraaortic nodes
rest - internal and external iliac
what is the blood supply to the uterus
uterine arteries
the uterine branch of the ovarian artery (forms anastomoses with uterine artery at Cornu)
what aree fibroids?
BENIGN tumour of thee MYOMETRIUM
what are some protective factors against fibroids?
protective:
COCP, depot prosgestogeens
childbirth
risk factors: afrocarribean, asian (more likely to get multiple) Fhx - 1st degree relative near menopause obesity
growth of fibroids is dependent on?
how can growth change in the lifecourse of a woman./
oestrogen (and progesterone) dependent
In pregnancy may grow, shrink or show no change
Regress after menopause due to less oestrogens
Monoclonal origin
which fibroids can sometimes form intracavity polyps?
submucosal
what are the presenting symptoms of a fibroid?
- 50% asymptomatic
- can be incidental finding during US or physical exam
Symptoms related to site rather than size
- Heavy menstrual bleeding in 30%
- InterMBleeding : Submucosal or polypoid
- Pain
- Only peroid pain
- outside period if torsion, red degeneration or sarcomatous change occur - Subfertility: distortion of uterine cavity
- Pressure symptoms- Urinary frequency or retention
why can fibroids cause impaired fertility?
Distortion of cavity - or not (intramural)
Prevention of implantation (submucosal)
Obstruction of tubal ostia
what symptoms will the following cause:
2 cm diameter submucosal fibroid
2 cm diameter subserosal fibroid
A 2 cm diameter submucosal fibroid will
often lead to abnormal menstrual bleeding:
- HeavyMB & InterMB
whereas
a 2 cm diameter subserosal fibroid will usually be
aymptomatic.
what are the types of uterine degeneration?
reasons they happen?
occur due to inadequate blood supply -perhaps fibroid has outgrown the supply
‘red degeneration’ is characterized by
pain and uterine tenderness; haemorrhage and necrosis
occur.
In ‘hyaline degeneration’ and ‘cystic degeneration’,
the fibroid is soft and partly liquefied.
what is the natural hx of a fibroid briefly?
Enlargement: slow
Degeneration
Malignancy : 0.1% .
what are the complications of a fibroid?
Torsion of pedunculated fibroid = pain
Degenerations: Red (particularly in pregnancy) -> pain
Hyaline/cystic
Calcification (postmenopausal and asymptomatic)
- can cause new sx: all those of a normal fibroid
Malignancy Leiomyosarcoma
what must be considered upon morcellatoin of a fibrod during a proceedure eg laparoscopic myomectomy?
if it turns out to be cancer not fibroid; leomyosarcoma, there is a small risk of tumour spread due to the morcellation - apple core piercing.
what issues can fibroids cause in pregnancy? what complications can arise?
Associated with premature labour, malpresentations, transverse lie, obstructed labour and post
partum haemorrhage
Red degeneration = common and can cause severe pain
Should not remove at C-section due to heavy bleeding
Torsion of pedunculated fibroids post-partum
how are fibroids investigated?
- Abdominal exam
- Bloods : Hb for anaemia
- Refer for TVUS
Others:
MRI
Laparaoscopy
Adenomyosis – fibroid-like mass, differentiated by MRI
Hysteroscopy or hysterosalpingogram -> assess distortion of uterine cavitiy, particularly if fertility is an
issue. remove small fibroid polyp/submucosal fibroid.
Hb
o Low due to bleeding
o Or high as fibroids can secrete EPO
how do you know if a fibroid is malignant?
fibroid growth in postmenopausal women not on HRT
or rapidly enlarging fibroids + pain
or sudden onset of pain in women of any age.
poor response to GnRH agonists or ulipristal acetate
how are fibroids managed?
- None if asymptomatic or slow growing
B. Larger fibroids should be kept under surveillance as
higher malignant potential - Medical
For HeavyMB: Tranexamic acid, NSAIDs (mefenamic acid),
Progestogen - IUS: not great evidence for fibroids ( surely you cant place an ius into a distorted cavity?)
GnRH agonists
Can be used if woman is near menopause or to shrink fibroid before surgery.
Max 6 months use. Loss of BMD. Not for teens
COCPs too no?
- Surgery
- Hysteroscopy: Fibroid polyp or small (<3cm) submucous fibroid
- Myomectomy: if medical tx failed but preservation of reproductive function is required
- Hysterectomy: high patient satisfaction
others:
Uterine artery embolization - 80% success rate
Ablation
what are the caveats of GnRH use for fibroids?
Restrict use to 6months due to loss of bone mineral density
Not appropriate for women trying to conceive
what are the caveats and. the considerations for the following in fibroid mx:
Hysterescopy
Uterine artery embolization
Hysterectomy
Hysterescopy:
Pretreatment with GnRH agonist for 1-2m shrinks fibroid, reduces vascularity and thins endometrium to make resection easier and safer
Uterine artery embolization :
Higher readmission rates than with myomectomy or hysterectomy
Unclear affect on fertility
Hysterectomy:
GnRH/ Ulipristal acetate : 2-3 months prior. can allow less invasive method. to be used
what are the caveats and. the considerations for the following in fibroid mx:
Myomectomy
Myomectomy:
- risk heavy blood loss -> hysterectomy/blood transfusion
- inc risk uterine rupture during labour
- Adhesions form at surgivcal site - reduced fertility
- GnRH preteatment needed if open
- Perioperative injection of vasopressin directly into myometrium can reduce blood loss
what is adenomyosis, how does it present, and its aetiology?
Formerly endometriosis interna
Presence of endometrium and underlying stroma within the myometrium. Endometrium grows into myometrium to form adenomyosis. severe: pockets of blood in myometrium.
common around 40 years old
Associated with endometriosis and fibroids
Sx: painful, regular and heavy menstruation (or no symptoms)
Ex: mildly enlarged, tender uterus.
Symptoms subside after menopause
How is adenomyosis ivx and MX?
Ivx: MRI
- only way to distinguish from fibroid
Mx: mirena IUS, COCP + NSAIDs Hysterectomy often required GnRH analogues Oestrogen dependent condition but cause not fully known – effects on fertility unclear
what is ulipristal acetate?
uses?
Selective progesterone receptor modulators (SPRMs)
(e.g. oral ulipristal acetate) are a new class of drug that
reduce HMB,
commonly cause reversible amenorrhoea
and shrink fibroids (volume reduced by 50%, similar to
GnRH agonists) without causing bone density loss and
menopausal side effects
used short term in
preparation for surgery or long term intermittently to
control fibroid symptoms and avoid surgery altogether
what are the indications for c-section use in all future pregnancies after treatment for fibroids?
If the endometrial cavity is opened during myomectomy
or if the fibroids are multiple and/or large
Endometrial tissue in myometrium is called?
adenomyosis
what is the difference between Adenomyosis and endometriosis?
endometriosis is when endometrial cells (the lining of the uterus) are in a location outside of the uterus.
Adenomyosis is when these cells are within the uterus, in the uterine wall. hence Formerly: endometriosis interna
How does endometritis present and What are some causes ?
Presentation:
Fever, Lower abdo pain, vaginal bleeding/discharge
Causes:
A few weeks post childbirth, Long labour
Miscarriage
C-section + intrauterine proceedures eg surgical termination, hysteroscopy, dilation & curettage etc
IUD placement
BASICALLY: anything that can place uterus at risk of infection
treatment for endometritis?
Antibiotics
possible Evacuation of Retained PC
Name 2 origins of intrauterine polyps?
where can they be found?
What is the ivx?
endometrial
submucous fibroids
found:
intracavity
proalpsed through cervix
ivx:
Ultrasound, Hysteroscopy (can remove them as you do this)
name some risk factors for intrauterine polyp growth?
Women aged 40-50 -High oestrogen
Tamoxifen- breast cancer tx but pro-oestrogen effects in the uterus
name some sx of IU polyps?
What is the treatment?
Heavy MB/ Menorrhagia
Inter menstraul bleeding
treatment:
Resection with cutting diathermy or avulsion
list some causes of haematometra?
Acquired:
fibrosis
(after endometrial resection, cone biopsy or by a carcinoma).
Congenital:
imperforate hymen
blind rudimentary uterine horn,
a septate vagina is present in which congenital uterine malformation?
uterus didelphys
what causes Congenital uterine malformations?
epidemiology?
Abnormalities result from differing degrees of failure
of fusion of the two Mullerian ducts at about 9 weeks
epidemiology: common but often NOT clinically important
what is the aetiology of uterus didelphys? how can this present?
Total failure of fusion of mullerian ducts:
leads to two uterine cavities and cervices (didelphys)
with sometimes a longitudinal vaginal septum;
or one duct may fail, causing a ‘unicornuate’ uterus.
If one duct develops better than
the other one, a smaller ‘rudimentary horn’ is formed
what are the risks of Congenital uterine malformations?
renal anomalies - get imaging!
25% -> pregnancy-related problems eg malpresentations
or transverse lie, preterm labour, recurrent miscarriage
(<5% of these) or retained placenta.
how are Congenital uterine malformations treated?
Simple septa can be resected hysteroscopically;
rudimentary horns need removal at either open
or laparoscopic surgery.
Bicornuate uteri are not treated surgically
after labour, if a woman is retaining the placenta, what are possible causes?
(at this stage of card making lol)
Congenital uterine malformation
what is the pathology of Endometrial cancer?
Type 1:
Adenocarcinoma of columnar endometrial gland cells = >90% cases
- low grade, less aggressive
- E2 sensitive, obesity related
Type2: adenosquamous carcinoma (malignant squamous + glandular tissue), clear cell, serous or carcinosarcoma
- high grade
- not E2 sensitive
- poorer prognosis
what is the epidemiology of Endometrial cancer EC?
Higherst prevalence at age 60
15% get it before menopause.
<1% get under age 35
1% lifetime risk
which is most common gynae cancer?
Endometrial cancer
what is most common risk factor/ cause of EC?
protective factors?
exposure to endogenous and exogenous oestrogens:
obesity, diabetes,
early age at menarche, nulliparity, late-onset menopause,
older age (>55 years), unopposed oestrogen HRT
and use of tamoxifen.
protective: COCP + pregnancy
A woman comes in for the results of pipelle biopsy and subsequent histology of the endometrium
atypical hyperplasia is found. what does this mean?
how do we proceed?
Endometrial hyperplasia with atypia is a pre-malignant presentation in ECancer.
it is due to E2 exposure
Treatment:
1. no fertility wanted / menopausal: hysterectomy + BSO
- Fertility preserved: progestogens (IUS or continuous oral)
if no atypia : 1st line - progestogens
+ 3–6-monthly hysteroscopy and endometrial biopsy (repeat sample again)
+referral to a fertility specialist
what are the presenting sx of EC?
examniatoin findings
Post-menopausal bleeding (MOST COMMON - 10%)
Intermenstraul bleeding or recent HMB/menorrhgia - in premenopausal
examination:
atrophic vaginitis
cervical smear: abnormal columnar cells possible - CGIN
what are the characteristics of EC: metastesis etc?
Spreads directly through myometrium to the cervix and upper vagina
Ovares may be involves
Lymphatic spread = pelvic, then para-aortic
Late blood-borne spread
How is EC staged/graded?
FIGO staging used (Stage for Spread)
Histological grading: G1-3, G1 = well differentiated
charcterise a stage 1 EC?
Stage 1 Lesions confined to uterus:
1 endometrium only
1a ½ of myometrial invasion
75% present with stage I disease
charcterise a stage 2 EC?
Stage 2 As above but in cervix also:
2 Cervical stromal invasion, but not beyond uterus
charcterise a stage 3 EC?
Stage 3 Tumour invades through the uterus:
3a Invades serosa or adnexae
3b Vaginal and/or parametrial involvement
3Ci Pelvic node involvement
3cii Para-aortic involvement
charcterise a stage 4 EC?
Stage 4 Further spread:
4a In bowel or bladder
4b Distant metastases
what are the ivx for EC?
- US and or Endometrial biopsy - required for diagnosis
- pipelle/hysteroscopy
- MRI if spread suspected – high risk histology seen or symptoms
before these:
ivx cuase of abnormal bleed
are they on menopause?
woman is stage 3 EC, what is her prognosis?
depends on grade!
How is EC treated?
- Surgical
- TAH + BSO performed
- use this for staging then determine nxt step:
- any lymph spread ?
- debatable benefit in lymphadenectomy
Adjuvants:
- Radiotherapy
a. External beam
o Following hysterectomy in patients with or at high
risk of LN involvement
b. Vaginal vault radiotherapy
o Reduces local recurrence. Does not prolong survival
- Chemotherapy
- high-risk early stage disease and advanced stage disease
what are the risk factors of LN involvement in EC?
o Risk factors =
deep myometrial spread,
poor tumour histology/grade or
cervical stromal involvement (stage 2)
what are prognostic indicators in EC?
Recurrence is most common at vaginal vault in first 3 years
Poor prognostic fx = older age, advanced stage,
deep myometrial invasion in stage 1 and 2,
high tumour grade and adenosquamous histology
what are the indications for radiotherapy in EC?
High risk for extrauterine disease: deep myometrial or
cervical stromal spread, poor grade
Proven extrauterine disease
Inoperable and recurrent disease
Palliation for symptoms, e.g. bleeding
what is the prognosis of ec?
5 year survival:
OVERALL 75%
stage 1v- 90
stage 4 -25
give exampels of uterine sarcomas?
Leiomyosarcoma - malignant fibroid
- fast growing and painful
Mixed mullerian tumours
Endomeetrial stromal tumours
what condition can present similarly to EC with IMB or Post menopausal bleeding?
Leiomyosarcoma - uterine sarcoma
Someone presents with HMB/PMB. TVUS shows thickened endometrium (>5). What do you do next?
Hysteroscopy + biopsy - if failed pipelle OR suspected polyp OR unknown cause
- higher specificity than pipelle
OR
pipelle biopsy alone
Kissing ovaries are caused by what condition?
It’s an US sign seen in endometriosis
most common causes of Heavy meeenstrual bleeding?
- Fibroids
- Polyps
Others
Endometrial, cervical cancer
etc
What are the different ways a biopsy of the endometrium can be done? indications?
Pipelle
Hysteroscopy - when pipelle cant get sufficient sample of lining or cant get through cervix. can do it as outpatient or inpatient procedure. or in cases where there is endometrial thickening on TVUS and cause is unknown - do this so if there is polyp can remove straight away.
what is the main presenting triad in endometriosis?
what are other key sx?
Triad: Dysmenorrhea, Dyspareunia, Subfertility
Others: Dyschezia (pain with stools), asymptomatic
How would endometriosis be most accurately diagnosed in her case?
Hx
Laparoscopy with biopsy (need histology for confirmation)
