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A - ObsNGynae > Uterus & its abnormalities > Flashcards

Uterus & its abnormalities Flashcards

1
Q

what is the lymph drainage of the uterus?

A

fundus - paraaortic nodes

rest - internal and external iliac

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2
Q

what is the blood supply to the uterus

A

uterine arteries

the uterine branch of the ovarian artery (forms anastomoses with uterine artery at Cornu)

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3
Q

what aree fibroids?

A

BENIGN tumour of thee MYOMETRIUM

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4
Q

what are some protective factors against fibroids?

A

protective:
COCP, depot prosgestogeens
childbirth

risk factors:
afrocarribean, asian (more likely to get multiple)
Fhx - 1st degree relative
near menopause 
obesity
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5
Q

growth of fibroids is dependent on?

how can growth change in the lifecourse of a woman./

A

oestrogen (and progesterone) dependent

In pregnancy may grow, shrink or show no change
Regress after menopause due to less oestrogens
Monoclonal origin

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6
Q

which fibroids can sometimes form intracavity polyps?

A

submucosal

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7
Q

what are the presenting symptoms of a fibroid?

A
  1. 50% asymptomatic
    - can be incidental finding during US or physical exam

Symptoms related to site rather than size

  1. Heavy menstrual bleeding in 30%
  2. InterMBleeding : Submucosal or polypoid
  3. Pain
    - Only peroid pain
    - outside period if torsion, red degeneration or sarcomatous change occur
  4. Subfertility: distortion of uterine cavity
  5. Pressure symptoms- Urinary frequency or retention
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8
Q

why can fibroids cause impaired fertility?

A

 Distortion of cavity - or not (intramural)
 Prevention of implantation (submucosal)
 Obstruction of tubal ostia

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9
Q

what symptoms will the following cause:

2 cm diameter submucosal fibroid
2 cm diameter subserosal fibroid

A

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.

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10
Q

what are the types of uterine degeneration?

reasons they happen?

A

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.

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11
Q

what is the natural hx of a fibroid briefly?

A

Enlargement: slow

Degeneration

Malignancy : 0.1% .

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12
Q

what are the complications of a fibroid?

A

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

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13
Q

what must be considered upon morcellatoin of a fibrod during a proceedure eg laparoscopic myomectomy?

A

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.

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14
Q

what issues can fibroids cause in pregnancy? what complications can arise?

A

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

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15
Q

how are fibroids investigated?

A
  1. Abdominal exam
  2. Bloods : Hb for anaemia
  3. 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

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16
Q

how do you know if a fibroid is malignant?

A

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

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17
Q

how are fibroids managed?

A
  1. None if asymptomatic or slow growing
    B. Larger fibroids should be kept under surveillance as
    higher malignant potential
  2. 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?

  1. 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

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18
Q

what are the caveats of GnRH use for fibroids?

A

Restrict use to 6months due to loss of bone mineral density

 Not appropriate for women trying to conceive

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19
Q

what are the caveats and. the considerations for the following in fibroid mx:

Hysterescopy
Uterine artery embolization
Hysterectomy

A

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

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20
Q

what are the caveats and. the considerations for the following in fibroid mx:

Myomectomy

A

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
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21
Q

what is adenomyosis, how does it present, and its aetiology?

A

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

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22
Q

How is adenomyosis ivx and MX?

A

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
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23
Q

what is ulipristal acetate?

uses?

A

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

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24
Q

what are the indications for c-section use in all future pregnancies after treatment for fibroids?

A

If the endometrial cavity is opened during myomectomy

or if the fibroids are multiple and/or large

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25
Q

Endometrial tissue in myometrium is called?

A

adenomyosis

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26
Q

what is the difference between Adenomyosis and endometriosis?

A

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

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27
Q

How does endometritis present and What are some causes ?

A

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

28
Q

treatment for endometritis?

A

Antibiotics

possible Evacuation of Retained PC

29
Q

Name 2 origins of intrauterine polyps?

where can they be found?

What is the ivx?

A

endometrial
submucous fibroids

found:
intracavity
proalpsed through cervix

ivx:
Ultrasound, Hysteroscopy (can remove them as you do this)

30
Q

name some risk factors for intrauterine polyp growth?

A

Women aged 40-50 -High oestrogen

Tamoxifen- breast cancer tx but pro-oestrogen effects in the uterus

31
Q

name some sx of IU polyps?

What is the treatment?

A

Heavy MB/ Menorrhagia
Inter menstraul bleeding

treatment:
Resection with cutting diathermy or avulsion

32
Q

list some causes of haematometra?

A

Acquired:
fibrosis
(after endometrial resection, cone biopsy or by a carcinoma).

Congenital:
imperforate hymen
blind rudimentary uterine horn,

33
Q

a septate vagina is present in which congenital uterine malformation?

A

uterus didelphys

34
Q

what causes Congenital uterine malformations?

epidemiology?

A

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

35
Q

what is the aetiology of uterus didelphys? how can this present?

A

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

36
Q

what are the risks of Congenital uterine malformations?

A

renal anomalies - get imaging!

25% -> pregnancy-related problems eg malpresentations
or transverse lie, preterm labour, recurrent miscarriage
(<5% of these) or retained placenta.

37
Q

how are Congenital uterine malformations treated?

A

Simple septa can be resected hysteroscopically;

rudimentary horns need removal at either open
or laparoscopic surgery.

Bicornuate uteri are not treated surgically

38
Q

after labour, if a woman is retaining the placenta, what are possible causes?

(at this stage of card making lol)

A

Congenital uterine malformation

39
Q

what is the pathology of Endometrial cancer?

A

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
40
Q

what is the epidemiology of Endometrial cancer EC?

A

Higherst prevalence at age 60

15% get it before menopause.

<1% get under age 35
1% lifetime risk

41
Q

which is most common gynae cancer?

A

Endometrial cancer

42
Q

what is most common risk factor/ cause of EC?

protective factors?

A

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

43
Q

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?

A

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

  1. 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

44
Q

what are the presenting sx of EC?

examniatoin findings

A

Post-menopausal bleeding (MOST COMMON - 10%)

Intermenstraul bleeding or recent HMB/menorrhgia - in premenopausal

examination:
atrophic vaginitis
cervical smear: abnormal columnar cells possible - CGIN

45
Q

what are the characteristics of EC: metastesis etc?

A

Spreads directly through myometrium to the cervix and upper vagina

 Ovares may be involves
 Lymphatic spread = pelvic, then para-aortic
 Late blood-borne spread

46
Q

How is EC staged/graded?

A

 FIGO staging used (Stage for Spread)

 Histological grading: G1-3, G1 = well differentiated

47
Q

charcterise a stage 1 EC?

A

Stage 1 Lesions confined to uterus:

1 endometrium only
1a ½ of myometrial invasion

75% present with stage I disease

48
Q

charcterise a stage 2 EC?

A

Stage 2 As above but in cervix also:

2 Cervical stromal invasion, but not beyond uterus

49
Q

charcterise a stage 3 EC?

A

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

50
Q

charcterise a stage 4 EC?

A

Stage 4 Further spread:

4a In bowel or bladder
4b Distant metastases

51
Q

what are the ivx for EC?

A
  1. US and or Endometrial biopsy - required for diagnosis
    • pipelle/hysteroscopy
  2. MRI if spread suspected – high risk histology seen or symptoms

before these:
ivx cuase of abnormal bleed
are they on menopause?

52
Q

woman is stage 3 EC, what is her prognosis?

A

depends on grade!

53
Q

How is EC treated?

A
  1. Surgical
    - TAH + BSO performed
    - use this for staging then determine nxt step:
    - any lymph spread ?
    - debatable benefit in lymphadenectomy

Adjuvants:

  1. 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

  1. Chemotherapy
    - high-risk early stage disease and advanced stage disease
54
Q

what are the risk factors of LN involvement in EC?

A

o Risk factors =

deep myometrial spread,

poor tumour histology/grade or

cervical stromal involvement (stage 2)

55
Q

what are prognostic indicators in EC?

A

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

56
Q

what are the indications for radiotherapy in EC?

A

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

57
Q

what is the prognosis of ec?

A

5 year survival:
OVERALL 75%

stage 1v- 90
stage 4 -25

58
Q

give exampels of uterine sarcomas?

A

Leiomyosarcoma - malignant fibroid
- fast growing and painful

Mixed mullerian tumours

Endomeetrial stromal tumours

59
Q

what condition can present similarly to EC with IMB or Post menopausal bleeding?

A

Leiomyosarcoma - uterine sarcoma

60
Q

Someone presents with HMB/PMB. TVUS shows thickened endometrium (>5). What do you do next?

A

Hysteroscopy + biopsy - if failed pipelle OR suspected polyp OR unknown cause
- higher specificity than pipelle

OR

pipelle biopsy alone

61
Q

Kissing ovaries are caused by what condition?

A

It’s an US sign seen in endometriosis

62
Q

most common causes of Heavy meeenstrual bleeding?

A
  1. Fibroids
  2. Polyps

Others
Endometrial, cervical cancer
etc

63
Q

What are the different ways a biopsy of the endometrium can be done? indications?

A

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.

64
Q

what is the main presenting triad in endometriosis?

what are other key sx?

A

Triad: Dysmenorrhea, Dyspareunia, Subfertility

Others: Dyschezia (pain with stools), asymptomatic

65
Q

How would endometriosis be most accurately diagnosed in her case?

A

Hx

Laparoscopy with biopsy (need histology for confirmation)

A - ObsNGynae (37 decks)

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