Uterine, Vag and Cervix Disorders

Question 1

Another name for uterine fibroids

Answer 1

Leiomyomas

Question 2

What makes a fibroid

Answer 2

Smooth muscle cells and fibroblasts. Form a round, benign tumour in the myometrium

Question 3

Location and different types of fibroids

Answer 3

Subserosal - near outer serial surface of uterus and can pressurise adjacent structures e.g. bladder. Mostly asymptomatic.
Intramural - within myometrium. Cause menorrhagia and dysmenorrhea.
Submucosal - Near inner mucosal surface and can extend into uterine cavity. Menorrhagia, sub fertility and dysmenorrhea
Pedunculated
Intracavitary

Question 4

Risk factors for fibroids

Answer 4

Afro-carribean ethnicity.
Family Hx
Increasing age
Early puberty
Obesity

Question 5

Complications of fibroids

Answer 5

Can create their own blood supply which can lead to torsion of a pedunculate fibroid.
Abnormal uterine bleeding.
Compression of adjacent organs = urinary frequency, pelvic pain, constipation.
Infertility.
Pregnancy problems e.g. malpresentation, miscarriage, pre-term.

Question 6

Clinical features of fibroids

Answer 6

Asymptomatic!
Menorrhagia, dysmenorrhea.
Pelvic pain.
Pelvic pressure or discomfort.
Subfertility.
Urinary symptoms.
Abdo and bimanual pelvic exam = Firm, enlarged, irregular shaped non-tender uterus. Mass able to be moved from side to side.

Question 7

Differentials for a pelvic mass on bimanual palpation

Answer 7

Ovarian cancer.
Endometrial carcinoma
Uterine sarcoma e.g. leiomyosarcoma.
Endometrial polyp
Endometrial hyperplasia
Adenomyosis
Pregnancy.

Question 8

Management of fibroids

Answer 8

No treatment if minimal symptoms.
Treat menorrhagia e.g. IUS.
Ulipristal acetate = progesterone receptor modulator. Need to monitor LFT!
GnRG analogues to shrink fibroid before surgery (return to original size when stop medication).
Surgery = myomectomy, hysterectomy, eterine artery ablation.

Question 9

Pharmacology of GnRH analogues

Answer 9

Bind to Gonadotropin-releasing hormone receptor, cause increase in FSH and LH - initial flare-up of symptoms. Continued activation however causes LH and FSH levels to decrease as receptors desensitise.
Side effects = hot flush, mood swings, vaginal dryness, low libido, headache, low BMD.

Question 10

Adenomyosis

Answer 10

Ectopic endometrial tissue in the myometrium (a type of endometriosis?)

Question 11

Endometriosis pathophys

Answer 11

Endometrial tissue and stroma outside the uterine cavity. Commonly deposits occur in the peritoneum, pouch of Douglas, ovary and uterosacral ligament.
The tissue is responsive to oestrogen and causes cyclical problems.

Question 12

Causes of endometriosis

Answer 12

Unknown cause.
Genetic predisposition.
Retrograde menstruation?
Mostly affects women between 30-40yrs.

Question 13

Complications of endometriosis

Answer 13

Endometriomas = ovarian cysts with blood and endometrial-like tissue. They can rupture causes abnormal pelvic anatomy.
Subfertility.
Adhesions
Bowel obstruction.

Question 14

Clinical features of endometriosis

Answer 14

Infertility.
Chronic and cyclical pelvic pain.
Dysmenorrhea, Dyspareunia and menorrhagia.
Lethargy.
Constipation.
Bimanual pelvic exam will be normal unless severe endometriosis which can cause tendernesss, palpable nodules or visible nodules.

Question 15

Investigating and diagnosing endometriosis

Answer 15

TVUS - can be normal.

Laproscopy + biopsy. Diagnose endometriosis and rule out malignancy.

Question 16

Management of endometriosis

Answer 16

1st line - simple analgesia e.g. NSAID
2nd line - hormone therapy e.g. COCP back-to-back.
3rd line - GnRG analogues, surgical.
Surgical - laparoscopic: diathermy, laser ablation or excision.

Question 17

Best imaging for adenomyosis

Answer 17

MRI

Question 18

Red degeneration

Answer 18

Fibroid (which is sensitive to oestrogen) grows during pregnancy. Blood supply is not proportionate to growth and the fibroid degenerates.

Question 19

Symptoms of red degeneration

Answer 19

Low grade fever, pain and vomiting, pregnant and Hx of fibroids. Mx = conservative as most resolve in 4-7days

Question 20

Malignant fibroid

Answer 20

Leimyosarcoma

Question 21

Causes of cervical excitation

Answer 21

Pain on contact with cervix. PID and ectopic.

Question 22

Adenomyosis V endometriosis

Answer 22

Adenomyosis = young and nulliparous
Endometriosis = older, multiparous.

Question 23

Bartholin’s cyst

Answer 23

Blockage of Bartholin’s glands and ducts. Lie under labia minora and secrete mucous on sexual excitation. Can become infected = abscess.

Question 24

Cervical polyp

Answer 24

Pedunculated, benign tumours. Increase mucus and PV discharge. Ix = TVUS and hysteroscopy to exclude malignancy.

Question 25

Endometritis aetiology

Answer 25

Miscarriage (septic)
Termination of pregnancy
Childbirth: C-section and vaginal, prolonged rupture of membranes, long labour, retained products of conception.
IUD or IUS insertion
Gynae surgery.

Question 26

Clinical features of endometritis

Answer 26

Lower abdo pain
Fever
Dyuria
Dyspareunia
Uterine tenderness on bimanual.
Offensive PV discharge

Question 27

Investigations and treatment of endometritis

Answer 27

FBC, blood cultures.
High vaginal swab
Rx = Cefalexin and metronidazole.

Question 28

Cervical ectropion pathophys

Answer 28

Glandular epithelium from inside the cervical cancer extends onto the outer squamous cells of the cervix

Question 29

Clinical features of ectropions

Answer 29

Asymptomatic
Picked up on cervical screening as appears red
PV discharge
Dyspareunia
Post-coital bleeding
Infection

Question 30

Aetiology of ectropion

Answer 30

Hormonal influence - pregnancy, COCP or POCP, puberty

Question 31

Management of an ectropion

Answer 31

Expectant
Change contraception
Silver nitrate or diathermy to remove cells.

Question 32

Teratoma

Answer 32

Contains hair and teeth