Fibroids, Polyps, Congenital abnormalities

Question 1

Define uterine fibroids

Answer 1

Benign tumours consisting of smooth muscle and fibrous connective tissue. Range from seedlings to large uterine tumours

Question 2

Classification of fibroids

Answer 2

Intramural: Most common in muscular layer
Subserosal: Beneath uterine serosa grows into pelvic cavity
Submucosal: under endometrial lining. Grows into uterine cavity
Cervical

Question 3

Signs and symptoms of fibroids

Answer 3

Menorrhagia: Primarily due to submucosal
Dysmenorrhea
Pelvic pressure 
Bloating
Dyspareunia

Question 4

Investigations for fibroids

Answer 4

Transvaginal USS
Sonohysterography (differentiate from polyps)
Hysteroscopy

Question 5

Managing bleeding from fibroids

Answer 5

<3cm: Mirena, COC or progesterone injectables
• Tranexamic acid: antifibrinolytic. Stops plasminogen forming into plasmin prevents degradation of fibrin clots, fibrinogen and plasma proteins (Factor V + VIII)
>3cm: • Ulipristal acetate 5 mg (up to 4 courses) inhibits cell proliferation and induction of apoptosis. Contra-indicated when it has been used repeatedly for emergency contraception or breast, cervical, ovarian and uterine cancers.

Question 6

Reduce size of fibroid

Answer 6

leuprorelin acetate (GnRH agonist). Reduce oestrogen production and shrink fibroids by 36-65%. Return to pre-treatment size shortly after treatment is stopped. Contraindicated in undiagnosed vaginal bleeding

Mifepristone: Antiprogestogen which shrinks fibroids by up to 50% in 6 months however causes vasomotor symptoms

Uterine artery embolisation, hysterectomy
Myomectomy: Surgical removal of fibroids

Question 7

Criteria for myomectomy

Answer 7

1 or more of the following:
• Excessive uterine bleeding not responding to conservative treatments
• Infertility with distortion of the endometrial cavity or tubal obstruction
• Recurrent pregnancy loss with distortion of the endometrial cavity
• Pain or pressure symptoms that interfere with quality of life
• Urinary tract symptoms (frequency and/or symptoms of obstruction)
• Iron deficiency anaemia secondary to chronic blood loss
• Growth of a fibroid after menopause.

Question 8

Uterine polyps

Answer 8

Overgrowth of endometrial cells on interior of uterus

Question 9

Cervical polyps

Answer 9

Grow from cervical canal or outside the cervix

Question 10

Clinical features of polyps

Answer 10

Often found incidentally on smear test
Most asymptomatic
Bleeding related symptoms

Question 11

Key investigations for polyps

Answer 11

Sonohysterogram or hysterosalpingogram

Biopsy

Question 12

Treatment for polyps

Answer 12

Polyp removed whilst doing biopsy. Ensure polyp removed from the base as that is the area with highest malignancy potential

Question 13

Congenital uterine abnormalities classification

Answer 13

 I – Hypoplasia/agenesis No reproductive potential; medical intervention in the form of in vitro fertilisation of harvested ova and implantation in a host uterus needed
 II – Unicornuate
 Non-communicating, cavitary horn: Always surgically resected, as it is associated with dysmenorrhoea, haematometra, endometriosis and ectopic pregnancy
 Non-communicating, non-cavitary horn: Surgery not currently recommended. No complications of endometriosis etc, as there is no endometrium
 Communicating, cavitary horn Also surgically removed because pregnancy that implants in the rudimentary horn rarely is viable
 No horn: No treatment. Reproductive potential is possible
 III – Didelphys: May consider metroplasty; however, full-term pregnancies have occurred
 IV – Bicornuate: Surgical intervention rarely needed; may consider metroplasty

Question 14

Bartholin cyst

Answer 14

Blocked bartholin’s duct in the lower third of the labia majora. It may present as a simple lump or an acute abscess after infection.

Question 15

Tx for bartholin’s cyst

Answer 15

incision and marsupialization; send pus to microbiology if infected (some are due to gonococcal infection and may need treatment and referral to GUM for contact tracing).