Gynae: Fibroids, Endometriosis, Adenomyosis, Polyps Flashcards
(39 cards)
what are fibroids? and what are they sensitive to?
benign tumours of the smooth muscle of the uterus which are oestrogen sensitive and grow in response to oestrogen
aka uterine leiomyomas
which ethnic groups are fibroids most common in?
black women
describe the 4 types of fibroids
- intramural - within the myometrium and they distort the shape of the uterus
- subserosal - just below the outer layer of the uterus and they grow outwards filling the abdominal cavity
- submucosal - just below the endometrium
- pendunculated - on a stalk
how can fibroids present?
- often asymptomatic
- heavy menstrual bleeding
- prolonged menstruation
- Abdominal pain often worse during menstruation
- bloating/feeling full in abdomen
- urinary or bowel symptoms
- deep dyspareunia
- reduced fertility
what may be seen on abdominal and bimanual examination of someone with fibroids?
palpable pelvic mass or an enlarged firm non-tender uterus
how are fibroids investigated?
hysteroscopy - initial investigation for submucosal fibroids presenting with HMB
pelvic ultrasound - larger fibroids
MRI scanning - helps to determine size and shape and blood supply before surgery
NICE guidelines on fibroids are included within the heavy menstrual bleeding guideline from 2018.
Management for less than 3 cm
medical = same as HMB
- Mirena coil (1st line) – fibroids must be < 3cm with no distortion of the uterus
- Symptomatic management with NSAIDs & tranexamic acid
- COCP
- Cyclical oral progestogens
surgical
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
what is the management of fibroids >3cm
Referral to gynaecology
Medical
- Symptomatic management with NSAIDs and tranexamic acid
- Mirena coil – depending on the size and shape of the fibroids and uterus
- COCP
- Cyclical oral progestogens
Surgical
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
what can be used prior to fibroid surgery to reduce the size of the fibroids?
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
they induce a menopause-like state and reduce the amount of oestrogen maintaining the fibroid
what are the complications of fibroids?
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
what is uterine artery embolisation?
surgical option for larger fibroids, performed by IR. inset catheter into femoral artery and passed through to uterine artery. particles injected that cause a blockage in the arterial supply to the fibroid = shrinks
what is myomectomy?
surgical removal of the fibroid via laparoscopic surgery or laparotomy
only treatment known to potentially improve fertility in pt with fibroids
what is endometrial ablation?
way of destroying the endometrium. now done using balloon thermal ablation where a specially designed balloon is inserted into the endometrial cavity and filled with a high temperature fluid that burns the endometrial lining
what is a hysterectomy?
removing the whole uterus and fibroids
can be keyhole, laparoscopic or vaginal approach
ovaries can be left or removed
what is red degeneration of fibroids?
refers to ischaemia, infarction and necrosis of fibroids due to disrupted blood supply.
when is red degeneration of fibroids most likely to occur?
in larger fibroids >5cm during the second and third trimester of pregnancy
may occur as the fibroid enlarges during pregnancy outgrowing its blood supply and becoming ischeamic.
may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy
how does red degeneration present and how is it managed?
presents with severe abdominal pain, low-grade fever, tachycardia, vomiting
managed is supportive with rest, fluid and analgesia
what is endometriosis?
a condition where there is ectopic endometrial tissue outside the uterus
what is a lump of endometrial tissue outside the uterus called?
an endometrioma
what is an endometrioma in the ovary known as?
chocolate cysts
what is the aetiology of endometriosis?
exact cause unknown - numerous theories
- no specific genes identified but some genetic component
- retrograde menstruation
- embryonic cells destined to become endometrial tissue remain outside the uterus during development of the fetus
- lymphatic spread (similar to cancer)
- metaplasia
one of the main symptoms of endometriosis is pain. describe the pathophysiology of this
endometrial tissue outside the uterus responds to hormones the same way the endometrial tissue inside the uterus does so during menstruation is sheds its lining and bleeds as the endometrial tissue inside the uterus would. this causes irritation and inflammation of the tissues around the sites of endometriosis resulting in cyclical dull, heavy or burning pain during menstruation
localised bleeding and inflammation can lead to adhesions - lead to chronic, non-cyclical pain that can be sharp, stabbing or pulling and is associated with nausea
why is it though that women with endometriosis struggle with fertility?
- adhesions around ovaries and fallopian tubes may block release of eggs or kinking them may obstruct route
- endometriomas in the ovary may damage eggs and prevent effective ovulation
how does endometriosis present?
- can be asymptomatic
- cyclical abdominal or pelvic pain
- deep dyspareunia
- Dysmenorrhoea
- infertility
- cyclical bleeding from other sites - bladder and bowel
