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Uterine Disorders Flashcards

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1
Q

What are uterine fibroids?

A

AKA leiomyomata
Benign smooth muscle tumours of the uterus arising from the myometrium
Most common benign tumours in women (incidence 20-40%)

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2
Q

What is the risk of a fibroids becoming malignant?

A

0.1%

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3
Q

How are fibroids classified?

A

According to their position in the uterine wall
Intramural (most common) - confined to the myometrium of the uterus
Submucosal - develops immediately underneath the endometrium of the uterus and protrudes into the uterine cavity
Subserosal - protrudes into and distorts the serosal surface of the uterus. They may be pedunculated (on a stalk)

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4
Q

What is the pathogeneis of fibroids?

A

Poorly understood.

Thought to be stimulated by oestrogen.

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5
Q

What are the risk factors for developing fibroids?

A

Obesity
Early menarche
Family history (1st degree relative - 2.5x)
African-Americans 3x more likely than Caucasians

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6
Q

What are the clinical features of fibroids?

A 
Majority asymptomatic (discovered incidentally on pelvic/abdominal exam)
Urinary frequency/chronic retention
Abdominal distension
Heavy menstrual bleeding
Subfertility (obstructive effects)
Acute pelvic pain (rare)
- may occur in pregnancy due to red degeneration - necrosis/haemorrhage of fibroid
- torsion of pedunculated fibroid
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7
Q

What can be seen on examination of a woman with fibroids?

A

Solid mass/enlarged uterus may be palpable on abdominal or bimanual examination
Uterus usually non-tender

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8
Q

What are the differentials for fibroids?

A

Endometrial polyps
Ovarian tumours
Leimyosarcoma
Adenomyosis

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9
Q

What are the investigations for fibroids?

A

Pelvic USS

MRI (rarely required unless sarcoma suspected)

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10
Q

What is the medical management for fibroids? (If the patients are asymptomatic with small fibroids may no need treatment).

A

Tranexamic/mefanamic acid
Hormonal contraceptives to control menorrhagia (COCP, POP, Mirena IUS)
GnRH analogues (zolidex)
- suppresses ovulation - temporary menopausal state (useful pre-operatively to reduce fibroid size and lower complications)
Selective progesterone receptor modulators (ullipristal/esmya)
- reduces size of fibroid and menorrhagia
- useful preoperatively/as an alternative to surgery

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11
Q

How long can GnRH analogues be used for and why?

A

6 months only

Due to osteoporosis risk

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12
Q

What is the surgical management of fibroids?

A

Hysteroscopy and transcervical resection of fibroid (TCRF)
- useful for submucosal fibroids
Myomectomy
- for women wanting to preserve their uterus
Uterine artery embolisation (performed by a radiologist via the femoral artery, commonly causes pain and fever post-operatively)
Hysterectomy

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13
Q

What is endometriosis?

A

It is a chronic condition in which endometrial tissue is located in sites other than the uterine cavity.

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14
Q

What is the common age range of women affected by endometriosis?

A

25-40

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15
Q

What is adenomyosis?

A

Endometrial tissue found in the uterine muscle.

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16
Q

What is a theory for the aetiology of endometriosis?

A

Retrograde menstruation
Endometrial cells travel backwards from the uterine cavity, through the Fallopian tubes and deposit on pelvic organs where they can seed and grow
May then travel to distant sites through the lymphatic system and vasculature

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17
Q

What is the pathophysiology of endometriosis?

A

Endometrial tissue is sensitive to oestrogen
Bleeding from ectopic tissue during menstruation
Results in pain, bloating and distension at the ectopic sites
Repeated inflammation and scarring can lead to adhesions
During pregnancy and menopause symptoms will be reduced

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18
Q

What are the risk factors for endometriosis?

A 
Early menarche
FH of endometriosis 
Short menstrual cycles
Long duration of menstrual bleeding
Heavy menstrual bleeding
Defects in the uterus or Fallopian tubes
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19
Q

What are the clinical features of endometriosis?

A

Cyclical pelvic pain (at time of menstruation) though pain may be constant where adhesions have formed
Dysmenorrhea, Dyspareunia, Dysuria, Dyschezia
Subfertility
Focal symptoms of bleeding at distant sites
On examination - fixed retroverted uterus, uterosacral ligament nodules, general tenderness
Enlarged tender and boggy uterus is indicative of adenomyosis

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20
Q

What are the differential of endometriosis?

A

PID
Ectopic pregnancy
Fibroids
IBS

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21
Q

What are the investigations for endometriosis?

A 
Laparoscopy - gold standard (differentiated from chronic infection)
Pelvic USS (determines severity, needs to be undertaken before surgery)
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22
Q

What are the typical findings in endometriosis on laparoscopy?

A

Chocolate cysts
Adhesions
Peritoneal deposits

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23
Q

What are the findings on pelvic USS for endometriosis?

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A

Kissing ovaries (bilateral endometrioma are adherent together)
Pelvic mobility
Involvement of bowel if any

24
Q

What is the management for endometriosis?

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A

No treatment if asymptomatic
Analgesia for pain
Suppress ovulation for 6-12 months
- causes atrophy and reduces symptoms
- low dose COCP/norethisterone/mirena coil
Surgery
- if symptoms seriously affect the patient’s life
Excision, fulgaration and laser ablation
- relapses will certainly occurand the surgery will have to be done again
Ultimate management is hysterectomy and removal of ovaries with subsequent replacement of hormones until the age of menopause

25
Describe the aetiology of endometrial cancer.
Most commonly adenocarcinoma Stimulation of the endometrium by unopposed oestrogen Longer periods of anovulation predispose to endometrial cancer (progesterone produced by the corpu luteum) Unopposed oestrogen can also cause endometrial hyperplasia with can predispose to malignancy
26
What are the risk factors for endometrial cancer?
Anovulation (early menarche, late menopause, low parity, PCOS, HRT with O alone, tamoxifen) Age (peak 65-75) Obesity (faster peripheral aromatisation of androgens to oestrogen) Genetics (e.g. hereditary non-polyposis colorectal cancer)
27
Why is early menarche/late menopause a risk factor for endometrial cancer?
At the extremes of mistrial age, menstrual cycles tend to be anovulatory This increases exposure to unopposed oestrogen without the protective factor of progesterone from the corpus luteum
28
What are the clinical features of endometrial cancer?
``` Post-menopausal bleeding Clear/white vaginal discharge Abnormal cervical smears If premenopausal - irregular/IMB Abdo pain/weight loss if advanced or metastatic ```
29
What may be seen on examination of a woman with endometrial cancer?
Abdo exam: abdo or pelvic masses Speculum exam: vulval/vaginal atrophy/cervical lesions Bimanual exam: assess size and axis of uterus prior to endometrial sampling
30
What are the differentials for endometrial cancer?
``` Vulval causes (vulval atrophy, vulval pre-malignant/malignant conditions) Cervical causes (polyps/cancer) Endometrial causes (hyperplasia, polyps, atrophy) ```
31
What are the investigations for endometrial cancer?
Transvaginal USS (1st line) Endometrial biopsy and histology (often using Pipelle biopsy) If high risk - hysteroscopy with biopsy MRI/CT - staging Before operation - baseline bloods + group and save
32
What are the indications for an endometrial biopsy?
If there is an endometrial thickness of >4mm in a postmenopausal woman on transvaginal USS If <4mm watch and wait
33
What are the indications for a hysteroscopy with biopsy in suspected endometrial cancer?
High risk patients | Heavy bleeding, multiple risk factors, very thickened endometrium on USS, patient unable to tolerate outpatient sampling
34
Describe the staging for endometrial cancer.
FIGO staging I - confined to uterine body II - may extend to cervix, not beyond uterus III - beyond uterus but confined to pelvis IV - involves bladder/bowel or has metastasised to distant sites.
35
What is the management for endometrial hyperplasia?
``` Without atypia - protgestogens e.g. mirena IUS. Surveillance biopsies to identify progression to atypia/malignancy Atypical hyperplasia (highest rate of progression to malignancy) - total abdominal hysteroscopy + bilateral salpingooophorectomy - regular surveillance biopsies if surgery contraindicated ```
36
What is the management for stage I endometrial cancer?
Total hysterectomy and bilateral salpingo-oophorectomy Peritoneal washings should be taken Generally by laparoscopic surgery
37
How is stage II endometrial cancer managed?
Radical hysterectomy (vaginal tissue surrounding the cervix and supporting ligaments also removed). Assessment and removal of pelvic lymph nodes (lymphadenectomy) May be offered adjuvant radiotherapy
38
How is stage III endometrial cancer managed?
Maximal de-bulking surgery if possible | Additional chemotherapy usually given prior to radiotherapy
39
What is the treatment for stage IV endometrial cancer?
Maximal de-bulking surgery if possible | But in many a palliative approach is preferred (low dose radiotherapy/oral high dose progestogens)
40
What follow up is required for endometrial cancer?
Frequent follow-up up to 5 years post-op due to recurrence risk
41
Describe the aetiology of adenomyosis.
Endometrial stroma allowed to communicate with the underlying myometrium after uterine damage (e.g. pregnancy, child birth, C-section, uterine surgery, surgery for miscarriage/termination)
42
Describe the pathophysiology of adenomyosis.
Invasion can be focal or diffuse. More commonly on the posterior wall of the uterus. Severe - pockets of mentrual blood can be seen in the myometrium of hysterectomy specimens Responsive to hormones.
43
What are adenomyoma?
When a collection of endometrial glands form grossly visible nodules
44
What are the risk factors for adenomyosis?
High parity Uterine surgery e.g. endometrial curettage, endometrial ablation Previous C section Genetics
45
What are the clinical features of adenomyosis?
Menorrhagia Dysmenorrhea (can begin as cyclical and then become daily pain) Deep dyspareunia Irregular bleeding Symmetrically enlarged, tender uterus may be palpable
46
What are the differentials for adenomyosis?
Endometriosis Fibroids Endometrial hyperplasia/carcinoma Endometrial polyps (not associated with dysmenorrhea) PID (not cyclical pain) Hypothyroidism and coagulation disorders (menorrhagia)
47
What are the investigations for adenomyosis?
Definitive diagnosis - histological after hysterectomy/hysteroscopic biopsy Transvaginal USS MRI
48
What are the signs of adenomyosis on transvaginal USS?
``` Globular uterine configuration Poor definition of the endometrial-myometrial surface Myometrium anterior-posterior asymmetry Intramyometrial cysts Heterogenous myometrium echo texture ```
49
What are the signs of adenomyosis that can be seen on MRI?
Endo-myometrium junctional zone distinguished from endometrium and outer myometrium An irregular thickening of this one
50
What is the main aim in the management of adenomyosis?
To control the dysmenorrhea and the menorrhagia
51
What is the only curative therapy for adenomyosis?
Hysterectomy
52
What are the hormonal therapies for adenomyosis?
COCP Progestogens (oral/IUS) GnRH agonists Aromatase inhibitors
53
How do the hormonal treatments for adenomyosis work?
Reduce proliferation of ectopic endometrial cells This decreases uterine size and volume of blood lost Continuous use may temporarily induce the regression of adenomyosis
54
What are the non-hormonal treatments for adenomyosis?
``` Analgesia Hysterectomy (only definitive management) Uterine artery embolisation Endometrial ablation and resection Laparoscopic excision Magnetic resonance-guided focused US ```
55
How does uterine artery embolisation work to treat adenomyosis and when might it be used?
In the short-medium term for women waning to avoid hysterectomy and/or preserve fertility Blocks the blood supply to the adenomyosis causing it to shrink

Gynaecology (12 decks)

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