Uterus and its abnormalities

Question 1

What is the most common genital tract cancer?

Answer 1

Endometrial carcinoma

Question 2

Prevalence of Endometrial Ca highest at?

Answer 2

60 years

Question 3

What % Endom Ca happen premenopausally?

Answer 3

15%

Question 4

What % Endo Ca under 35 years?

Answer 4

<1%

Question 5

Most common pathology of Endom ca?

Answer 5

Adenocarcinoma of columnar endometrial glands. >90%

Question 6

Main risk factor principle involved in EndoM ca?

Answer 6

High oestrogen to progesterone ratio

Question 7

Risk factors for EndoM Ca? (1+6)

Answer 7

Exogenous oestrogens- Obesity, PCOS, Nulliparity, late menopause, Ovarian granulosa cell tumours, tamoxifen

Question 8

Why is tamoxifen a risk factor for EndoM ca?

Answer 8

Its an oestrogen antagonist in the breast but an agonist in the postmenopausal uterus.

Question 9

What is the premalignant type of EndoM ca?

Answer 9

Cystic hyperplasia–>Atypical hyperplasia/ endometrial hyperplasia with atypia. Often co-exists with malignancy (40%)

Question 10

How do you treat Endometrial hyperplasia?

Answer 10

Progestogens with 6 monthly endometrial biopsy OR hysterectomy

Question 11

What are the wishy washy risk factors for EndoM Ca? 3

Answer 11

Diabetes, Hypertension, Lynch type 2 syndrome

Question 12

How does Endometrial Ca present?

Answer 12

PMB or IMB/ irregular periods/menorrhagia

Abnormal smear.

Question 13

How do you stage Endometrial Ca?

Answer 13

Stage 1a,b,c Endometrium, 1/2 myometrium.
Stage 2a,b- Cervical glands, cervical stroma
Stage 3A,B,Ci,ii- outside uterus locally
Stage 4 A,B- Bowel bladder, distant mets

Question 14

When can you stage an Endometrial Ca?

Answer 14

After hysterectomy

Question 15

What is diagnostic of an EndoM Ca?

Answer 15

Biopsy

Question 16

How do you treat stage 1 EndoM Ca?

Answer 16

Hysterectomy and a BSO abdominally or laprascopically.

Question 17

What do you find in surgery sometimes while operating a stage 1 EndoM ca?

Answer 17

Lymph node involvement- staging!

Question 18

What do you do for late stage EndoM ca?

Answer 18

Offer External beam radiotherapy

Question 19

What is vaginal vault radiotherapy?

Answer 19

Stops EndoM Ca recurrence which is very common in first 3 years- but doesnt prolong survival.

Question 20

What are poor prognostic features of EndoM ca?

Answer 20

Old age, advanced clinical age, Deep myometrial invasion, high tumour grade, adenosquamous histology.

Question 21

What are uterine sarcomas?

Answer 21

Malignant cancer of the smooth muscle of the uterus

Question 22

What are the 3 main types of uterine sarcomas?

Answer 22

Leiyomyosarcoma, Endometrial stromal tumour, Mixed mullerian tumours

Question 23

Endometrial stromal tumours are most common in what age group?

Answer 23

Perimenopausal

Question 24

Mixed mullerian tumours are most common in what age group?

Answer 24

Old age

Question 25

How would leiyomyosarcoma present?

Answer 25

rapidly enlarging painful fibroid

Question 26

Another name for fibroids

Answer 26

leiomyomata

Question 27

What are leiyomyomata

Answer 27

benign tumours of myometrium

Question 28

Risk factors for fibroids (4)

Answer 28

More oestrogen- Common near menopause, Afro-caribbean, family history, nulliparous

Question 29

Types of fibroids and where they form

Answer 29

Subserous polyp, Subserous, Intracavity polyp, Intramural, Submucosal, Cervical

Question 30

Fibroid growth is dependent upon..

Answer 30

oestrogens and progesterone

Question 31

What happens to fibroids after menopause

Answer 31

Regress, often calcify

Question 32

How do fibroids present

Answer 32

Menorrhagia, Intermenstrural loss, dysmenorrhoea, Pressure effects- urinary frequency and retention, subfertility- tual ostia

Question 33

Complications/natural history of fibroids (5)

Answer 33

Oestrogen dependent enlargement Calcification Torsion in pedunculated fibroids. Degenerations due to poor blood supply- red/hyaline/cystic Leiomyosarcomata

Question 34

How does red degeneration present?

Answer 34

Pain and uterine tenderness, haemorrhage and necrosis

Question 35

How do fibroids complicate pregnancy? (6)

Answer 35

Premys, Malpresentation, transverse lie, Obstructed labour, PPH, Red degeneration (severe pain)

Question 36

Diagnosis of fibroids?

Answer 36

MRI/Laproscopy

Question 37

Connection between fibroids and vaginal bleeding?

Answer 37

Hb can be low from vaginal bleeds but high because fibroids can produce EPO

Question 38

How to medically treat fibroids (5)

Answer 38

Conservative- dont treat if asymp, US for malignancy Medical- Tranexamic acid, NSAIDS, and progestagens for menorrhagia. GnRH agonists- induces menopause- shrinks fibroids

Question 39

How to surgically treat fibroids (5)

Answer 39

1) Hysteroscopy- pre treat with GnRH analogues and then TCRF 2) Myomectomy- open/lap with preop gnrh and vasopressin in myometrium to reduce blood loss 3) Hysterectomy- lap/vag/open, 2-3m GnRH 4) UAE- Uterine artery embolization 5) Ablation- MRI guided transcutaneous focussed ultrasound

Question 40

How do GnRH agonists help in Fibroids

Answer 40

They shrink the fibroid- before surgery/otherwise, reduce vascularity, thin endometrium

Question 41

What is adenomyosis?

Answer 41

Presence of endometrium and underlying stroma within myometrium.

Question 42

Risk/associations of adenomyosis?

Answer 42

Age 40, endometriosis, fibroids, oestrogen dependent

Question 43

How does adenomyosis present?

Answer 43

Absent symptoms or painful, regular and heavy menses

Question 44

How do you treat adenomyosis?

Answer 44

Medical- IUS COCP +/- NSAIDS Surgical- Hysterectomy GnRH analogue therapy to see if hysterectomy would work

Question 45

Endometritis is?

Answer 45

Inflammation of the endometrium

Question 46

Endometritis is caused by?

Answer 46

secondary to STDs, complication of surgery, caesarian/TOP, RPOC, foreign tissue.

Question 47

Infection in a post menopausal uterus is usually due to....

Answer 47

malignancy

Question 48

Treatment for endometritis (2)

Answer 48

Antibiotics, occasionally ERPC.

Question 49

Brief summary of intrauterine polyps

Answer 49

benign tumours in intrauterine cavity, endometrial origin, oestrogen dependent, sometimes derived off fibroids, 40-50 years, Menorrhagia, IMB,prolapse through cervix,resect with diathermy/avulsion.

Question 50

Haematometra is

Answer 50

blood accumulation in uterus because of outflow obstruction

Question 51

haematometra is caused by?(3)

Answer 51

Cervical canal obstructed due to fibrosis post endometrial resection, cone biopsy, carcinoma.

Question 52

congenital uterine malformations usually present with...(4)

Answer 52

recurrent miscarriages, malpresentation, transverse lie and preterm labour

Question 53

External bean radiotherapy is offered to

Answer 53

patients considered to be high risk for having lymph node involvement after theyve had a hysterectomy