BENIGN DISEASE OF BENIGN DISEASE OF UTERUS AND CERVIXUTERUS AND CERVIX

4/11/2011

DR KASHFILMBBS (IMU)

BENIGN DISEASE OF UTERUSBENIGN DISEASE OF UTERUS

- UTERINE FIBROID- ADENOMYOSIS- ENDOMETRIAL POLYP- ENDOMETRIAL HYPERPLASIA

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Definition:

- Benign solid tumour of uterus, which consists of smooth muscle and fibrous tissue- Arises from the muscular wall of uterus

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Risk Factors:

- increasing age (>35yo)- low parity/infertility- family history – 1st degree relatives- obesity

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Aetiology:

- Hormonal influence (oestrogen dependant)- Growth rapidly during pregnancy, OCP, PCOS, granulosa cell tumour- Rarely before menarrche and regress after menopause

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Types:

- Submucous- Intramural- Subserosal- Pedunculated- Cervical

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)

Effect of Pregnancy on Fibroids Effect of Fibroids on Pregnancy

Rapid growthRed degeneration

(10%)

- presented as pain,

tenderness, fever,

leucocytosis

Recurrent abortionPreterm labour (15-

20%)PPROM IUGR (10%)Malpresentation (20%)Obstructed labourHigh risk of caesarean

deliveryPPH

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)

Clinical history: Physical examination:

- asymptomatic (50%)

- menorrhagia

- palpable mass

- compressive symptoms

- pelvic pain

- pallor

- palpable uterine mass

per abdomen (usually

firm, lobulated & non

tender)

- speculum

- bimanual palpation

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Investigations:

- FBC – Hb level (severity of anaemia)- Pelvic ultrasound scan- Endometrial biopsy – TRO uterine hyperplasia or malignancy- Hysteroscopy

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Management:

- medical- surgical

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Indications for interventions:

- significant symptoms- large fibroid >16 weeks size- infertility- previous pregnancy complications caused by fibroids- rapidly growing or suspicion of leiomyosarcoma

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Mode of treatment should based

on:- symptoms- size of the fibroid- age- parity and desire of fertility- availability of local expertise

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)

SUMMARY OF TREATMENT OPTIONS FOR FIBROIDS

Treatment Symptoms

MEDICAL Pain Heavy menstrual bleeding

NSAIDs, COX-2 inhibitors

Tranexamic acid +/- NSAIDs

Danazol

COCs

Levonorgestrel IUD (Mirena)

GnRH agonist (Lucrin/Zoladex)

INTERVENTIONAL RADIOLOGY

Uterine artery embolization

SURGICAL Myomectomy – open, laparoscopic, vaginal, hysteroscopic

Hysterectomy

UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA) Uterine artery embolization (UAE)

- by interventional radiologist

- under local anaesthesia

- catheter is inserted into the femoral artery at the level of groin

- enter selectively into both uterine arteries and inject small (500

µm) particles that will block the blood supply to the fibroids

- UAE results in shrinking of fibroids and alleviation of symptoms

ADENOMYOSISADENOMYOSISDefinition:

- A form of endometriosis- Presence of ectopic endometrial glands

and stroma in the myometrium of uterus- With hypertrophy and hyperplasia

of myometrium

- More commonly seen in multiparous women in theirlate 30s until menopause

ADENOMYOSISADENOMYOSIS

Clinical history: Physical examination:

- asymptomatic (50%)

- secondary

dysmenorrhoea

- menorrhagia

- infertility

- uniformly enlarged

uterus but usually <14

weeks size

- tender on bimanual

palpation, especially

perimenstrual period

COMPARISON BETWEEN UTERINE FIBROID WITH ADENOMYOSIS

UTERINE FIBROID ADENOMYOSIS

Commonest benign uterine tumour

Relatively less common

> Nulliparous > Multiparous

Age group 30yo and above Age group 40yo and above (older)

Main complaint menorrhagia Main complaint severe dysmenorrhoea

Any size Grows up to <14 weeks size

Non tender Tender especially perimenstrual period

ADENOMYOSISADENOMYOSISInvestigations:

- FBC – Hb level (if menorrhagia)- Pelvic ultrasound scan- Hysterosalpingography

Diagnosis:- Only confirmed by HPE

ADENOMYOSISADENOMYOSISSUMMARY OF TREATMENT OPTIONS FOR ADENOMYOSIS

MEDICAL • NSAIDs +/- Tranexamic acid• COCs• Danazol• Progestogens• Levonorgestrel IUD (Mirena)• GnRH agonist

SURGICAL • Wedge resection• Hysteroscopic resection of endometrium• Hysterectomy (definitive)

ENDOMETRIAL POLYPSENDOMETRIAL POLYPSDefinition:

- Localized overgrowth of endometrial tissues, which is covered by epithelium

ENDOMETRIAL POLYPSENDOMETRIAL POLYPSClinical presentation:

- asymptomatic (majority)- abnormal uterine bleeding i.e. menorrhagia, intermenstrual, postcoital and postmenopausal

bleeding- small polyps may regress

ENDOMETRIAL POLYPSENDOMETRIAL POLYPSDiagnosis:

- Diagnostic hysteroscopy

Management:- Hysteroscopic resection (gold standard)

ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIADefinition:

- Proliferative endometrium that is hyperplastic, due to prolonged or unopposed oestrogen stimulation- Premalignant condition

ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIA

Aetiology & Predisposing Factors:- Raised oestrogen levels- Endogenous stimulation, eg:

i) Anovulatory cycles in PCOS and infertile women ii) Obesity iii) Ovarian stromal hyperplasia iv) Carcinoma of ovary that produces oestrogen- Exogenous stimulation, eg:

i) Unopposed oestrogen replacement therapy ii) Tamoxifen therapy- Family history of endometrial and colonic cancer

ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIA

Clinical history: Physical examination:

- irregular menstrual

cycles (often excessive

and/or prolonged

menstrual loss)

- post menopausal

bleeding

- +/- Tamoxifen therapy

- obese

- pallor (if menorrhagia)

- usually has no

significant abdominal or

pelvic findings

ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIAInvestigations:

- FBC – Hb level (severity of anaemia)- Transvaginal ultrasound – ET- Endometrial Pipelle sampling- Diagnostic hysteroscopy and biopsy

ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIASUMMARY OF TREATMENT OPTIONS FOR ENDOMETRIAL HYPERPLASIA

MEDICAL • Progestogen (Medroxyprogesterone acetate)• Danazol• COCs• Levonorgestrel IUD (Mirena)• GnRH agonist

SURGICAL • Hysterectomy +/- BSO

BENIGN DISEASE OF CERVIXBENIGN DISEASE OF CERVIX- CERVICITIS- CERVICAL ECTROPION- NABOTHIAN CYST- CERVICAL AND ENDOCERVICAL POLYP

CERVICITISCERVICITIS Inflammation of the endocervical glands or

the ectocervix Infection: chlamydia, gonococcal, herpes

simplex, trichomonas, other gram positive and negative organisms

Mucopurulent discharge, cervical erythema, ulceration and contact bleeding

CERVICAL ECTROPIONCERVICAL ECTROPION

Occurs when squamous epithelium covering the ectocervix and vagina mucosa is replaced by columnar epithelium, arising from the endocervical canal

Often seen during pregnancy, COCs use, tampon usersMucoid vaginal discharge, irregular spotting or

postcoital bleedingSpeculum: red base lesion of ectocervix with

sharp borders, may bleed on touchCervical cytology screening (TRO CIN/malignancy)Treatment: cauterisation with diathermy, freezing using

cryosurgery

NABOTHIAN CYSTSNABOTHIAN CYSTSObstruction to the flow of secretions from

endocervical glandsFollowing chronic inflammation, infections or

squamous metaplasia of the cervixContains thick clear mucusSpeculum: raised lesion on ectocervix. May

appeared as translucent, white, with yellowish

or bluish tinge

Reassurance is important

CERVICAL AND ENDOCERVICAL CERVICAL AND ENDOCERVICAL POLYPSPOLYPSUsually small Irregular menstrual bleeding, post coital or

post menopausal bleeding, excessive vaginal discharge

Speculum: smooth, red and elongated mass at os

Cervical cytology screeningRemoved by polyp forcep and sent for HPE If there is bleeding from base of stalk→

cauterisation

THANK YOU THANK YOU HAVE A NICE DAYHAVE A NICE DAY