Uterus Problems

Fibroids

• Leiomyomata  benign tumours of the myometrium
• Present in around 25% or all women, more common in those approaching menopause
• Less common in parous women and those who have taken the contraceptive pill

• May be intramural, submucosal or subserosal
• On section fibroid has a whorled appearance
• Fibroid growth is oestrogen and probably progesterone dependant

Clinical features

• 50% are asymptomatic
• Menorrhagia or intermenstrual bleeding
• Dysmenorrhoea  rare, can occur when pedunculated fibroids undergo torsion
• May press on bladder cause frequency and urinary retention. Those pressing on the ureters may cause hydronephrosis
• Fertility may be affected if the tubial ostia are blocked or a submuscosal fibroid prevents implanation

Complications

• Torsion
• Degeneration due to inadequate blood supply, may result in haemorrhage or necrosis
• Malignancy  leiomyosarcoma
• Pregnancy premature labour, malpresentations, transverse lie, obstructed labour and postpartum haemorrhage. Red degeneration may occur when blood supply is inadequate which results in pain. Pedunculated fibroids may tort postpartum.

Investigations

• Ultrasound
• Laparoscopy may be required to distinguish fibroid from ovarian mass
• Hysteroscopy assess distortion of uterine cavity

Treatment

Medical

• GnRH agonist can be used to induce a temporary menopausal state to inhibit fibroid growth but use is limited to 9 mth due to side effects and bone density loss

Surgical

• Hysteroscopic
• Radical hysterectomy
• Myomectomy – removal of fibroids from the uterus. May result in heavy blood loss and recurrence
• Embolization – uterine artery embolization by radiologist. Can result in increased pain

Adenomyosis

• The presence of endometrial tissue and stroma in the myometrium
• Used to be termed ‘endometriosis interna’
• Most common around the age of 40 – symptoms reduce with the menopause
• Associated with endometriosis and fibroids
• Oestrogen dependant

Clinical features

• Symptoms may be absent
• May be associated with dysmenorrhoea or menorrhagia

Investigations

• MRI  not ultrasound

Treatment

• NSAIDs
• Progestogens
• Hysterectomy

Endometritis

• Infection confined to the uterine cavity
• Often a result of instrumentation of the uterus or is a complication of pregnancy
• Common after caesarean section, miscarriage or abortion when products of conception can be retained.
• Infectious organisms include Chlamydia and gonococcus

Clinical features

• Presents with persistent and often heavy bleeding
• Often accompanied by dysmenorrhoea
• Uterus is tender and the cervical os is often open
• Can result in septicaemia

Investigation/Management of Endometritis

• Vaginal and cervical swabs
• FBC
• Broad spectrum antibiotics given
• Evacuation of retained products of conception (ERPC)

Intrauterine Polyps

• Usually small benign endometrial derived tumours that grow into the uterine cavity
• Most common in women aged 40-50 and when oestrogen levels are high
• In post menopausal women they are found in those taking tamoxifen for breast cancer
• Can be asymptomatic or cause menorrhagia or intermenstrual bleeding

Haematometria

• Outflow obstruction resulting in blood accumulating in the uterus
• Cervical canal can be obstructed by fibrosis after endometrial resection, cone biopsy or carcinoma
• May also be caused by congenital abnormalities such as imperforate hymen or blind rudimentary uterine horn

Endometrial Carcinoma

• Most common genital tract cancer
• Prevalence highest in those aged over 60
• Usually presents early

Pathology

• 90% due to adenocarcinoma of columnar endometrial gland cells
• The rest are mostly adenosquamous carcinoma which contains malignant squamous and glandular tissue and has a poor prognosis

Aetiology

• Biggest risk is having a high ratio of oestrogen to progestogen

Risk factors

• Exogenous oestrogen without progestogen
• Obesity
• PCOS
  nulliparity
• Late menopause
• Ovarian oestrogen secreting tumours (derived from granulosa and thecal cells)
• Tamoxifen (acts as an oestrogen antagonist in the breast but an oestrogen agonist in the post menopausal uterus
• History of breast or ovarian carcinoma
• Lynch type II syndrome (familial non polyposis colonic carcinoma)

Positive factors

• Pregnancy
• Combined contraceptive pill

Clinical features

• PMB (10% risk of carcinoma)
• Irregular or intermenstrual bleeding
• Recent onset menorrhagia

Spread

• May spread directly through myometrium to cervix and upper vagina
• Ovaries maybe involved
• Lymphatic spread to pelvic and para-aortic nodes
• Blood borne spread occurs late
• Staging is surgical and histological and unlike cervical carcinoma includes lymph node involvement

Staging

• Stage 1 lesion confined to uterus
• 1a  in endometrium only
• 1b – invasion to less than ½ of myometrium
• 1c invasion greater that ½ of myometrium

• Stage 2 spread to cervix
• 2a in endocervical glands only
• 2b  in cervical stroma

• Stage 3 tumour invades through uterus
• 3a  invades serosa or adnexae
• 3b  vaginal metastases
• 3c  metastases to pelvic and para-aortic lymph nodes

• Stage 4 further spread
• 4a  in bowel or bladder
• 4b  distant metastases

Histological grading of Endometrial Carcinoma

• G1-3 is included for each stage
• G1 is well differentiated

Investigations

• Endometrial biopsy at hysteroscopy
• Examination under anaesthetic (EUA)
• CXR
• Ultrasound/MRIÂ - to assess spread

Treatment of Endometrial Carcinoma

• 75% present with stage 1 disease
• Laparotomy with total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
• External beam radiotherapy – used for patients considered to be high risk for lymph node involvement
• Vaginal vault radiotherapy
• Chemotherapy – limited role in advanced diseaseÂ

Prognosis of Endometrial Carcinoma

• Recurrence commonest at the vaginal vault
• Poor prognosis with age, advanced clinical stage, deep invasion, high tumour grade and adenosquamous histology

Uterine Sarcomas

• Rare, 150 cases a year in the UK
• Three categories
• Leiomyosarcoma – ‘malignant fibroids’
• Endometrial stromal tumours – most common around menopause
• Mixed Mullerian tumours – derived from embryological elements of the uterus. Most common in old age

Clinical features of Uterine Sarcomas

• Usually present with irregular or PMB
• In the case of leiomyosarcoma can present with rapid painful enlargement of a fibroidÂ

Treatment of Uterine Sarcomas

• Hysterectomy
• Radiotherapy and chemotherapy following surgery

Prognosisof Uterine Sarcomas

• Survival is 30% after 5 years