Uterine disorders
  • Endometrial Cancer

A uterine cancer usually seen in post-menopausal women, in 2 types:

i) Uterine sarcoma –a malignant proliferation of muscles of the uterus

ii) Adenocarcinoma – malignant proliferation of the endometrial glands – It is the most common invasive carcinoma of the female genital tract which is further divided into two subtypes:

– Type 1 ➔ Called an endometroid carcinoma where the tumours look like normal endometrial glands
– Associated
with high oestrogen levels and often preceded by endometrial hyperplasia

– Type 2 ➔ This has multiple subtypes, is a rarer and not linked to oestrogen exposure

Full adenocarcinoma is usually preceded by hyperplasia of the glands, which occurs due to oestrogen.
Oestrogen stimulates endometrial growth whereas progesterone stimulates shedding of this tissue
– The hyperplasia of the glands is subdivided into two types, one which is more dangerous:

i) Endometrial hyperplasia without atypia ➔ low risk of progression to cancer

ii) Endometrial hyperplasia with atypia ➔ abnormal cell with higher risk of progression to cancer

Risk factors
– Most are related to unopposed oestrogen exposure
– Early menarche + late menopause
– Obesity
– Infertility with anovulatory cycles
– Nulliparity
– Oestrogen only HRT
– Tamoxifen
– Polycystic Ovarian Syndrome
– Lynch syndrome (HNPCC)

 

Protective Factors COCP, later pregnancy, Breastfeeding, Smoking

Symptoms
– Post-menopausal bleeding (bleeding 1 year after the last menstrual period)
– In premenopausal women it can present as a change in menstrual bleeding or intermenstrual bleeding

Diagnosis
– Bimanual examination to assess uterus, ovaries
– 1
st line is transvaginal ultrasound ➔ used to measure the endometrial thickness
    – Also looks for free fluid, heterogeneity and invasion of endo/myometrium
    –> If thickness <4mm, no further investigations required
    –> If thickness > 4mm (post-menopause) or >7 (premenopausal) –> proceed to 2nd step
– Also do Pipelle biopsy 
➔ thin blind biopsy which the GP uses to get a sample of the endometrium

– 2nd step is hysteroscopy + biopsy ➔ Diagnostic test which indicates severity of disease.

Management:
– If hyperplasia without atypia (low risk of cancerous progression:
    – 1st line is discharge and manage risk factors (e.g. obesity)
    – If persists 
 progesterone treatment with Mirena coil or LNG-IUS to reduce hyperplasia

– If hyperplasia with atypia (high risk of cancerous progression):
    – If post-menopausal or does not want children
hysterectomy
    – If wants children 
➔ progesterone treatment quickly, have baby and then hysterectomy after

If full adenocarcinoma ➔ The FIGO1 staging system is used to decide treatment:

Stage

Description

Treatment

I

Carcinoma confined within the uterine body

Total abdominal hysterectomy with bilateral salpingo-oophorectomy (+ post- op radiotherapy)

II

Carcinoma may extend to the cervix but not beyond the uterus

III

Carcinoma extends beyond the uterus but is confined to the pelvis

IV

Carcinoma involves bladder/bowel or has distant metastases

Probably palliative progestogen therapy

 

NICE Referral Guidelines2:
Urgent (2 weeks):
if Age > 55 with post-menopausal bleeding

  • Adenomyosis

A condition in which endometrial tissue is present within the myometrium (muscle layer) of the uterus
– Thought to result from abnormal healing of damaged endometrium in which the endometrium aberrantly invaginates into the myometrium

Risk factors
– Uterine damage: childbirth, previous C-section or surgery

Symptoms
– Typically seen in multiparous women age 40-50yrs
Dysmenorrhoea
– Menorrhagia
– Enlarged, boggy uterus

Diagnosis
– Transvaginal Ultrasound or MRI

Management:
– Non-hormonal –> mefenamic/tranexamic acid to relieve menorrhagia
– Hormonal –> Low dose COCP, high-dose oral progestogens, Mirena
– Surgical = uterus-conserving (e.g. endometrial ablation, uterine artery embolization), or hysterectomy

  • Fibroids (leiomyomas)

These are benign tumours of the uterine wall composed of smooth muscle and fibroblasts.

Risk factors
– Age, early puberty, obesity, ethnicity (more common in black and Asian women)

Fibroids are classified according to their wall position:
i) Intramural 
➔ develop completely within the myometrium and do not extend into the uterine or peritoneal cavity
ii) Submucosal 
➔ develop in the inner aspect of myometrium (under the inner mucosa) and extend into the uterine cavity
iii) Subserosal 
➔ develop in the outer aspect of the myometrium (under the serosa) and extend into the peritoneal cavity

Symptoms – Can by asymptomatic
– Most common symptom is heavy menstrual bleeding
– Pelvic pain
– Subfertility
– Pressure symptoms –> urinary frequency, bloating, constipation                                                                                   
– Firm, large, irregularly shaped uterus on bimanual exam

– Can cause red degeneration:
    – A haemorrhage into the tumour that usually occurs during pregnancy
    – Gives heavy bleeding and acute pelvic pain

Diagnosis
– Transvaginal ultrasound is the diagnostic test

Management
First medical approaches are used, but if uncontrolled then surgical options:
i) Reducing bleeding –> 1
st line is insertion of a Mirena (progesterone coil)
     – If not suitable: COCP, cyclical oral progestogen, mefenamic acid, tranexamic

ii) Shrink Fibroids —> Selective progesterone modulator (Ulipristal)
– GnRH analogues (Zolidex), can only be used for 6 months due to osteoporosis risk

iii) If symptoms are still not controlled with medical management, then options for surgery include:
-Hysteroscopic resection of fibroids -> can be used for submucosal fibroids
– Hysterectomy -> most effective way of preventing recurrence
– Myomectomy -> alternative to hysterectomy if the woman wishes to preserve her fertility

iv) Non-Invasive procedures provide an alternative option to surgery and include:
– Uterine artery embolization -> risk of early miscarriage and placenta misplacement
– Endometrial ablation -> can be used for small fibroids in the uterine lining

 

  • Asherman Syndrome

This is the development of intrauterine adhesions
– It is caused by damage to the basal layer of the endometrium leading to formation of adhesions
– Amenorrhoea may occur in this condition as the adhesion tissue does not respond to oestrogen
– Mostly caused by procedures performed on the uterus -> typically surgical management of miscarriage/termination of pregnancy (but also endometrial biopsy, fibroid surgery)

Symptoms
– Secondary amenorrhea or little/infrequent menstrual bleeding and infertility

Diagnosis
– Hysteroscopy is the gold standard

Management
– Surgical excision of the adhesions

  • Endometriosis

This is a condition in which there is growth of endometrial tissue outside the uterine cavity
– The deposits are mostly found within the pelvis (e.g. ovaries, pouch of Douglas, bladder, rectum) but in rare cases may be seen in extra-pelvic locations like the diaphragm and pleural cavity
– As endometrial tissue responds to oestrogen, symptoms vary with the menstrual cycle
– At the time of menstruation there may be bleeding at the location of the ectopic tissue which can lead to pain and inflammation at these sites occurring in a cyclical fashion
– The chronic inflammation reduces fertility, but with treatment women can become fertile again

Symptoms:
– Pain –> chronic pelvic pain (>6 months), dysmenorrhea
– Deep dyspareunia
– GI symptoms –> painful bowel movements
– Urinary symptoms –> dysuria, haematuria
– Subfertility
– On examination there may be reduced organ mobility, enlargement and tender nodules in posterior vaginal fornix.
– Endometriotic lesions may be visible.

Diagnosis
Laparoscopy is used to identify ectopic lesions

Management:
Pain can be managed with:
– 1
st line is NSAIDs and/or paracetamol
– 2
nd line is COCP, progestogens (pill, implant or injection), Mirena

If these are ineffective, not tolerated or contraindicate, refer to gynaecology
    -Treatment may involve 
laparoscopic excision/ablation of endometriosis
    – GnRH agonists may be given as an adjunct before surgery

N.B. Subfertility in endometriosis should be managed by an MDT team involving fertility specialists. Surgical interventions can improve the chance of spontaneous pregnancy.

 

Sign up to our mailing list to get an exclusive 10% discount on In2Med courses!