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Congenital Anomalies and Benign Conditions of the Utererus and

Cervix

Prepared by: Mr’s Raheegeh Awni25/10/2010

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• Benign conditions of the uterine affect woman's fertility and can cause abnormal uterine bleeding or pelvic pain.

• A uterine anomaly is a form of congenital birth defect – in that the uterus forms when the fetus is inside her mother’s womb.

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• About ten weeks after conception, the uterus is comprised of a pair of structures called mullerianducts.

• The top of the ducts will become the fallopian tubes – they remain separated throughout development.

• The bottom of the mullerian ducts, however, begin to fuse together to become one structure that will become the uterus.

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Uterine anomalies result from:

• failure of one of the two mullerian ducts to form (unicornuate),

• failure of the two ducts to fuse completely (bicornuate), or

• failure of the two fused mullerian ducts to dissolve the median septum (septate).

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The most common anomalies of the uterus

• Uterus didelphys, which presents with two separate uterine bodies, each with its own cervix and attached fallopian tube and vagina.

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• A bicornuate uterus with a rudimentary horn also represents a fusion failure.

• Less complete fusion failure is seen in the bicornuate uterus with or without double cervices.

• Incomplete dissolution of the midline fusion of the paramesonephria explains the septate uterus.

• In müllerian agnesis, there is complete lack of development of the paramesonephric system.

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• The affected woman generally has an incomplete development of the fallopian tubes associated with the absence of the uterus and most of the vagina.

• All of these conditions occur in normal karyotypic and phenotypic females but can be associated with important anomalies of the urinary system.

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• Although all of these anomalies can occur spontaneously, they may also be caused by early maternal exposure to certain drugs.

• A diethylstilbestrol (DES)-exposed female infant has an increased risk for a small, T-shaped endometrial cavity or cervical collar deformity.

• DES exposure in utero can also produce fallopian tube abnormalities although it does not appear to cause abnormalities of the urinary tract.

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• A unicornuate uterus is a uterus that has a single horn and a banana shape and it can have a negative effect on fertility and pregnancy. Approximately 65% of women with a unicornuate uterus also have a second smaller or rudimentary uterine horn.

• A unicornuate uterus is a uterus that has a single horn and a banana shape and it can have a negative effect on fertility and pregnancy

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Uterine fibroid

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UTERINE LEIOMYOMAS

• ("fibroids") are benign tumors derived from the smooth muscle cells of the myometrium.

• They are the most common neoplasm of the uterus.• Estimates are that more than 45% of women have

leiomyomas by the fifth decade of life, but most are asymptomatic.

• However, leiomyomas can cause excessive uterine bleeding, pelvic pressure and pain, as well as infertility.

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• They are the primary indication for 200,000 to 300,000 hysterectomies in the United States each year.

• Although leiomyomas have the potential to grow to impressive sizes, their malignant potential is minimal.

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Risk factors

• increasing age during the reproductive years,• ethnicity (African-American women have at

least a 2- to 3-fold increased risk compared to Caucasian women),

• Nulliparity• family history.• higher body mass index.• Oral contraceptive pills and dep injections

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Pathogenesis

• ovarian sex steroids are important for their growth.

• Leiomyomas rarely develop before menarche and seldom develop or enlarge after menopauseLeiomyomas can also enlarge dramatically during pregnancy.

• Leiomyomas have increased levels of estrogen and progesterone receptors compared to other smooth muscle cells.

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• Estrogen stimulates the proliferation of smooth muscle cell, whereas progesterone increases the production of proteins that interfere with programmed cell death (or apoptosis).

• Leiomyomas also have higher levels of growth factors that stimulate the production of fibronectin and collagen, major components of the extracellular matrix that characterizes these lesions.

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Characteristics• Leiomyomas are usually spherical, well-circumscribed, white,

firm lesions with a whorled appearance on cut section. • Appears discrete, it does not have a true cellular capsule. • Compressed smooth muscle cells on the tumor's periphery

provide the false impression of such a capsule. • Calcification may occur in degenerated fibroids, particularly

after the menopause.• During pregnancy, 5% to 10% of women with fibroids

undergo a painful red or carneous degeneration caused by hemorrhage into the tumor.

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types

• Leiomyomas arise within the myometrium (intramural), but some migrate toward the serosal surface (subserosal) or toward the endometrium (submucosal).

• Individual tumors may migrate further by developing large pedicles.

• An aborting leiomyoma causes significant bleeding and cramping pain.

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types1- Submucous fibroids• the submucous type is the one that should be

recognized as it is a cause of fertility problems or excessive bleeding.

• If there is a view to operative intervention, the proportion of the fibroid that is related to the

uterine cavity should be assessed and an idea of the depth of penetration of the fibroid into the myometrium is made.

• can extend through the endometrial canal and about from the cervical os.

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DX.• Saline infusion sonography (SIS)

• Saline introduced into the uterine cavity, via a fine catheter, improves the specificity of the diagnosis of submucous fibroids.

• It defines the relationship of fibroid to uterine cavity.• Both transvaginal ultrasound alone and with saline

in the uterine cavity are more sensitive than hysteroscopy for diagnosing fibroids.

• Submucous fibroids characteristically have an overlying rim of endometrialtissue that aids recognition and confirms the submucous location.

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2- Subserosal fibroids• These are of lesser importance than submucous

fibroids, but if they become pedunculated they may be difficult to distinguish from an ovarian mass.

• In this situation a connection between the mass and uterus should be looked for.

• Colour flow Doppler may identify blood flow showing the connection between the two.

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• A subserosal leiomyoma on a long pedicle can present as a mass that feels separate from the uterus.

• Rarely, pedunculated subserosal myomata attach to the blood supply of the omentum or bowel mesentery and lose their uterine connection to become parasitic leiomyomas.

• Leiomyomas can also arise in the cervix, between the leaves of the broad ligament (intraligamentous), and in the various supporting ligaments (round or uterosacral) of the uterus.

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Symptoms

• The majority cause no symptoms. • The patient may become aware of a lower

abdominal mass if it protrudes above the pelvis.

• pelvic pressure, congestion, bloating, a feeling of heaviness in the lower abdomen, or lower back pain.

• frequency of urination.

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• has been associated with submucous myomas ulcerating through the endometrial lining.

• Excessive bleeding may result in anemia, weakness, dyspnea, and even congestive heart failure.

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• Menorrhagia may be associated with intramural or submucosal tumor.

• Metrorrhagia has been associated with submucous myomas ulcerating through the endometrial lining.

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• Fibroids are not generally painful, but severe pain may be associated with red degeneration (acute infarction) within a fibroid.

• Dyspareunia is also common with incarceration. • secondary dysmenorrhea caused by the increased

blood loss. • Although many women with uterine myomas

become pregnant and carry their pregnancies to term, these lesions may be associated with an increased incidence of infertility because of placentation challenges.

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Signs

• Very large fibroids can be palpated abdominally.

• on bimanual pelvic examination a firm, irregularly enlarged uterus with smoothly rounded in subserosal or intramural.

• nontender.• If the mass moves with the cervix, it is

suggestive of a leiomyoma.

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differential diagnosis

• an ovarian neoplasm, • a tubo-ovarian inflammatory mass, • a pelvic kidney, • a diverticular or inflammatory bowel mass,• cancer of the colon.• Ultrasonography may visualize the fibroids

and identify normal ovaries apart from the leiomyomas.

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Management

• if a small asymptomatic fibroid is detected, a repeat ultrasonic examination within 6 months is prudent to rule out a rapidly growing uterine sarcoma.

• The need for other interventions is determined by the clinical concerns presented by the leiomyoma.

• If menorrhagia is the chief complaint, an endometrial aspiration or dilatation and curettage (D&C) be performed to rule out related pathology.

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• Menorrhagia caused by fibroids may be managed hormonally in many cases.

• Progestin-only therapies (oral or injected) or combination hormonal contraceptive methods (oral contraceptive pills, or patches) are usually a first therapeutic option.

• The goal may be to reduce monthly menstrual blood loss with cyclic hormonal methods or to eliminate menses with extended or continuous use of these methods.

• GnRH agonists have considerable efficacy in blocking ovarian steroidogenesis, which halts endometrial proliferation

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Surgical Management

• Surgical interventions are important to treat these problems as well as to treat leiomyoma that are not responsive to medical management.

• Myomectomy is the preferred surgical procedure for women with a limited number of tumors who desire uterine preservation.

• Myomectomy occasionally can be performed hysteroscopically for submucous masses or transabdominally (either laparoscopically or with laparotomy) for other leiomyomas.

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• Pretreatment for 3 months with GnRH agonists and the use of vasoconstrictive agents intraoperatively may improve surgical outcomes

• Myomectomy may not be successful in avoiding hysterectomy.

• Not all the tumors may be removed, and new leiomyomata may grow in the future.

• About 25% of women will require a subsequent operation. • If the endometrial cavity is entered during myomectomy,

future deliveries must be by cesarean.

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• Hysterectomy provides definitive therapy.• If the uterus is large (>12 to 14 cm), laparotomy is

generally the preferred approach. • Vaginal hysterectomy is generally preferred if the

uterus is not bulky and the vagina is not constricted.• Laparoscopically assisted vaginal hysterectomy

permits excellent visualization of the adnexae and controlled dissection from above without a large abdominal incision.

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Emerging therapies

1- Embolization of the uterine arteries supplying the leiomyomas for controlling leiomyoma-induced bleeding and to shrink the myomas.

2- Endometrial ablation with hysteroscopic resection, laser ablation,

3- newer thermal balloon methods.

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ENDOMETRIAL POLYPS• Endometrial polyps form from the endometrium to

create abnormal protrusions of friable tissue into the endometrial cavity.

• They can cause menorrhagia and spontaneous bleeding during the reproductive years and postmenopausal bleeding after menopause.

• They can be recognized on sonohysterography or by sonohysteroscopy.

• Endometrial polyps may evade detection by endometrial aspiration or D&C

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CERVICAL POLYPS

• Ectocervical and endocervical polyps are the most common benign neoplastic growths of the cervix.

• Endocervical polyps tend to the more beefy red in color and arise from the endocervical canal on a long, pedunculated stalk.

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• Ectocervical polyps are less common, are generally pale, and arise from the ectocervix to create a broad-based protrusion.

• May be isolated or multiple• Vary from a few millimeters to several centimeters. • They most commonly cause coital bleeding or menorrhagia. • Narrow-based polyps are removed by twisting the polyp off at

its base. • Broader-based polyps may be better removed with cautery or

other modalities that can control bleeding after removal. • All specimens must be sent for pathologic examination.

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