Benign Disease of Uterus and Cervix
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BENIGN DISEASE OF BENIGN DISEASE OF UTERUS AND CERVIXUTERUS AND CERVIX
4/11/2011
DR KASHFILMBBS (IMU)
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BENIGN DISEASE OF UTERUSBENIGN DISEASE OF UTERUS
- UTERINE FIBROID- ADENOMYOSIS- ENDOMETRIAL POLYP- ENDOMETRIAL HYPERPLASIA
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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
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UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Risk Factors:
- increasing age (>35yo)- low parity/infertility- family history – 1st degree relatives- obesity
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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
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UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Types:
- Submucous- Intramural- Subserosal- Pedunculated- Cervical
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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
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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
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UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Investigations:
- FBC – Hb level (severity of anaemia)- Pelvic ultrasound scan- Endometrial biopsy – TRO uterine hyperplasia or malignancy- Hysteroscopy
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UTERINE FIBROIDS UTERINE FIBROIDS (LEIOMYOMA)(LEIOMYOMA)Management:
- medical- surgical
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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
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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
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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
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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
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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
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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
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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
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ADENOMYOSISADENOMYOSISInvestigations:
- FBC – Hb level (if menorrhagia)- Pelvic ultrasound scan- Hysterosalpingography
Diagnosis:- Only confirmed by HPE
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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)
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ENDOMETRIAL POLYPSENDOMETRIAL POLYPSDefinition:
- Localized overgrowth of endometrial tissues, which is covered by epithelium
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ENDOMETRIAL POLYPSENDOMETRIAL POLYPSClinical presentation:
- asymptomatic (majority)- abnormal uterine bleeding i.e. menorrhagia, intermenstrual, postcoital and postmenopausal
bleeding- small polyps may regress
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ENDOMETRIAL POLYPSENDOMETRIAL POLYPSDiagnosis:
- Diagnostic hysteroscopy
Management:- Hysteroscopic resection (gold standard)
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ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIADefinition:
- Proliferative endometrium that is hyperplastic, due to prolonged or unopposed oestrogen stimulation- Premalignant condition
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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
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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
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ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIAInvestigations:
- FBC – Hb level (severity of anaemia)- Transvaginal ultrasound – ET- Endometrial Pipelle sampling- Diagnostic hysteroscopy and biopsy
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ENDOMETRIAL ENDOMETRIAL HYPERPLASIAHYPERPLASIASUMMARY OF TREATMENT OPTIONS FOR ENDOMETRIAL HYPERPLASIA
MEDICAL • Progestogen (Medroxyprogesterone acetate)• Danazol• COCs• Levonorgestrel IUD (Mirena)• GnRH agonist
SURGICAL • Hysterectomy +/- BSO
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BENIGN DISEASE OF CERVIXBENIGN DISEASE OF CERVIX- CERVICITIS- CERVICAL ECTROPION- NABOTHIAN CYST- CERVICAL AND ENDOCERVICAL POLYP
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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
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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
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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
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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
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THANK YOU THANK YOU HAVE A NICE DAYHAVE A NICE DAY