Uterine disorders

1. UTERINE DISORDERS

2. 1. Endometrial polyps
 Are discrete outgrowths of endometrium,
attached by a pedicle
 They may be pedunculated (has stalk) or sessile
(no stalk)
 Can cause intermenstrual bleeding
 They should be removed in women over the age of
40, premenopausal and menopausal women.

3. 2. Uterine fibroids
 A fibroid is a benign tumor of uterine smooth
muscle
 Also called a leiomyoma or myoma
 They appear as firm, whorled tumor
 Fibroids are estrogen dependent.

4. Classification of fibroids
 Based on the location within the layers of the uterus.
a) Submucous fibroid- located adjacent to and bulging into
the endometrial cavity
b) Intramural fibroid- centrally within the myometrium
c) Subserosal fibroid- at the outer border of the
myometrium
d) Pedunculated fibroid- attached to the uterus by a narrow
pedicle containing blood vessels

5. Risk factors
 Nulliparity
 Obesity
 Positive family history
 Race- African
 Older age- incidence of leiomyomas increases as
the woman gets older

6. Clinical features
 Majority are asymptomatic
 Clinical features include:
Firm pelvic mass
Menstrual disturbance
Pressure symptoms, esp. urinary frequency

7. Investigations
 Ultrasound
 Hb- will be low

8. Treatment
 Conservative management for asymptomatic
fibroids
 Gonadotrophin releasing hormone (GRH) agonists
for heavy menstrual bleeding
 Myomectomy (uterus is preserved) or
hysterectomy where a bulky fibroid uterus causes
pressure symptoms
 Uterine artery embolization- involves injection of
polyvinyl alcohol pellets into the uterine artery

9. 3. Endometriosis
 Is a condition in which the endometrial tissue lies outside the
endometrial cavity
 Endometriotic tissue responds to cyclical hormonal changes and
therefore undergoes cyclical bleeding and local inflammatory reaction
 Repeated bleeding and healing leads to fibrosis
 The cyclical damage causes adhesions between associated organs
causing pain and infertility.
 Common sites involved include:
 Uterosacral ligaments
 Umbilicus
 Pleural cavity
 Abdominal scars

10. Clinical features
 Dysmenorrhea
 Deep dyspareunia- endometriosis in the pouch of
Douglas
 Lower back pain
 Lower abdominal and pelvic pain
 Infertility
 Local symptoms for distant sites e.g., cyclical
epistaxis with nasal deposits, cyclical rectal
bleeding with bowel deposits.

11. Investigations
 Transvaginal ultrasound- ovarian endometriosis
 MRI for small lesions in deep tissues
 Laparoscopy

12. Management
 It is impossible to guarantee complete cure
 Medical treatment:
 Analgesics- NSAIDS for dysmenorrhea and pelvic pain
 COCs initially for 6 months; if symptoms are relieved,
continued indefinitely or until pregnancy is desired
 Progestogens e.g., medroxyprogesterone acetate,
levonorgestrel intrauterine systems (LNG-IUS)
 Gonadotrophin releasing hormone agonists

13. Cont’d
 Surgical treatment:
 Conservative surgery- laparoscopic surgery with
diathermy, laser vaporization or excision
 Definite surgery- hysterectomy and bilateral
salpingoophorectomy (removal of ovaries and tubes

14. 4. Adenomyosis
 Is a condition where endometrial tissue/ glands
invade the myometrium
 Incidence is highest in women 40-50 years.

15. Clinical features
 Severe secondary dysmenorrhea
 Increased menstrual blood loss (menorrhagia)
 Enlarged, firm, and tender uterus

16. Investigations
 Ultrasound
 MRI scan- more definitive

17. Treatment
 Treatments that induce amenorrhea will relieve
pain and excessive bleeding e.g., COCs, POPs
 Hysterectomy is the only definitive treatment

18. MALIGNANT DISORDERS OF THE UTERUS
1. Endometrial cancer
2. Cervical cancer

19. 1. Endometrial cancer
 Adenocarcinoma is the most common type of cancer
affecting the uterus
 Staging:
I. Stage I endometrial cancer: confined to
endometrium
II. Stage II cancer: also involves the cervix
III. Stage III: reaches the vagina or lymph nodes
IV. Stage IV: spread to the bowel; or bladder mucosa
and/ or beyond the pelvis

20. Risk factors
 Women in reproductive age
 Nulliparity
 Family history
 Uterine polyps
 Late menopause
 Chronic conditions e.g., DM and HTN
 Tamoxifen

21. Clinical manifestations
 Post-menopausal bleeding
 Watery, bloody vaginal discharge
 Low back pain
 Abdominal and low pelvic pain
 Palpable uterine mass or uterine polyp
 Enlarged uterus if the cancer is advanced

22. Investigations
 Serum tumor markers to assess for metastasis-
AFP, CA-125
 Transvaginal ultrasound
 Endometrial biopsy
 Chest X-ray
 MRI of the abdomen and pelvis
 Liver and bone scans

23. Management
 Surgical management:
 Stage I disease- total hysterectomy and bilateral
salpingoophorectomy (removal of uterus, fallopian
tubes, and ovaries)
 Stage II- radical hysterectomy with bilateral pelvic
lymph node dissection and removal of the upper third
of the vagina
 Brachytherapy- prevent disease recurrence
 Chemotherapy- palliative treatment in advance and
recurrent disease, with distant metastasis

24. 2. Cervical cancer
 The ectocervix is covered with squamous cells
 The endocervical canal is lined with columnar
(glandular) cells
 The squamocolumnar junction (SCJ) is the
transformation zone where most cell
abnormalities occur- because of rapid cell division
 Papanicolaou (PAP) tests sample cells from both
areas as a screening test for Ca cervix.

25. Cervical Intraepithelial Neoplasia (CIN)
 Premalignant changes are described on a
continuum from atypia (suspicious) to CIN to
Carcinoma In-Situ (CIS)
 CIS is the most advanced premalignant change
 CIS is cancer that has extended through the full
thickness of the epithelium of the cervix.

26. CIN
 CIN is graded on a scale of 1 to 3 depending on
the appearance of the cervical tissue under a
microscope:
1. CIN 1 (Mild dysplasia): little abnormal tissue
2. CIN 2 (moderate dysplasia): more tissue appears
abnormal
3. CIN 3 (severe dysplasia and CIS): most tissue
looks abnormal

27. Origin
 Most cervical cancers arise from the squamous
cells on the outside of the cervix.
 The other cancers arise from the mucus-secreting
glandular cells (adenocarcinoma) in the
endocervical canal.

28. Spread
 By direct extension to the vaginal mucosa, lower
uterine segment, parametrium, pelvic wall,
bladder, and bowel.
 Distant spread can occur through lymphatic
spread and circulation to the liver, lungs, or
bones.

29. Etiology and risk factors
 Most cases of ca cervix are caused by HPV (Human Papilloma Virus),
especially strains 16 and 18.
 The risk factors include:
 Girls and young women
 HPV infection
 Multiparity
 HIV/AIDS
 Family history of ca cervix
 Multiple sexual partners
 Early sexual debut (<18 yrs)
 History of STIs
 Obesity
 Intrauterine exposure to DES (Diethylstilbestrol)- synthetic estrogen

30. Clinical manifestations
 Pre-invasive cancer is often asymptomatic
 Invasive cancer presents with painless vaginal
bleeding, spotting between menstrual periods or
after sexual intercourse.
 Increased vaginal discharge
 Indurated cervix
 Stony hard and enlarged cervix
 Large fungating mass

31. Cont’d
 Metastatic disease may present with:
 Unexplained weight loss
 Dysuria
 Rectal bleeding
 Coughing
 Pelvic pain
 Hematuria
 Chest pain

32. Diagnosis
 Colposcopy- acetic acid solution (VIA VILLI)
 Endocervical biopsy- for histology

33. Management
 Surgery for early disease:
 Loop Electrosurgical Excision Procedure (LEEP)- diagnostic and
therapeutic procedure
 Laser therapy
 Cryotherapy
 Conization- cone biopsy
 Hysterectomy- total hysterectomy for treatment of microinvasive
cancer
 Radial hysterectomy and bilateral pelvic lymph node dissection for
cancer that has extended beyond the cervix (but not pelvic walls)
 Radiotherapy- invasive cervical cancer
 Chemotherapy- adjunctive therapy

34. Health promotion for Ca Cervix
 HPV vaccines:
1. Gardasil- a quadrivalent vaccine against HPV 16, 18, 31, and 38.
Given to adolescents at 0, 2, and 6 months IM in the deltoid
muscle
2. Cervarix- bivalent against HPV 16 and 18. Given 0.5mls at 0, 1,
and 6 months.
 Girls and young women (9-26 years) should get HPV
vaccine before their first sexual contact.
 Boys and young men (9-26 Yrs) are also given to prevent
genital warts (caused by HPV strains 6 and 11) and
prevent anal cancer (caused by HPV strains 16 and 18).

35. Cont’d
 Immunity lasts 10 years, and re-immunization may
be required.
 Periodic pelvic examinations and Pap tests to
screen for ca cervix early.
 Screening starts at the ae of 21 years.
 Women between 21-65 years should have a Pap
smear test every 3 years.