Benign lesions of uterus

Benign lesions of uterus

1. BENIGN LESIONS of

2. BODY OF UTERUS AND ENDOMETRIUM The uterus has two major components: Myometrium - composed of tightly interwoven bundles of smooth muscle that form the wall of the uterus Endometrium - composed of glands embedded in a cellular stroma

3. BODY OF UTERUS AND ENDOMETRIUM Diseases of uterus result from endocrine imbalances complications of pregnancy neoplastic proliferation

4. Benign disease of the uterus is an important problem for many women and their gynaecologists. The commonest condition in this category is fibroids but adenomyosis and uterine polyps are also importan t . Both fibroids and endometrial polyps are very common and although asymptomatic in many women, they can cause considerable morbidity for others.

5. Uterine polyps are benign polyps comprising endometrial, fibroid, cervical and placental polyp

6. Number • Single or multiple Types • Pedunculated • Sessile • Mucous • Fibroid • Placental Age • All age group • Peak (40-49 years) Size • Few mm – several cm

7. Endometrial polyps Endometrial polyps are discrete outgrowths of the endometrium that contain a variable amount of glands, stroma and blood vessels. They are attached to the endometrium by a pedicle and they may be pedunculated or sessile.

8. Endometrial polyp Localized overgrowths of the endometrial glands and stroma projecting beyond the endometrial surface Mostly arises from hyperplasia of endometrium Some of the endometrial lining protruding into the uterine cavity as polyps Composed of endometrial glands and stroma covered with a single layer of columnar epithelium Secondary malignant change may occur

9. Epidemiology The presence of endometrial polyps is being increasingly recognized since the widespread adoption of transvaginal ultrasound and outpatient's hysteroscopy . It is mostly seen in 25% of women with abnormal vaginal bleeding Peak age incidence is at 40-49 years At least 10% of asymptomatic women are also likely to have polyps They are particularly common in women taking preparations - such as tamoxifen for ca breast. Cause is unknown; - but in menopause, common in women with HRT Mostly are asymptomatic, mostly are detected by sonography. Common manifestation is intermenstrual bleeding in perimenopausal or postmenopausal bleeding.

10. RISK FACTOR S H R T T am o xi f en therapy Diabetes Hype r t ension Obesity Increased patient age

11. PAT HO L O G Y a part of thick endometrium project into the cavit y and ultimately attained pedicle/sessile CUT SECTION: grey or reddish brown GROSS APPEARANCE: Core : contain stromal cells , gland s and large thick walled vascular channel. Surface : lined by proliferative endometrial lining with cystic hyperplasia or squamous metaplasia Pedicle : contain thin fibrous tissue with thin blood vessel MICROSCOPIC

12. ENDOMETRIAL POLYP

13. PREDICTOR OF MALIGNANCY Size >10 mm Postmenopa usal status Ab n or m al uterine bleeding Malignant transformation is estimated at 0.5%

14. CLINICAL FEATURE S Maybe a s ym p t om a tic Menorrhagia I n t ermen s t r ual bleeding Contact bleeding (polyps situated outside cervix) Infertility and miscarriage (multiple polyps) Unscheduled vaginal bleeding or spotting is the commonest presentation for endometrial polyps

15. Single/multiple Pink swellings 1-2cm in diameter - With a pedicle

16. Site: within the endocervical canal Size: small and sessile to large (5-cm masses that protrude through the cervical os ) Consistency: soft& mucoid CERVICAL POLYP

17. Differential diagnosis: Submucous leiomyoma Adenomyoma Retained products of conception Endometrial hyperplasia Endometrial carcinoma Uterine sarcoma

18. ON EXAMINATION Uterus is in normal size /uniformly enlarged Cervix appears s oft, slippery and small in size (outside the cervix) PER SPECULUM : Reddish in color attached with s mall pedicle .

19. INVESTIGATION S Must be ruled out in women with abnormal uterine bleeding who do not respond to regular treatment .

20. 1 . Transvaginal ultrasound 2. Intrauterine injection of saline can markedly increase the diagnostic performance of transvaginal ultrasound . 3 . Hysteroscopy – The best method for diagnosing polyps is hysteroscopy; so it is a possibility that they might then be treated at the same time. They can be distinguished from pedunculated fibroids since they have fewer vessels over the surface.

21. MANAGEMENT Curettage of H y s t e r os c opi c endo m e trium polypectomy (to rule out hyperplasia)

22. Diagnosis of Malignant polyps: Malignant polyps are more likely to be irregular, vascular or friable . Biopsy should be carried out to confirm the diagnosis , since appearance is not sufficient . Treatment Optimal management is removal by Hysteroscopy with D and C In the symptomatic women, treatment will normally be performed under general anaesthesia . However, they can also be treated in the outpatients setting either by removal under direct vision or by treatment with specially developed diathermy instrumentation .

23. Placental polyp Formed from retained placental tissue May cause: Secondary postpartum hemorrhage Intermittent vaginal bleeding following an abortion or normal term delivery

24. Clinical features Menorrhagia Metrorrhagia Postmenopausal bleeding Postcoital bleeding (if it protrudes through the os)

25. Diagnosis Clinically, uterine polyp may not be evident and uterus may or may not be enlarged . It is easy to diagnose when the polypus protrudes through the cervical canal . Ulrasound can detect the uterine polyp Saline sonosalphingogram/hysterosalphingogram

26. Management D&C can scrape the polyp Hysteroscopic removal of multiple polyps may be desirable to ensure their complete removal.

27. Commonest benign tumor of the uterus Commonest benign tumor in female

28. fib r o m y oma Tumor is composed of fibrous connective tissue and smooth muscle

29. L E IO M Y OMA These are the b enign tumors of muscle cell origin . These are t he most frequent pelvic tumor s and the most common tumor s in women . Highest prevalence is above the 3 th decade of woman’s life Found in 30-50% of perimenopausal women Symptomatic leiomyomas are the primary indication for approximately 30% of all hysterectomies Risks factors: Increasing age Low parity Obesity positive family history Early menarche Tamoxifen use High fat diet African racial origin. A fibroid is a benign tumour of uterine smooth muscle, termed a s a leiomyoma.

30. Incidence: At least 20% of women at the age of 30 have got fibroid in their wombs 50% remains asymptomatic Incidence higher in black women More common in nulliparous / one child infertility

31. Prevalence: highest between 35-45 years (childbearing age group) Rarely before 20 years Although leiomyomas have the potential to grow to impressive sizes, their malignant potential is minimal. Sarcomatous changes occur in less than 1 per 1000 uteri with fibroids

32. Risk factors for developing leiomyomas include: 1 – Increasing age during the reproductive years, – Ethnicity : African-American women have at least 2- to 3 fold increased risk compared to Caucasian women , – Nulliparity, – Family history. – Higher body mass index is associated with a greater risk of leiomyomata.

33. Risk /Modifying factors for fibroid Increase Nulliparity Obesity Hyperestrogenic state Black women Decrease Multiparity Oral contraceptive pills and ( depot medroxyprogesterone acetate ) DMPA injections may be associated with reduced risk. Athletic women

34. Predominantly an estrogen-dependant tumor Evidenced by: Potentially limited during child-bearing period Increased growth during pregnancy Rarely occur before menarche Cessation of growth and there is no new growth at all following menopause Contain more estrogen receptors than the adjacent myometrium Frequent association of anovulation

35. Pathogenesis Factors that initiate leiomyomata are not known, but ovarian sex steroids are important for their growth. Leiomyomas rarely develop before menarche and seldom develop or enlarge after menopause, unless stimulated by exogenous hormones. Leiomyomas can also enlarge dramatically during pregnancy. Leiomyomas have increased levels of estrogen and progesterone receptors compared to other smooth muscle cells. 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.

36. GROWTH Not squarely distributed amongst the fibroids which are usually multiple Some grow faster than the others

37. On the whole, rate of growth is SLOW Takes about 3-5 years for the fibroid to grow sufficiently to be felt per abdomen

38. grows RAPIDLY  During pregnancy  Amongst pill users (high dose pills)  Due to malignant change * T he newer low dose OCP are not associated with increase in the growth of a fibroid

39. T y p es Body (Corpo r eal) Intramural (75%) Subserosal (15%) S u b m u c os a l (5%) C e r vi c al Fibroids consist of varying proportions of smooth muscle and fibroblasts. They may be single or multiple and can occur anywhere in the uterus

40. Fibroids are usually located in the body and are usually multiple

41. Morphology Site – Leiomyoma can occur within the myometrium – intramural - just beneath endometrium - submucosal - beneath the serosa - subserosal Size - varying in size from small to massive tumors that fill the pelvis . Number – single or most often multiple

42. Shape - sharply circumscribed, discrete, round Color & Consistency - firm, gray-white tumors on cut section – characteris ed by the pattern of smooth muscle bundles red degeneration- areas of yellow-brown to red softening in large tumors

43. Morphology On histologic examination leiomyoma is composed of , whorled bundles of smooth muscle cells that resemble the uninvolved myometrium T he individual muscle cells are, uniform in size and shape have the characteristic of oval nucleus l ong cytoplasmic processes

44. Initially, fibroids are intramural in position but subsequently, some are pushed outward or inward about 70% persist in that position INTERSTITIAL/INTRAMURAL

45. Intramural fibroid is pushed outwards towards the peritoneal cavity SUBSE R O S AL/SUBPERI T ON E AL

46. When it completely covered by peritoneum, it usually attains a pedicle – “ pedunculated subserosal fibroid ” SUBSE R O S AL/SUBPERI T ON E AL

47. On rare occasion, the pedicle may be torn; the fibroid gets its nourishment from the omental or mesenteric adhesions – “ w anderin g /p a r asitic fibroid ” SUBSE R O S AL/SUBPERI T ON E AL

48. SUBMU C O S AL Intramural fibroid, when pushed toward the uterine cavity and is lying under the endometrium Can make the uterine cavity IRREGULAR & DISTORTED

49. SUBMUCOSAL Least common but MAXIMUM symptoms

50. SUBMU C O S AL Pedunculated submucosal fibroid may come out through the cervix May be infected/ulcerated to cause METRORRHAGIA

51. CERVICAL Rare (1-2%) May be anterior, posterior, lateral or central May displace the cervix or expand it so much that the external os is difficult to recognize

52. SECONDARY CHANGES IN FIBROIDS D egenerations A trophy N ecrosis I nfection Va scular changes S arcomatous changes DANIVaS

53. D egenerations: Hyaline degeneration Cystic degeneration Fatty degeneration Calcific degeneration Red degeneration

54. A trophy: due to loss of support from estrogen following menopause Following pregnancy enlargement N ecrosis: due to circulatory inadequacy (central necrosis of the tumor ) Pedunculated subserous fibroid

55. I nfection: access through the thinned and sloughed surface epithelium of the submucous fibroid. Following delivery or abortion Intramural fibroid may also be infected following delivery.

56. Va scular changes: Telangiectasis (dilatation of the vessels) or lymphangiectasis (dilatation of the lymphatic channels) inside the myoma may occur. Cause is not known. S arcomatous changes: may occur in <0.1% cases. The usual type is leiomyosarcoma.

57. Other Complications Hemorrhage Intracapsular Ruptured surface vein of subserous fibroid  intraperitoneal Polycythemia Erythropoietic function by the tumor Altered erythropoietic function of the kidney through ureteric pressure Torsion of subserous pedunculated fibroid Inversion of uterus Endometrial carcinoma associated with fibromyoma Endometrial and m y o h yperplasia Accompanying adenomyosis Parasitic fibroid

58. S ymp t oms Menstrual disturbances Infertility, recurrent abortions Pain Pressure symptoms Abdominal lump Vaginal discharge

59. S ymp t oms Menstrual disturbances Menorrhagia Conspicuous in IM & SM fibroid due to increased vascularity, endometrial hyperplasia & enlarged uterine cavity Metrorrhagia/irregular bleeding Ulceration of SM fibroid or fibroid polyp Torn vessels from the sloughing base of polyp Associated endometrial carcinoma

60. S ymp t oms Infertility, recurrent abortions Infertility: Distortion / elongation of uterine cavity  difficult sperm a c cent Poor rhythmic uterine contraction during intercourse  impaired sperm transport Menorrhagia and dyspareunia Recurrent abortions: Defective implantation Poorly developed endometrium Reduced space for the fetal growth

61. S ymp t oms Pain Usually painless Pain may be due to some complications of the tumor / associated pelvic pathology Due to tumor: Degeneration Torsion Extrusion of polyp Associated pathology: Endometriosis PID

62. S ymp t oms Pressure symptoms Bladder  frequency and retention of urine Ureter  hydroureter & hydronephrosis (in broad ligament fibroids) Rectum  constipation (rare)

63. S ymp t oms Vaginal discharge Abdominal lump Heaviness in the lower abdomen A pedunculated fibroid feels separate from the uterus and gives impression of ovarian tumor

64. S ymp t oms Vaginal discharge Vaginal discharge Rare Often blood-stained

65. Physical signs Anemia Abdominal lump Arising from pelvis Well-defined margins Firm in consistency Smooth /bossy surface Mobile from side to side unless fixed by large size or adhesions

66. Bimanual examination: Enlarged uterus Cervix moves with the swelling which is not felt separate from uterus unless it is pedunculated In cervical fibroid, the normal uterus is perched on top of the tumor Broad ligament fibroid displaces the uterus to the opposite side

67. Differential diagnosis ? Pregnancy Full bladder Ha e m a t om e t r a / pyometra Adenomyosis Bi c ornu a t e uterus Ectopic p r e gnancy Chronic PID B e nign/ m aligna n t ovarian tumor

68. I n v e s ti g a tio n s Haemoglobin , blood grouping Ultrasound abdomen & pelvis Hysterosalphingography (to identify submucous myoma) Hysteroscopy D&C (to rule out endometrial cancer) Laparoscopy MRI (to identify adenomyosis and myoma) In majority cases, the clinical features are clear cut. Elaborate investigations are not required.

69. TREATME NT There's no single best approach to uterine fibroid treatment

70. Type of fibroid MANAGEMENT PROTOCOL OF UTERINE FIBROIDS B O D Y SYMPTOMATIC ME D IC A L S URGE R Y MYOMECTOMY, HYSTERECTOMY, MYOLYSIS, EMB OLOT H ERA P Y A S Y MP T O M A TIC REGULAR S UP E RV I S ION (6 MONTHS INTERVAL) IF SIZE INCREASE & SYMPTOMS APPEAR  SURGERY S URGE R Y IF SIZE >12 WEEKS, DX UNCERTAIN, UNEXPLAINED AB O R TIO N/INFE RTILITY, PE D UN C U L A TED CERVIX SUPRAVAGINAL MYOMECTOMY HYSTERECTOMY V A GIN A L MYOMECTOMY POLYPECTOMY

71. MEDICAL MANAGEMENT To improve menorrhagia and to correct anemia before surgery To minimize the size and vascularity of the tumor in order to facilitate surgery As an alternative to surgery in postmenopausal women or women with high-risk for surgery Where postponement of surgery is planned temporarily

72. Antiprogesterones Mifepristone (daily dose of 25-30mg for 3mo) Danazol 200-400mg divided dose for 3mo GnRH analogs Agonists (luporelin, goserelin, buserelin, nafarelin) Antagonists (cetrorelix, ganirelix) PG synthetase inhibitor - t o relieve pain To minimize blood loss

73. L e v ono g e s t r e l - r ele a sing intrauterine system (LNG-IUS)  Reduce the size and vascularity of the fibroid

74. SURGICAL MANAGEMENT Factors affecting the type of surgical approach: Age of the patient Parity Future reproductive plans Classic indications for Myomectomy: Persistent abnormal bleeding Pain or pressure Enlargement of an asymptomatic myoma to more than 8 cm in a woman who has not completed chilbearing

75. Contraindications to Myomectomy: • • • • Pregnancy Advanced adnexal disease Malignancy Myomectomy maybe performed through: • • • • Laparoscopy H y s t e r o s c o p y Laparotomy Vaginally

76. Indications for Hysterectomy: • • All indications for myomectomy, plus: Asymptomatic myomas when the uterus that has reached the size of 14-16 weeks gestation Rapid growth of myoma after menopause

77. Fibroids complicating pregnancy Pregnancy generally cause an increase in the size of the fibroids Increase vascularity High tendency to undergo degenerative changes

78. Red degeneration result of the softening of the s u r r o und ing supportive tissue c apill a ries tend to rupture blood effuses out into the myoma (diffuse reddish discolouration) severe acute abdominal pain (restricted to the site of fibroid uterus)

79. EFFECT OF PREGNANCY ON FIBROID Subinvolution Ascending infection Torsion

80. EFFECTS OF FIBROID ON PREGNANCY 1 - I n fe r t i l ity 2- Abortion 3 - preterm labor - Abruptio placentae - abnormal Lie & position - Increase rate of operative delivery - PPH (uterine atony) .

81. Common condition in which islands of endometrium are found in the wall of the uterus “ ADENOMYOSIS ”

82. ADENOMYOSIS Presence of endometrial tissue in myometrium >2.5mm from the basal layer of endometrium Endometrial gland and stroma must present

83. Observed frequently in elderly women Women are usually parous Around the age of 40 years The disease often coexists with uterine fibromyomas, pelvic endometriosis (15%) and endometrial carcinoma

84. PATHOGENESIS Oestrogen recepter mutation Gene polymorphism Basal layer of endometrium including stroma and gland infiltrating myometrium. Surrounding myometrial tissue hypertrophied and hyperplasia Uterine enlargement

85. PATHOLOGY • DIFFUSE – Involve anterior an – Causes uniform ute – Thickened myomet osterior uterine walls e enlargement m and hemorrhagic foci of d p rin riu adenomyosis • ma (no capsule or distinct LOCALIZED – Grossly mimic leiomyo plane of dissection)

86. CLINICAL FEATURE S Common in multiparous age 40-50 Does not occur before menarche and regress after menopause Uterus uniformly enlarged Palpable abdominally (<14 week’s size) May co-exist with other pelvic pathology Leiomyoma endometrial hyperplasia endometriosis endometrial carcinoma Dysmenorrhea ( increased with duration of disease and depth of infiltration Menorrhagia

87. Gross examination Uterus appears symmetrically enlarged to not more than 14-weeks size Cut section may show only a localized nodular enlargement Affected area reveals a peculiar, diffuse, striated and non-capsulated involvement of the myometrium, with tiny dark hemorrhagic areas .

88. INVESTIGATION S Transvaginal ultrasonography Asymmetrical thickening of uterine walls Doppler sonography To differentiate from fibroid MRI Conservative surgical or medical management preferred Young lady with infertility Image directed needle biopsy

89. Differential diagnosis A localised adenomyosis  asymmetrical enlargement of uterus – resembles myoma But, myoma of this size is rarely painful . Therefore, menorrhagia , with painful , assymmetrical enlargement of the uterus suggests adenomyosis

90. MEDICAL MANAGEMENT NSAID COMBINED OCP DANAZOL Reduce in size, menorrhagia reduce Temporary effect GnRH ANALOGUE Prior to surgery to reduce size and vascularity LEVONOGESTREL INTRAUTERINE SYSTEM (LNG-IUS) DANAZOL LOADED INTRAUTERINE DEVICE Reduce pain and bleeding

91. SURGICAL MANAGEMENT Definitive surgery Perimenopausal age Poor response to medical therapy Associated pelvic pathology

92. CONSERVATIVE SURGERY Localized adenomyoma by adenomyomectomy Resection of adeno m y oma Diffuse adenomyosis Partial resection of uterine walls M y ometr i al reduction Submucosal adenomyosis/ polypoidal lesion H y s t e r os c opic reduction

93. NEWER INTERVENTIONAL TECHNIQUE Endometrial ablation Uterine artery embolis a tion MRI guided focused ultrasound surgery

94. That’s all!