BENIGN DISEASE OF

UTERUS AND CERVIX

4/11/2011

DR KASHFIL
MBBS (IMU)
BENIGN DISEASE OF UTERUS

- UTERINE FIBROID
- ADENOMYOSIS
- ENDOMETRIAL POLYP
- ENDOMETRIAL HYPERPLASIA
UTERINE FIBROIDS
(LEIOMYOMA)
Definition:
- Benign solid tumour of uterus, which consists of
smooth muscle and fibrous tissue
- Arises from the muscular wall of uterus
UTERINE FIBROIDS
(LEIOMYOMA)
Risk Factors:
- increasing age (>35yo)
- low parity/infertility
- family history – 1st degree relatives
- obesity
UTERINE FIBROIDS
(LEIOMYOMA)
Aetiology:
- Hormonal influence (oestrogen dependant)
- Growth rapidly during pregnancy, OCP,
PCOS, granulosa cell tumour
- Rarely before menarrche and regress after
menopause
UTERINE FIBROIDS
(LEIOMYOMA)
Types:
- Submucous
- Intramural
- Subserosal
- Pedunculated
- Cervical
Effect of Pregnancy on Fibroids Effect of Fibroids on Pregnancy

 Rapid growth  Recurrent abortion

 Red degeneration (10%)  Preterm labour (15-20%)

- presented as pain,  PPROM

tenderness, fever,  IUGR (10%)

leucocytosis  Malpresentation (20%)

 Obstructed labour
 High risk of caesarean
delivery
 PPH

UTERINE FIBROIDS
(LEIOMYOMA)
Clinical history: Physical examination:

- asymptomatic (50%) - pallor

- menorrhagia - palpable uterine mass
- palpable mass per abdomen (usually
- compressive symptoms firm, lobulated & non
- pelvic pain tender)
- speculum
- bimanual palpation

UTERINE FIBROIDS
(LEIOMYOMA)
UTERINE FIBROIDS
(LEIOMYOMA)
Investigations:
- FBC – Hb level (severity of anaemia)
- Pelvic ultrasound scan
- Endometrial biopsy – TRO uterine
hyperplasia or malignancy
- Hysteroscopy
UTERINE FIBROIDS
(LEIOMYOMA)
Management:
- medical
- surgical
UTERINE FIBROIDS
(LEIOMYOMA)
Indications for interventions:
- significant symptoms
- large fibroid >16 weeks size
- infertility
- previous pregnancy complications
caused by fibroids
- rapidly growing or suspicion of
leiomyosarcoma
UTERINE FIBROIDS
(LEIOMYOMA)
Mode of treatment should based on:
- symptoms
- size of the fibroid
- age
- parity and desire of fertility
- availability of local expertise
 UTERINE FIBROIDS
(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 Uterine artery embolization
RADIOLOGY
SURGICAL Myomectomy – open, laparoscopic, vaginal,
hysteroscopic
Hysterectomy
UTERINE FIBROIDS
(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
ADENOMYOSIS
Definition:
- 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 their

late 30s until menopause
Clinical history: Physical examination:

- asymptomatic (50%) - uniformly enlarged

- secondary uterus but usually <14
dysmenorrhoea weeks size
- menorrhagia - tender on bimanual
- infertility palpation, especially
perimenstrual period

ADENOMYOSIS
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

ADENOMYOSIS
Investigations:
- FBC – Hb level (if menorrhagia)
- Pelvic ultrasound scan
- Hysterosalpingography

Diagnosis:
- Only confirmed by HPE
ADENOMYOSIS
SUMMARY 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)
ENDOMETRIAL POLYPS
Definition:
- Localized overgrowth of endometrial
tissues, which is covered by epithelium
ENDOMETRIAL POLYPS
Clinical presentation:
- asymptomatic (majority)
- abnormal uterine bleeding
i.e. menorrhagia, intermenstrual,
postcoital and postmenopausal
bleeding
- small polyps may regress
ENDOMETRIAL POLYPS
Diagnosis:
- Diagnostic hysteroscopy

Management:
- Hysteroscopic resection (gold standard)
ENDOMETRIAL
HYPERPLASIA
Definition:
- Proliferative endometrium that is hyperplastic, due to
prolonged or unopposed oestrogen stimulation
- Premalignant condition
 ENDOMETRIAL
HYPERPLASIA
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
Clinical history: Physical examination:

- irregular menstrual - obese

cycles (often excessive - pallor (if menorrhagia)
and/or prolonged - usually has no
menstrual loss) significant abdominal or
- post menopausal pelvic findings
bleeding
- +/- Tamoxifen therapy

ENDOMETRIAL HYPERPLASIA
ENDOMETRIAL
HYPERPLASIA
Investigations:
- FBC – Hb level (severity of anaemia)
- Transvaginal ultrasound – ET
- Endometrial Pipelle sampling
- Diagnostic hysteroscopy and biopsy
ENDOMETRIAL
HYPERPLASIA
SUMMARY OF TREATMENT OPTIONS FOR ENDOMETRIAL
HYPERPLASIA
MEDICAL • Progestogen (Medroxyprogesterone
acetate)
• Danazol
• COCs
• Levonorgestrel IUD (Mirena)
• GnRH agonist
SURGICAL • Hysterectomy +/- BSO
BENIGN DISEASE OF CERVIX
- CERVICITIS
- CERVICAL ECTROPION
- NABOTHIAN CYST
- CERVICAL AND ENDOCERVICAL POLYP
CERVICITIS
 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
 CERVICAL 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 users
 Mucoid vaginal discharge, irregular spotting or postcoital
bleeding
 Speculum: red base lesion of ectocervix with

sharp borders, may bleed on touch

 Cervical cytology screening (TRO CIN/malignancy)
 Treatment: cauterisation with diathermy, freezing using

cryosurgery
NABOTHIAN CYSTS
 Obstruction to the flow of secretions from endocervical
glands
 Following chronic inflammation, infections or
squamous metaplasia of the cervix
 Contains thick clear mucus
 Speculum: raised lesion on ectocervix. May appeared as

translucent, white, with yellowish or bluish

tinge
 Reassurance is important
CERVICAL AND ENDOCERVICAL
POLYPS
 Usually small
 Irregular menstrual bleeding, post coital or post
menopausal bleeding, excessive vaginal discharge
 Speculum: smooth, red and elongated mass at os
 Cervical cytology screening
 Removed by polyp forcep and sent for HPE
 If there is bleeding from base of stalk→ cauterisation
 THANK YOU
HAVE A NICE DAY