Benign Diseases of Cervix, Uterus & Ovary
Benign Diseases of Cervix, Uterus & Ovary
Benign Diseases of Cervix, Uterus & Ovary
Benign Disease of
Cervix
Cervical Ectropion
Formation
Squamocolumnar
junction is located at the
external os before
puberty
Causes
Puberty
During pregnancy
Oral contraceptive pill
Congenital
Sexual intercourse
Treatment
No treatment for asymptomatic
Hormonal therapy
Discontinuing oral contraceptives
Ablation treatment
Cervical Stenosis
Definition
The endocervical canal is more narrow
than is typical. In some cases, the
endocervical canal may be completely
closed.
Symptoms
Before menopause
Menstrual abnormalities
Amenorrhea, dysmenorrhea and abnormal
bleeding.
Infertility
After menopause
Not cause symptoms
A hematometra or pyometra can cause
pain or cause the uterus to bulge
Causes
congenital cervical stenosis
chronic infection (chronic cervicitis)
trauma
from previous instrumentation
cone biopsy/loop electrosurgical excision procedures (LEEP)
cryotherapy
laser treatment
Investigation
Hysterosalpingogram
narrowing of the endocervical canal (normal
diameter: 0.5-3.0 cm)
complete obliteration of the cervical os,
preventing insertion of the
hysterosalpingographic catheter.
Pelvic ultrasound
visualisation of an underlying mass if its
complicated by proximal dilatation of the
female genital tract (e.g. hematometra)
Treatment
Vaginal delivery of a baby
Insertion of dilators with ultrasound
guidance
Laser treatment if caused by scar tissue
Hysteroscopic shaving of cervical tissue
Cervical Intraepithelial
Neoplasia
Potentially premalignant transformation
and abnormal growth (dysplasia) of
squamous cells on the surface of the
cervix.
May progress to become cervical cancer,
usually cervical squamous cell carcinoma
(SCC)
Major cause - human papillomavirus
(HPV) 16, 18
Risk Factors
Infected by a high risk type of HPV, such
as 16, 18, 31, or 33
Immunodeficient
Women who give birth before age 17
Poor diet
Multiple sexual partners
Lack of condom use
Cigarette smoking.
Classification
Pap Smear
Cells are collected from the cervical surface
and examined under microscope to look for
the signs of abnormal and cancerous cells
In Malaysia, all women who are, or who have
been sexually active, between the ages of
20 and 65 years, are recommended to
undergo Pap smear testing.
If the first two consecutive Pap results are
negative, screening every three years is
recommended.
Management
CIN 1 Conservative
CIN 2, 3 & persistent CIN 1 (more than 1
year)
Surgical
Loop electrosurgical excision procedure (LEEP)
Cold knife conization
Laser vaporization and cryotherapy
Endometrial Polyps
&
Asherman syndrome
Endometrial Polyps
Discrete outgrowth of endometrium, attached by a
pedicle which move with the flow of the distension
medium.
It may be pedunculated or sessile, single or multiple
and vary in size. (0.5-4 cm)
Women under 40 years old unlikely to have this.
May cause intermenstrual bleeding and treatment is
by removal if the symptoms persistent at least 3
months or more.
Investigation:
Transvaginal ultrasoud
Hysteroscopy
Curretage
Treatments
Watchful waiting.Small polyps without
symptoms (asymptomatic) may resolve on their
own. Treatment is unnecessary unless you're at
risk of uterine cancer.
Medication.Certain hormonal medications,
including progestins and gonadotropin-releasing
hormone agonists, may shrink a uterine polyp
and lessen symptoms.
Curettage
Asherman Syndrome
An irreversible damage of the single layer thick
basal endometrium does not allow normal
regeneration of endometrium.
It undergoes fibrosis and adhesion formation
termed Asherman Syndrome
Result is reduced or absent menstrual shedding.
Can happen because of overzealous curettage of
the uterine cavity during evacuation of retained
product of conception after miscarriage
Causes:
DNC
Tuberculosis & schistosomiasis
Symptoms:
The adhesions may cause amenorrhea
(lack of menstrual periods), repeated
miscarriages, and infertility.
However, such symptoms could be
related to several conditions. They are
more likely to indicate Asherman
syndrome if they occur suddenly after a
D&C or other uterine surgery.
Investigation:
A pelvic exam is usually normal.
Tests may include:
Blood tests to detect tuberculosis or
schistosomiasis
Hysteroscopy
Hysterosonogram
Infertility evaluation
Transvaginal ultrasound examination
Management:
Hysteroscopic technique to manually
breakdown or lyse the intrauterine adhession.
After scar tissue is removed, the uterine
cavity must be kept open while it heals to
prevent adhesions from returning.
Your health care provider may place a small
balloon inside the uterus for several days and
prescribe estrogen therapy while the uterine
lining heals.
Uterine Fibroids
Sites:
Submucosal
Fibroids grow into the uterine cavity.
Intramural
Fibroids grow within the wall of the uterus.
Subserosal
Fibroids grow on the outside of the uterus.
Pedunculated fibroids
Some fibroids grow on stalks that grow out from
the surface of the uterus or into the cavity of the
uterus.
Symptoms:
Heavy menstrual bleeding
Prolonged menstrual periods seven
days or more of menstrual bleeding
Pelvic pressure or pain
Frequent urination
Difficulty emptying bladder
Constipation
Causes:
Genetic changes.
Changes in genes that differ from those in normal uterine
muscle cells. Fibroids also run in families and that identical
twins are more likely to both have fibroids than non identical
twins.
Hormones.
Fibroids contain more estrogen and progesterone receptors
than normal uterine muscle cells do. Fibroids tend to shrink
after menopause due to a decrease in hormone production.
Other growth factors.
Substances that help the body maintain tissues, such as
insulin-like growth factor, may affect fibroid growth.
Risk factors:
Nulliparity
Obesity
Heredity.
If your mother or sister had fibroids, you're at increased risk of
developing them.
Race.
Black women are more likely to have fibroids than women of other racial
groups.
Other factors:
Onset of menstruation at an early age, having a diet higher in red meat
and lower in green vegetables and fruit, and drinking alcohol and beer.
Factors that lower the risk of fibroids:
Pregnancy (the risk decreases with increasing number of pregnancies)
Long-term use of progestin-only birth control pills or oral contraceptives
Use of the birth control shot (depot medroxyprogesterone acetate or
Depo-Provera)
Investigations:
Blood:
FBC to determine if the patient
has anemia duet to chronic blood
loss and other blood tests to rule
out bleeding disorders or thyroid
problems.
Imaging:
Pelvic USS
MRI
Show the size and location of
fibroids, identify different types of
tumours and help determine
appropriate treatment options.
CT SCAN
Special tests:
Hysterosalpingogram
X-ray test that looks at the inside
of the uterus and fallopian tubes
and the area around them.
Hysterosonography.
(Saline
infusion sonography)
Injection of salt solution into the
uterus
to
help
create
the
ultrasound image.
Laparoscopy
Look and locate fibroids on the
outer surface of the uterus.
Treatments:
Conservative Medical:
:
Surgical:
Emotional
support
Bed rest
Practice
healthy and
balanced
diet
Endometrial Ablation
Destroys the lining of the
uterus. It is used to treat
small fibroids inside the
uterus.
Myomectomy
This procedure removes
only the fibroids and leaves
the healthy areas of the
uterus intact. Preserve the
ability to get pregnant.
Hysterectomy
Cure uterine fibroids
completely. Recommended
if fibroids are large, very
heavy bleeding, near or
past menopause.
Uterine Artery
Embolization
cuts off the blood supply to
Pain medication
Birth control pills &
hormonal birth
control pills.
These medications
control heavy bleeding
and painful periods.
Progestin-releasing
intrauterine device
(IUD)
Reduces heavy and
painful bleeding but
does not treat the
fibroids themselves.
Gonadotropinreleasing hormone
agonists.
Stop ovulation, helps
in reducing the size of
fibroids.
Complications:
Iron-deficiency anaemia.
Bladder frequency, constipation (due to increased pelvic
pressure).
Torsion of pedunculated fibroid.
Ureteral obstruction causing hydronephrosis.
Infertility: as a result of narrowing of the isthmic portion of
the Fallopian tube or as a consequence of interference with
implantation (submucosal fibroids).
In pregnancy:
Recurrent miscarriage.
Fetal malpresentation.
Intrauterine growth restriction.
Premature labour.
Postpartum haemorrhage.
History Taking
Physical Examination
Causes of benign
ovarian tumours
Types
Functional
Follicular cyst
Corpus luteal cyst
Theca luteal cyst
Inflammatory
Tubo-ovarian abscess
Endometrioma
Germ cell
Benign teratoma
Epithelial
Serous cystadenoma
Mucinous cystadenoma
Brenner tumour
Fibroma
Thecoma
Corpus luteal
Theca luteal
Epithelial tumours
Increase with age, most common in perimenopausal women
Serous
cystadenomas
Mucinous
cystadenomas
Brenner tumours
Most common
20-30% of benign tumours in
women under 40
Unilocular, rarely involve opposite
ovary
Large multiloculated
Bilateral in 10% of cases
Often small, found incidentally
Secrete estrogen
Thecom
as
Oestrogen-secreting tumours
Often in post-menopause, with
manifestations of excess oestrogen
production (post-menopausal bleeding)
May induce endometrial Ca
History
Pain
Pelvic/ abdominal swelling (DDx??)
Pressure on bowel or bladder
Acute, intermittent pain torsion of cyst,
rupture or haemorrhage
Age-causes vary with age
Physical Examination
Pelvic/abdominal mass (separate from
the uterus) **sometimes incidentally
found in USS
Tenderness
Investigation
Management
FBC infection,
haemorrhage
UPT
Inflammatory markers (CRP,
WCC)
Tumour markers
Imaging- USS/ CT scans/ MRI
Diagnostic laparoscopy
Fine-needle aspiration and
cytology
alpha-fetoprotein (AFP) and
human chorionic
gonadotrophin (hCG)
Follow-up
Analgesic
Antibiotics
Surgical excision/
drainage