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    Fibroids

    Uploaded by

    Usman AR Vaince

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    © All Rights Reserved
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    oy) Benign disease of the uterus Rea Ret ee Be Ca C Endometrial polyps ‘Tae endometrial polyp is common gynaecological lesion associated with abnormal Bleeding and infertility It can also be an asymptom- atic incidental finding during imaging. Its a localized overgrowth ofthe uterine endometrium that can be sesile or polypoid. Itusually grows from the fundus towards the internal os and occasionally pro- trades through the external os into the vagina, Aetiology ‘Age, hypertension, obesity, and tamoxifen use are some ofthe risk factors (1-3). The causation is likely to be multifactorial. Thus in obese women, while an excess of oestrone may play a role, hyper tension may be a confounding factor, There is a 30-60% prevalence of polyps im women using tamoxifen. In women with infertility, the use of gonadatropins may be associated with the development of polyps. Endometrial polyps are also associated with cervical polyps in 24-27% of cases and the astociation becomes stronge with advancing age and abnormal vaginal bleeding (4). Atypical glandular cells in a cervical smeae are also astociated with endo: retrial polyps in 3.4-5% of cases (5). Genetic factors play a role with altered endometrial proliferation and overgrowth being as- sociated with specific alleles on chromosomes 6 and 12 (6), Ithas been hypothesized that an excess of endometrial cytokines and metalloproteinases may increase the risk of developing polyps, fi- broide, and adenomyosis, the same mediators that are implicated in intrauterine disease associated with infertility. In postmenopausal ‘women there is an excess of growth regulating protein P63, which is also-a marker ofthe reserve cells of the basalis layer, The latter is thought tobe the precursor of polyps (7,8) ‘While oestrogen and progesterone are key factors in the prolifer ation and apoptasis ofthe endometrium, their role in the aetiology and pathophysiology of polyps is controversial, Both hormones ap- pear to contribute tothe elongation ofthe glands, stroma, and spiral arteries that give polyps the characteristic polypoid appearance. In postmenopausal women there is an excess of oestrogen recep. tors but limited evidence for an excess of progesterone receptors ‘There also seems to be an excess of these receptors in the glandular epithelium and not the stroma. ‘The timing ofthe cycle may play a role, Notwithstanding the controversy, there are apparent functional similarities between polyps and normal endometsiurs with similar fonctional changes occurring cyclically (9). Epidemiology ‘The reported prevalence of polyps is between 7.88% and 34.9% depending on the poptlation studied, the diagnostic tool used, and the definition of polyps. While iti generally thought that polyps are mote prevalent in postmenopausal (11.8%) compared to premeno- ppausal women, this could simply reflect the fact chat any abnormal bleeding in postmenopausal women will be investigated, which is not the eae in premenopausal women (10). Clinical presentation Approximately 68% of ll women with polyps present with abnormal vaginal bleeding (11) and 6-88% of premenopausal women with polyps have abnormal vaginal bleeding inthe form of menorrhagia, intermenstrual bleeding, or postcoital bleeding (11). Endometsial polyps account for 395% of all abnormal vaginal bleeding in pre- ‘menopausal women and thsi thought to be due to stromal conges- ton leading to venous stasis and apical necrosis. In contrast, postmenopausal women with polyps are more often symptom free, with approximately 56% presenting with abnormal bleeding (11), Polyps account for only 21-28% ofall vaginal bleeding in postmenopausal women (11). In premenopausal women, polyps ae associated with infertility (12). This might be due to mechanical ‘obstruction at the tubal ostium or duc toa mechanical or biochemn- ical effect on implantation of the developing embryo, possibly due to the excese of intrauterine metalloproteinase and cytokines as- sociated with polyps (7). The incidence of polyps is 38-38.5% in primary infertility, 18-17% in secondary infertility, and 1.9-24% ‘when combined (12). Natural history Polyps can regress spontaneously, with one study reporting a re- gression rate of 27%, and a correlation between size and regres: sion: polyps smaller than 1 cr ate more likely to regress than larger ones (13) ‘While most polyps are benign, some can become hyperplastic with malignant transformation in 0-12.9% of cases (1). The risk is highest in postmenepausal women with symptoms and low in, ry SECTION 7 Benign Disease of the Uterus premenopausal women, There isa significant correlation between age, menopausal status, obesity, hypertension, tamoxifen use, and size of the polyp and incidence of malignant transformation (2). In ‘one study the risk of malignancy was similar in symptomatic and asymptomatic patients, suggesting that polyps should be removed ‘whenever identified (14). Ultrasonography may aid in identification ‘of malignancy with a sensitivity of 67-100% and a specificity of 71 489%. The variation in range is dependent upon the thickness of the ‘endometrium used for further invasive testing. Diagnosis ‘Transvaginal ultrasound ‘On trancvaginal ultrasound (TVUS),a polyp typically appeare as @ hyperechoic lesion with regular contours within the uterine lumen, foulining the endometrial wall on which it rests, surrounded by 2 hyperechoic halo. Cysti spaces within the polyp corresponding to dilated glands filled with proteinaceous material may be seen, or it say appear ata thickening of the endometsial lining or focal mass within the endometrial cavity. However, such appearances are not pathognomonic of endometrial polyps, since submucosal fibroids can also look similar. To minimize false-positive or false-negative results in the premenopausal woman, TVUS should be performed within the fist 10 days of the menstrual eycle ‘Compared to hysterascopy and guided biopsy, studies have re- ported that TVUS has a sensitivity of 19-96% specificity of 53 10086, postive predictive value of 75-1006, and negetive predictive value of 87-9756. Such a wide variation reflects the poor quality of the studies, and also the inclusion of other conditions such as sub- smicosal fibroids. In a single, large prospective study evaluating the ‘causes of menorthagia, the sensitivity specificity, postive predictive value, and negative predictive value of TVS in diagnosing polyps ‘were 86%, 949, 91%, and 90% respectively (15) “There are limited data to substantiate the use of colour or povrer Doppler in the diagnosis of malignant change or hyperplasia in ‘polyp. In one study the specificity and the negative predictive value were claimed to be 95% and 94% respectively for identifying a single large feeding vessel by colour flow Doppler in TVUS (16) whereas others have shown limited value in the diagnosis of endo- -metial cancer, with no significant difference in histology of polyps depending on their resistive or pulatilty index. Power Doppler seems to be a more promising technique for the depiction ofthe vascular network (17) and in one study the sensi- Luvity and specificity were reported to be 878 and 85% respectively in identifying a single large feeding vessel as a marker of an endo- ‘metral polyp compared to anetvvork of muluple or scattered vessels for hyperplasia or malignancy (17), However, the study showed this tobe more effective for women in whom the polyp wae an incidental finding. Ukimately the only way to confirm or exclude malignancy is histological examination following it removal. Saline infusion sonography ‘The use of saline infusion sonography (SIS; also refered to as sonohysterography) increases the sonographic contrast helping in the delineation of size, location, and other features of endometrial polyps. Polyps appear as echogenic intracavitary masses with either ‘abroad base ora thin stalk floating inthe uid. This technique is thought to increase diagnostic accuracy and small polyps missed fon grey-scale sonography are picked up on SIS, Differentiating @ polyp from a submucosal fibroid can be dificult but examining the cechotexture and identifying echogenic endometrium overlying the polyp ean be helpfl ‘A number of studies comparing the diagnostic accuracy of diag- nostic hyslerascopy and SIS showed no significant difference be- tween the two (18). When comparing SIS and hysteroscopy with guided biopsy, the sensitivity, specificity, positive predictive value, and negative predictive value were 58-100%, 35-100%, 70-100%, and 83-100% respectively (18) When compared with hysterotcopy, SIS hat the advantage of allowing the assessment of the myometrium and other pelvie or ¢gans, I has also been reported (o be less painful than diagnostic hhysteroscopy when the atteris performedasan outpatientprocedure ‘under similar conditions to SIS: both techniques involve insertion of vument through the cervix and distending the uterine cavity with fluid. However, these reports are from earlier studies before the advent of present-day hysteroscopes of much smaller diameter (19) The disadvantages of SIS include an inability to give a histological diagnosis, alonges learning curve, and discomfort caused by leakage of fuid or pain by distension withthe balloon catheter. ‘Three-dimensional TVUS and three-dimensional SIS ‘Three-dimensional (3D) ultrasound can generate multiplanar re constructed images ofthe uterus including coronal views and there. {ore improve the diagnostic accuracy compared to two-dimensional (2D) ultrasound. Three-dimensional SIS includes addition of saline infusion to 3D ultrasound. However, this technique has been shown to improve diagnostic accuracy only slightly and given the greater expense and less frequent availability of 3D SIS, 2D ultrasound with {intrauterine contrast will remain the preferred eflective and reliable non-invasive method to diagnose polyps, Histological iagnosis Blind biopsy In contemporary practice, blind dilatation and curettage should rng longer be used as a diagnostic technique due to its poor sensi Luvity and negative predictive value compared to bysteroscopy and guided biopsy, which has a specificity and positive predictive value fof 100% (20). Use of an endometrial sampler or curete can miss a pedunculated polyp or cause fragmentation of a sessile polyp making histological diagnosis difficult. This is particularly important in postmenopausal women in whom polyps tend to be broad based with an uneven surface covered by atrophic endometrium, Hysteroscopy with guided biopsy “This is considered the gold standard in the diagnosis of endo: metrial polyps (21). The ability to diagnose and remove polyps concurrently makes it superior to diagnostic hysteroscopy alone. Despite the growing popularity of outpatient hysteroscopy, most of the diagnostic hysteroscopies are still performed under gen- ceralanaesthesia, particularly if operative hysteroscopy is required. The evidence supports uze of outpatient hysteroscopy for diag- nosis witha reported success rate of 92-96% and no difference be tween premenopausal and postmenopausal women (22). Studies have shown it to be superior both in terme of expense and patient preference, Flexible hysteroscopy is less painful for patients and allows ‘easier passage through the cervical canal when compared to rigid hhysteroscopy, making it more acceptable for office procedures, Cis thought co have inferior image quality compared to rigid Ihysteroscopy as the light and images are transferred through the same fibreoptic bundle. Nev flexible bysteroscopes with video chips are superior in this respect, although these may be susceptible to breakage. have a limited operative scope, and may be more costly than rigid hysteroscopes, With new, technologically improved narrow scopes, more and more operative hysteroscopies can be per= {formed in the outpatient setting. While smaller endometsial polyps ‘can be removed with minimal patient discomfort, polypslarger than Ue internal cervical os are beet removed wader general anaesthesia “The choice of distension medium is an important consideration {for patient comfort and diagnostic accuracy in outpatient settings. ‘Normal saline causes less discomfort and less shoulder tip pain ‘when compared with carbon dioxide and therefore produces im- ages which are clear and reliable, Use of paracervical blocks and intrauterine anaesthesia can also be helpful in outpatient operative bhysteroscopy. Complication rates ae low in hysteroscopic polypectomy. When ‘compared to hysteroscopic myomectomy, endometrial ablation, and hysteroscopic adhesiolysis the risks of perforation, cervical acer ation infection, and haemorrhage remain low (23). Management ‘The management of polyps is guided by the presence of symptoms, desire for future fertility, rek of malignancy, and operator sls, The ‘options are conservative non-surgical, conservative surgieal, and radical surgical Conservative non-surgical management ‘While the removal of polyps is associated with alow risk of compli- ‘ations, ts nat a completely risk-free procedure and therefore pre- intervention patient counselling ie mandatory. The rate of egression ‘of polyps less than 10 mm in size is 27% over 12:months and the risk. ‘of malignancy is very low: such polyps can therefore be managed ‘conservatively in asymptomatic patients (13), Medical treatment may have some role in the management of polyps. Gonadotropin-releasing hormone (GaRH) agonists have ‘been shown to cause temporary regression of polyps and can be used as a treatment adjunct before polypectomy. However, the cost and side effect of such treatment need to be compared with simple al temative extispative treatment without the uze of such medications A variety of progesterone preparations including norethisterone, ‘medroxyprogesterone, and ibolone have been used in the context ‘of hormone replacement therapy in postmenopausal women and tibolone, which has the highest androgenic activity, is thought to ‘cause regression of polyps. Hysteroscopic examination at 3 years after treatment revealed a low risk of recurrence after use of these preparations, However, these teatments are not without side elects, and high-quality studies ate required to further establish theie place In a randomized controlled trial of the levonorgestrel-rleasing intrauterine system (LNG-TUS) compared with observation, a re duced rate of polyp recurrence was shown in the LNG-IUS group. Ina 45-year study observation period, eight cases of polyp occur rence were seen in the observation group compared to three in the LLNG-IUS group. Out of these three, one woman did not have an CHAPTER 49. Benign disease of the uterus 1S inserted and in other two it was taken out after 1 year due to side elects Reduction in endometrial thickness due to progesterone suppression is thought to contribute to the regression or reduced development of polyps (24). Conservative surgical treatment Blind dilatation and curettage hasbeen used asa treatment for endo- seicial polyps for many years. A survey of practice sn the United Kingdom carried outin 2002 showed that 2% of gynaecologists used this technique and 51% used blind curettage after hysteroscopy (21, 23), Evidence suggests tha this technique has a high complication ‘at witha perforation rate of approximately! in 100 and an infec- tion rate of approximately 1 in 200 (21). Studies suggest that with blind curettage alone, the rate of polyp removal s oly 4% which increases to 419 ifa polyp removal forceps is also used. The rate of incomplete removal is also high (26). TVUS-guided polypectomy hasbeen suggested aan alternative in order to improve the rate of semoval of polyps, however this has received lite enthusiasm (27). ysteroscopicescetion of polyps safe with alow complication rat, is widely available, and can be performed inthe outpatient setting, and therefore should replace blind methods of polyp removal. Hysteroscopic polypectomy “This is a safe and effective method for polyp removal which allows rapid recovery and can be sometimes be performed in an outpatient sctting (28) There are various techniques of polypectomy depending ‘on the type of instrument used, This is dependent on availability, ex pense, surgical expertise, and also the size and location of polyps Large and sesile polyps ate best removed with a reectoscape, lectrosurgical loop fitted to the hysteroscope, while smaller polyps are best removed either by scissors or polyp forceps under dizect Ihysteroscopie vision (28). Hysteroscopic resection carries more ‘complications, probably due to the greater cervial dilatation re- ‘quired in these cases, However, the polyp recurrence rate is neatly zero after use of the resectozcope compared with about 159% with grasping forceps (28) ‘Other instruments that may be considered include the bipolar ‘Versapoint, which requizes less cervical diltation and uses normal sain instead of glycine thus reducing the potential risk of postop- erative hyponatraemia (11). The hysteroscopic morcellat the polyp chips while resecting, thus reducing the operating time, fluid loss, and movement through the cervix Such techniques are, however, expensive and not readily available and the outcomes are rot significantly different from other methods of hysteroscopic removal Radical surgical treatment Hysterectomy is @ definitive treatment for endometrial polyps, {guaranteeing no recurrence. However, ican only be justified inthe presence of other pathology sich as symptomatic broids, given the signiicant mo:bidity associated with such a radical approach, ‘Outcome of treatment “the outcome of treatment is generally good with reduction or ces- sation in abnormal vaginal bleeding. The rick of intrauterine adhe- sion formation after polypectomy is law, asthe myomettium is nat damaged and the endometrium has excellent regenerative capacity. In women undergoing polypectomy asa treatment of subfertlity oT oz SECTION 7 Benign Disease of the Uterus reported postoperative pregnancy rates vary between 43% and 80% with improvement seen in both chances of natural and assisted com: ception (28). In a class 1 study, polypectomy before intrauterine in- scmination significantly increased subsequent pregnancy rates (29) "The rat of pregnancy inthe study group was 51%, and af these, 65% hhad a epontancous conception belove the fist intrauterine insem- ination, whereas all pregnancies in the control group were obtained during the ferity treatment (29). There i a lack of consensus over the size ofthe polyps that may fect fertility, with data suggesting that removal of a polyp less than 2 cm in size docs not improve fertility (30) Conclusion Endometrial polyps ate common gynaecological condition whose prevalence increases with age. They are rarely associated with malig- nancy. They ean be associated with both subferiity and abnormal uterine bleeding. Non-invasive techniques such az grey-scale 'TVUS give a reliable diagnosis and diagnostic enhancement can bbe achieved by the use of contrast medium. In the management of polyps, hysteroscopic resection is safe and eflectve and allowshisto logical examination. Blind techniques should be avoided because of the high incidence of incomplete resection and complications such as perforation, Polypectomsy isan effective treatment of infertility although evidence from randomized controlled trialt to demon- strate improvement ini vitro fertilization outcome is still needed. ‘Conservative medical treatmentis a viable option pending definitive surgical treatment, Radical surgical treatment such as hysterectomy is unnecessary inthe treatment of polyps Adenomyosis i a common benign uterine pathology that is char- acterized by the presence of ectopic endometrium within the myo retrium, About two-thirds of afected women are eymptomatic With dysmenorshoea and menorthagia. The two diagnostic tools are good-quality TVUS seanning and magnetic resonance imaging. “Treatment remainsa challenge and canbe ether surgical or medical boa theultimate deintve treatment remains hysterectomy Epidemiology Adenomyosis typically affects mulipsrous premenopausal women ‘ver the age of 30 years (31), but itis also found in nulliparous ‘women, where it may contribute to subfertiity. Pathogenesis Adenomyosis is often associated with hormone-dependent pelvic lesions such as Sbroids, endometrial hyperplasia, and endometri- ‘sis thas been postulated that these other lesions could be cases of| ‘external’ adenomyosis, with connections to deep pelvic endometri- ‘sis invading the myometrium from outside inwards. A particular correlation has been found between adenomyosis and lesions of the rectovaginal septum, and itis thought that both adenomyosis and cendomeitiosis are governed by a single pathophysiological/genetic process (32-35), A number of factors appear to promote the devel- ‘opment of adenomyosis including multiparty, spontaneous miscat rage, surgical termination of pregnancy, curettage, hysteroscopic resection of the endometrium, myomectomy, caesarean section, and tamoxifen, A genetic predisposition for adenomyosis has also been proposed (36). Apart from high cestrogen levels, a cortl: ation has also been made between adenomyosis and high levels fof human leucocyte antigen 2-type immune response proteins interleukin-18 and leukaemia inhibitory factor, without necessarily implying that there sea causalive relationship. Abnormal secretion of intesleukin-6 from endometrial stromal cells and overexpression of cyclooxygenase-2 are additional factors implicated in the patho- genesis of adenomyosis. However, the exact mechanisms have yet to be elucidated, Histology _Adenomyosis is characterized by the presence of ectopic endomet. rium within the myometrium (with the depth of invasion being at least 2.5 mm below the basal level ofthe endometrium) that eads to hypertrophy of the smooth muscle. The thickened myometrium is composed of haphazardly distributed hypertrophied muscular tra beculae surrounding the ectopic endometrial tissue. Adenomyosis can be nodular with single or muliple fot scattered in the myome- ‘ium or more diffuse with numerous foc affecting the whole of the myometrium. Its often asymmetric, most frequently affecting the posterior uterine corpus (36). There may be superficial lesions, not extending beyond the one-third of the depth of the myometrium, and deep lesions that invade deeper (36). Brownish old haemor: shagic foci corresponding to blood and haemosiderin pigment de. posits may be contained within an area of adenomyosis, Symptoms One-thied of women remain asymptomatic, and these women probably have superficial rather than deep adenomyosis. ‘Ihe te maining two-thirds experience menorthagia, dysmenorthoea, and sometimes dyspareunia, On exeminstion, the uterus feels globular and the woman often complains of pain on palpation ofthe ulerus

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