Leukemia (Blood Cancer)

   In this blog I shall be discussing uterine pathologies these are going to be split into a series of two blogs; in Part 1 we are going to discuss polyp’s adenomyosis and fibroids. So starting off with polyps first endometrial polyps are hyperplastic overgrowths of endometrial glands and stroma and these are usually benign they are most common in patients in their 40s and 50s, now polyps may arise from the endometrium so we have intermediate polyps or the cervix where we have cervical polyps sometimes an individual polyp mite prolapse through the cervix and might be mistaken as a cervical polyp like we said these endometrial polyps are usually benign, however, it is always important to keep in mind that sometimes these polyps may be malignant.

Now these patients might present with heavy menstrual bleeding with postmenopausal bleeding or with intermenstrual bleeding they might also present with absolutely no symptoms whatsoever and a polyp might be identified coincidentally on an ultrasound scan patients might or might also present with infertility because large or multiple polyps may disrupt the endometrial cavity and can result in miscarriage and infertility like we said polyps might also be malignant so especially in postmenopausal women with a polyp size of more than 1cm and abnormal uterine bleeding, the chances of a malignant polyp are higher, so how do we diagnose these polyps so we usually perform a transvaginal ultrasound scan to find them but the gold standard is a hysteroscopy because here you're seeing them under direct vision and in fact in this picture we can see where the polyp would look like when looking down the scope treatment of these polyps typically involves removal of the polyp during hysteroscopy and this is referring to us hysteroscopic polypectomy.

This is basic Larry carried out if the polyps are causing problems like heavy menstrual bleeding or if we find the polyp in a postmenopausal woman or if we are suspecting malignancy great so on to the next uterine pathology so next, we're going to talk about adenomyosis. Adenomyosis refers to the presence of endometrial stroma within the myometrium so essentially what this means is that the endometrium which is the lining that is built up during every cycle and is shed during menstruation is present within the muscular layer of the uterus so every cycle these endometrial deposits will bleed within the myometrium forming pockets of blood as we can see over here these patients will typically present with heavy and painful menstrual periods and this is most common in patients who are 40 years of age. The uterus might also be mildly enlarged and tender now classically the diagnosis of adamant adenomyosis is made on histology of hysterectomy specimens so it's actually very difficult to get a confirmation about adenomyosis clinically.

In fact, it's not easy to identify an ultrasound but some changes can be identified by an experienced photographer MRI on the other hand is better at seeing Adam iOS's now management of adenomyosis is based on treating the heavy menstrual bleeding so we've got medical options here like the Mirena the oral contraceptive pill and NSAIDs and in severe heavy menstrual bleeding we can also opt for a hysterectomy. Now moving on to fibroids so these are also referred to as leiomyomas but they are more commonly referred to as fibroids so essentially they are benign smooth muscle tumors of the uterus they are very common and in fact, by the age of 50 they will be present in more than 80% of black women and around 70% of white women so as you can see they are more common in black women now fibroids I can't grow in a different location so you can have sub-zero's and fibroids which are present under the peritoneum you can have submucosal fibroids which are present just under the endometrium these tend to distort the uterine cavity.

So they can cause problems in terms of fertility they can also grow into the cavity of the uterus and are now called pedunculated submucosal fibroids you can have intramural fibroids which are located within the myometrium cervical fibroids grow in the cervix, sometimes fibroids might also prolapse out of the cervix which is referred to as fibroma. Now as you can see from this fondle fibroid, fibroids can also grow very large and sometimes in fact patients can present the mass in their abdomen now on a cross section of these fibroids they tend to have a horrid appearance as you can see from this picture over here okay so fibroids are very likely to be dependent on estrogen and progesterone in fact they tend to enlarge in the presence of a lot of estrogen and progesterone such as in pregnancy or when a woman is on the pill or taking HRT, on the other hand fibroids will atrophy and calcify in times of low estrogen, progesterone such as the menopause when they can safai they are sometimes referred to as womb stones now there are a few complications of fibroids which we need to know about so these are degeneration so basically the generation occurs when there is an adequate blood supply to the fibroid there are different types so Heinen degeneration is the most common type red degeneration typically occurs in pregnancy and patients will present with abdominal pain and bleeding and there's also cystic regeneration another complication is the risk of malignancy so even though most of the time these tumors are benign it less than 1% of the time they might become malignant resulting in a leiomyosarcoma Goodes.

Now move on to the presentation of these fibroids so presentation is related to the location number and size of the fibroids so if they are small and the most common present incidentally and patients are completely asymptomatic however most often they present with abnormal uterine bleeding such as heavy menstrual bleeding, this heavy bleeding might also results in the patient having symptoms of iron deficiency anemia like we said before large fibroids can present as an abdominal mass they can also present with abdominal pain because of the pressure that fibroids put on pelvic organs, this pressure may also be applied to ureters causing hydronephrosis on the bladder causing urinary retention and on tubal ostium causing infertility when fibroids disrupt the endometrial cavity they can also result in infertility and recurrent miscarriage in pregnancy, fibroids can result in Mal presentation, preterm labor, postpartum, hemorrhage and patients might also presented severe pain due to red the generation of fibroids now to diagnose fibroids and endovaginal exam are very important to see Vica feel any masses or if there is any tenderness which again is a sign of fibroid degeneration now an ultrasound is very important to take a look at the fibroids and an MRI is sometimes also carried out if we are planning an intervention such as uterine artery embolization.

So moving on to the treatment of fibroids now so this is very individualized in fact I've divided the management and turned it into several criteria so first we're checking whether the patient is symptomatic or asymptomatic so those patients who have no symptoms we don't give them anything but we just monitor them with ultrasounds because we want to make sure that they are stable and they are not growing rapidly because that may point towards needing some sort of intervention if the patient is symptomatic however we also want to see if they are premenopausal or post menopause and if they are premenopausal we want to ask whether they wish to preserve fertility even they wish to preserve their uterus or if they don't want to preserve fertility or their uterus so if they wish to preserve their fertility we also need to assess if they would like some form of contraception if they don't want contraception because they are trying to conceive. We can opt for NSAIDs such as men Phenom accosted and anti tribunal ethics such as tranexamic acid if they want contraception we can opt for DiMarino or the oral contraceptive pill now every patient is not concerned about fertility but wants to conserve her uterus we can opt for a myomectomy where the fibroid is removed.

This can be done with a laparoscopic or an open approach this, of course, depends on the size of the fibroid GnRH agonists can be given her pre-op for around three to four months to shrink the fibroid. This will make the operation easier and also reduces surgical complications advocate RT may be given two easements and opposes symptoms now a new product on the market is only Cristal acetate which is a selective progesterone receptor modulator that has been found to shrink fibroids and can also be used pre-op. Another option is uterine artery embolization where an interventional radiologist uses a catheter to block the blood supply to the fibroids which would result in the fibroids shrinking further research is being carried out to assess the effect on fertility if the patient has completed her family and does not wish to preserve fertility or her uterus hysterectomy can be performed, once again GnRH agonists can be given before the surgery to shrink the fibroids. So when looking at those patients who are postmenopausal and we typically also opt for a hysterectomy so it's all slapped on hysterectomy and bilateral side bingo offer ectomy great so that's all you need to know about fibroids. I hope this blog will be helpful for you and in my next blog I will be discussing cancer and congenital uterine anomalies.

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