BENIGN LESION OF THE UTERUSNUR SAKINAH BINTI ZULKIFLI

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ENDOMETRIAL POLYPS

ADENOMYOSISLEIOMYOMA UTERUS (FIBROID)

ENDOMETRIAL POLYPS

• Localized outgrowth of the endometrium• contain an inner core of blood vessel• surrounded by blood vessel and stroma

• Maybe benign or malignant• Benign : attached by pedicle

Age • All age group• Peak (40-49 years)

Size• Few mm – several cm

Number• Single or multiple

Types • Pedunculated• Sessile• Mucous• Fibroid • Placental

RISK FACTOR

HRT

Tamoxifen therapy

Diabetes

Hypertension

Obesity

Increased patient age

PATHOLOGY

• BODY : a part of thick endometrium project into the cavity and ultimately attained pedicle/sessile

• CUT SECTION: grey or reddish brown

GROSS APPEARANCE

:

• Core : contain stromal cells gland 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• Smooth muscle invade polyps : adenomyomatous polyps

MICROSCOPIC

PREDICTOR OF MALIGNANCY

Size >10 mm

Postmenopausal status

Abnormal uterine

bleeding

CLINICAL FEATURE

Maybe asymptomatic

Menorrhagia

Intermenstrual bleeding

Contact bleeding (polyps situated outside cervix)

Infertility and miscarriage

(multiple polyps)

ON EXAMINATION

• Uterus normal/uniformly enlarged• Soft, slippery and small in size (outside the

cervix)

• PER SPECULUM : Reddish in color attached with slender pedicle

INVESTIGATION

• Must be ruled out in women with abnormal uterine bleeding who do not respond to traditional treatment

MANAGEMENT

Hysteroscopic polypectomy

Curettage of endometrium (to rule out

hyperplasia)

ADENOMYOSIS

• Presence of endometrial tissue in myometrium >2.5mm from the basal layer of endometrium

• Endometrial gland and stroma must present

PATHOGENESIS

• Oestrogen recepter mutation• Gene polymorphism

• Basal layer of endometrium including stroma and gland infiltrating myometrium.

• Surrounding myometrial tissue hypertrophied and hyperplasia

• Uterine enlargement

PATHOLOGY

• DIFFUSE– Involve anterior and posterior uterine walls– Causes uniform uterine enlargement– Thickened myometrium and hemorrhagic foci of

adenomyosis• LOCALIZED– Grossly mimic leiomyoma (no capsule or distinct

plane of dissection)

CLINICAL FEATURE

• 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 (> with > duration of disease and depth of infiltration

• Menorrhagia

INVESTIGATION

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

MEDICAL MANAGEMENTNSAID

• Androgen,estrogen and progesterone receptor present in lesion• Reduce in size, menorrhagia reduce• Temporary effect

COMBINED OCP

• Prior to surgery to reduce size and vascularity

DANAZOL

• Reduce pain and bleeding

GnRH ANALOGUE

AROMATASE INHIBITOR (anastrozole)

LEVONOGESTREL INTRAUTERINE SYSTEM (LNG-IUS)

DANAZOL LOADED INTRAUTERINE DEVICE

SURGICAL MANAGEMENT

• Definitive surgery • Perimenopausal age• Poor response to medical

therapy• Associated pelvic pathology

CONSERVATIVE SURGERY

•Localized adenomyoma by adenomyomectomy•Plane of dissection id difficult since no capsule

Resection of adenomyoma

•Diffuse adenomyosis•Partial resection of uterine walls

Myometrial reduction

•Submucosal adenomyosis/ polypoidal lesion

Hysteroscopic reduction

NEWER INTERVENTIONAL TECHNIQUE

Endometrial ablation

Uterine artery embolisation

MRI guided focused

ultrasound surgery

REFERENCE

• Essentials Of Gynaecology, Lakshmi Seshadri• DC Dutta Textbook Of Gynaecology

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