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Cervical & Uterine Pathologies - Endometriosis, Polyps, Prolapse, etc.

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Cervical & Uterine Pathologies - Endometriosis, Polyps, Prolapse, etc.

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Cervical & Uterine Pathologies

We show the uterus, uterine tubes, cervix, and vagina.

The uterus comprises three layers, from outer to inner: the perimetrium (aka, serosa), myometrium (the muscular layer), and the endometrium (the glandular epithelial layer that proliferates and sheds during the menstrual cycle). Uterine Histology

The ovaries are held in place by the ovarian ligament, which attaches to the side of the uterus, and the suspensory ligament, which attaches to the pelvic wall and carries blood vessels, nerves, and lymph vessels to the ovary.

Anatomical/mechanical disorders:

Pelvic Organ Prolapse

Occurs when the pelvic muscles and ligaments are too weak to hold the organs in place, and the pelvic organs descend, bulging into the vaginal wall.

Organ descent can occur anteriorly, with the urinary bladder, at the midline, with the uterus, and posteriorly, with the colon. A patient may experience some or all of these variations.

Risk factors:
70 years or older
Higher parity with vaginal delivery
Connective tissue disorders
Chronic constipation

Pathology:
Pelvic organ prolapse is quite common, and, to a certain extent, nonpathological.
It becomes pathological when patients experience sexual, urinary, or defecatory dysfunction.

Treatment:
In mild cases, pessaries can be beneficial; when pessaries are not helpful, corrective surgery can be performed.

Uterine Rupture

Most often a complication of late-term pregnancy and labor, in which all three layers of the uterus split open.

Uterine Dehiscence: when division does not involve all three layers of the uterus.

Risk Factors:
The most common risk factor is previous cesarean delivery, which leaves scars that are vulnerable to rupture.

In unscarred uteri, risk factors include exposure to uterotonic drugs (such as oxytocin and prostaglandins), multiple gestation, advanced maternal age, shorter pregnancy intervals, and trauma (such as from motor vehicle accidents or falls). Some genetic disorders, such as Ehlers-Donlos and Loeys-Dietz, also predispose patients to uterine rupture.

Pathology:
Uterine rupture causes severe uterine bleeding and fetal distress, and the fetus and placenta can be expelled into the abdominal cavity.

Treatment:
Emergency cesarean and uterine repair are crucial.

Adnexal Torsion

Torsion of the ovary and/or uterine tube.

Risk Factors:
Risk factors include hydrosalpinx, ectopic pregnancy, paratubal cysts, ovarian masses, and other extrinsic lesions that pull the tubes out place.

Pathology:
Patients present with acute onset of pain with nausea and vomiting, particularly in patients with ovarian cysts.

On imaging, we'll see ovarian edema from impaired vascular flow, a "whirlpool sign" characterized by a paraovarian structure with concentric rings, and abnormal positioning of the ovary itself.

Isolated uterine torsion is rare, and the ovaries will look normal upon imaging.

Treatment:
Torsion requires emergency surgery to avoid necrosis and permanent damage to the ovary and/or uterine tube.

Unfortunately, the symptoms of adnexal torsion are vague, and diagnosis and treatment are often delayed.

Uterine Pathologies

Endometrial hyperplasia

Characterized by proliferation of the endometrial glands.

Risk Factors:
Over-exposure to unopposed estrogen is the primary risk factor, as we seen patients who are perimenopausal, menopausal, or diabetic, or who have polycystic ovarian syndrome.

Pathology:
Endometrial hyperplasia is a benign condition, but be aware that it is a precursor to endometrial cancer, which we discuss in detail, elsewhere.

Treatment:
Synthetic progesterone, called Progestin, can be provided to counteract the effects of estrogen overexposure.

Endometriosis

Present in more than 10% of women; there is no definitive test for endometriosis, and it often goes undiagnosed.

Pathology:
Endometriosis is an estrogen-dependent, chronic inflammatory condition in which endometrium-like tissue grows outside the uterus, resulting in adhesion and scar tissue in and around the pelvic organs.

We show lesions and adhesions on the uterine tube, ovary, bladder, colon, and in the recto-uterine pouch. In extreme cases, lesions and adhesions have been found in the diaphragm, spinal cord, and elsewhere in the body.

Endometriosis Phenotypes: Superficial lesions, ovarian endometriomas, deep infiltrating endometriosis (invasion of pelvic structures).

The endometric lesions produce inflammation and facilitate peripheral nerve sensitization.

Proposed causes:
Retrograde menstruation – menstrual blood with endometrial cells flows "backwards" through the uterine tubes, into the pelvic cavity. Endometrial cells implant and grow ectopically.

Cellular metaplasia – cells outside the uterus transform to endometrial-like cells and proliferate.

Stem cells – spread via blood and lymph vessels.

Diagnosis:
No specific test. Laparoscopy has historically been gold-standard, but patient interviews and imaging can be enough to start medical treatments.

Signs and Symptoms:
Patients often present with chronic pelvic, back, and abdominal pain that can be debilitating; the pain is often worse during menstruation.

Patients may also report pain during intercourse, defecation, and urination, as the lesions and adhesions affect various pelvic organs.

Not surprisingly, since endometrial lesions can interfere with ovulation and gamete transport, endometriosis can cause infertility.

Unfortunately, many patients suffer unnecessarily from endometriosis due to misconceptions regarding what "normal" menstrual pain should feel like. Health care providers should ask patients about their pain levels during and outside of menstrual cycles; earlier diagnosis and treatment can help to prevent formation of the scars and adhesions that lead to life-long problems, including infertility.

Treatment:
Options include hormonal contraceptives and GnRH-agonists, which reduce the cyclical growth and shedding of lesions, and surgical removal of lesions, scar tissue, and adhesions can reduce the pain associated with these masses.

Endometrial lesions on the Peritoneum:

Endometrioma:

Adenomyosis

Pathology:
Occurs when endometrial tissue grows within the myometrium; larger lesions can cause myometrial hypertrophy.

Signs/Symptoms:
The most common clinical manifestations are dysmenorrhea and heavy menstrual bleeding.

Treatment:
NSAIDs for pain management, hormone therapies to limit endometrial tissue growth, and surgery to remove the adenomyomas.

Endometritis

Pathology:
Occurs when normal bacterial flora from cervix and vagina are transferred to the uterus.

Most infections are due to both anerobes and aerobes (including Peptostreptococcus, Clostridium, Stretptococi, Enterococcus, and Staphylococcus).

Infection can affect all uterine layers.

Endometritis is the most common post-partum infection, particularly in cesarean sections, where damaged uterine tissue facilitates bacterial colonization.

Endometritis can also occur in sexually transmitted infections and pelvic inflammatory disease, or following dilation and curettage, endometrial biopsy, and IUD insertion.

Signs/Symptoms:
Post-partum acute endometritis typically manifests 24-72 hours after delivery with fever, low abdominal pain, and purulent, foul-smelling vaginal discharge (lochia).

Chronic endometritis can be asymptomatic, or it can cause abnormal uterine bleeding and infertility.

Treatment & Prevention:
Treat the infection with the appropriate antibiotics to avoid sepsis and shock.

As a preventative measure, we can administer antibiotics and vaginal cleaning prior to cesarean sections.

Chronic endometritis with plasma cells and neutrophils

Asherman syndrome

Pathology:
Characterized by intrauterine adhesions.

This is a rare condition that can cause amenorrhea and infertility.

Risk Factors:
Asherman syndrome is associated with dilation and curettage, which is done to remove placental tissue postpartum or to remove pregnancy tissue after miscarriage or abortion.

Asherman syndrome can also occur following endometrial infection with tuberculosis and other pathogens.

Treatment:
Surgical removal of adhesions; prevention of reformation of adhesions is also important and may involve the use of intrauterine devices, Foley catheters, or intrauterine balloon stents.

Cervical and Uterine Polyps

Grow on the surface of the cervix and endometrium.

In our drawing, we show pedunculated version, but polyps can also be flat.

Pathology:
Cervical and uterine polyps are common, and usually benign and asymptomatic.

However, they carry a higher malignancy risk in post-menopausal patients, and large polyps can cause abnormal uterine bleeding and infertility.

Treatment:
When indicated, treatment options include hormonal contraceptives, which may shrink polyps, or surgery to remove them (D&C and/or hysteroscopy).

Parauterine tube cysts

Fuid-filled cysts grow adjacent to fallopian tubes.

Pathology:
They are typically benign and asymptomatic, but larger lesions can cause feelings of pelvic pressure and pain, and can facilitate adnexal torsion.

Treatment:
Surgical removal if painful/torsion is occurring.

Board Review

Endometriosis

Getting ready for boards? Review these concise, bulleted high yield reviews for your exam.

USMLE & COMLEX-USA

Nurse Practitioner (NP)

Physician Assistant (PA)

Internal Medicine (ABIM)

Board Review

Uterine Polyps

USMLE & COMLEX-USA

Nurse Practitioner (NP)

Physician Assistant (PA)

Internal Medicine (ABIM)

References & Recommended reading:

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Images:

  • Peritoneal endometriosis: https://en.wikipedia.org/wiki/File:Peritoneal_endometriosis.jpg
  • Endometrioma: https://en.wikipedia.org/wiki/File:Endometrioma.jpg
  • Adenomyosis: https://commons.wikimedia.org/wiki/File:Uterine_adenomyosis_--_low_mag.jpg
  • Chronic endometritis: https://en.wikipedia.org/wiki/Endometritis#/media/File:Endometritis_-2-cropped-_very_high_mag.jpg