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polyp and adenomyosis.pptx

  1. POLYP (AUB P) Athira Radhakrishnan 38
  2. Uterine polyp • Are usually benign • Comprising of 1. Endometrial Polyps 2. Fibroid 3. Adenomyomatous 4. Placental
  3. Endometrial polyps • Mostly arise from hyperplasia of endometrium, some part of endometrial lining protruding into uterine cavity as polyps • Single or multiple • Pink swellings, 1-2 cm diameter with a pedicle
  4. • Composed of endometrial glands and stroma covered with single layer of columnar epithelium • 2⁰ malignant change may occur • Malignant polyp arising ab initio, entire polyp shows malignancy including its base • Tamoxifen cause endometrial hyperplasia and polyps
  5. • Fibroid polyp • submucous fibroid developing a pedicle and protruding into uterine cavity or projecting through os with a long pedicle • Pale looking , firm with infection and necrosis at base if it protrudes thru cervix • Can be sessile or a pedunculated cervical fibroid
  6. • Placental polyps • Formed from retained placental tissue • Cause 2⁰ PPH or intermittent vaginal bleeding • Following an abortion or a normal delivery
  7. Clinical features • Heavy menstrual bleeding • Intermittent vaginal bleeding • Post menopausal bleeding • If these protrude thru os, post coital bleeding or continuous bleeding in a young woman
  8. • Clinically may not be evident as uterus may or may not be enlarged • Eavaluation of structure of endometrial cavity: Trans vaginal ultrasonography (TVUS) : • appropriate & imp screening tool • Performed early in course of investigation • Not 100% sensitive
  9. • If there are imaging features indicating presence of endometrial polyps or if examination is suboptimal include hysteroscopy &/or TVUS with intra uterine contrast – either gel or saline ( Sonohysterography) • When vaginal access is difficult / impossible ( adolescents & virginal women)  TVUS , contrast Sonohysterography and office hysteroscopy may not be feasible Role for MRI
  10. • Alternatively, hysteroscopic examination with indicated biopsies performed under appropriate anesthesia may be the best approach • Presence of polyp(s)  AUB – P is confirmed only with documentation of one or more clearly defined polyps with either hysteroscopy or Sonohysterography
  11. Management • Hysteroscopic polypectomy  young women who wish to preserve fertility • In women with multiple endometrial polyps & not desirous of continued fertility  hysteroscopic polypectomy may be followed by LNG IUS insertion • Polyp sent for histopathology & if it suggests malignancy  Further managed as AUB - M
  12. ADENOMYOSIS (AUB A) • Uterine endometriosis • Islands of endometrium in the wall of uterus • Elderly women • Often coexist with uterine fibromyomas, pelvic endometriosis and endometrial carcinoma
  13. Clinical features • Usually parous • Around 40 yrs • Heavy menstrual bleeding • Progressively increasing dysmenorrhoea • Pelvic discomfort • Backache • Dyspareunia
  14. • Clinical examination : • If adenomyosis is diffuse  symmetrical enlargement of uterus • Uterus is tender • Uterine enlargement rarely exceeds that of a 3mon pregnant uterus • If adenomyosis is localised asymmetrical enlargement resemblance to myoma is closer  A myoma of this size is rarely painful
  15. • Gross : uterus appears symmetrically enlarged to not more than 14 weeks size • Cut section : localised nodular involvement. Affected area : • peculiar, diffuse, striated & non capsulated involvement of myometrium • mostly posterior wall • with tiny dark hrrgic areas in between
  16. • Laparoscopy : a uniformly enlarged uterus • Histological examtn : • islands of endometrial glands surrounded by stroma in the midst of myometrial tissue • at least two low power fields beyond endomyometrial jn. • more than 2.5 mm beneath the basal endometrium
  17. • Ultrasound : • ill defined hypoechoic areas • Heterogeneous echoes in myometrium • Asymmetrical uterine enlargement • Subendometrial halo thickening • Endometrial infiltration into myometrium
  18. • MRI • is superior to ultrasound showing hypo or anechoic area in the uterine wall • Necessary for evaluation of myometrium to distinguish b/w leiomyomas & adenomyosis
  19. Adenomyosis diagnostic criteria • Presence of 2 or more of these criteria are highly associated with a diagnosis of Adenomyosis
  20. Management • Consider • Age • symptomatology ( AUB, pain & infertility) • Association with other conditions ( leiomyomas, polyps & endometriosis)
  21. • In women with AUB A desirous of preserving fertility, but not immediate conception  progestogens especially LNG IUS • If resistant to LNG IUS/unwilling to use it : GnRH agonists with add back therapy as 2nd line therapy • Not desirous of preserving fertility: LNG IUS or GnRH agonists with add back therapy is initiated
  22. • COCs , danazol, NSAIDs & progestogens for symptomatic relief when LNG IUS & GnRH agonist cannot be indicated • Conservative Sx in selected cases presenting with infertility or with strong desire to retain uterus : Adenomyomectomy • Failure / refusal for medical Mx : vaginal or laparoscopic hysterectomy is indicated