2. What is cancer of the uterus?
Cancer of the womb (uterus) is a common cancer that affects the female
reproductive system. It's also called uterine cancer and endometrial cancer.
Abnormal vaginal bleeding is the most common symptom of womb cancer. If you
have been through the menopause, any vaginal bleeding is considered abnormal.
What are the diseases that affect the reproductive system?
Examples of cancers of the reproductive system include:
• Prostate cancer - Cancer of the prostate gland.
• Breast cancer - Cancer of the mammary gland.
• Ovarian cancer - Cancer of the ovary.
• Penile cancer - Cancer of penis.
• Uterine cancer - Cancer of the uterus.
• Testicular cancer - Cancer of the testicle/(plural:testes)
Is the womb in the uterus?
The uterus (from Latin "uterus", plural uteri) or womb is a major female
hormone-responsive reproductive sex organ of most mammals, including humans. One
end, the cervix, opens into the vagina, while the other is connected to one or both
fallopian tubes, (uterine tubes) depending on the species.
3. Diseases of the uterus
Some pathological states include:
• Prolapse of the uterus
•Carcinoma of the cervix – malignant neoplasm
•Carcinoma of the uterus – malignant neoplasm
•Fibroids – benign neoplasms
•Adenomyosis – ectopic growth of endometrial tissue within the myometrium
•Endometritis, infection at the uterine cavity.
4. • Pyometra – infection of the uterus, most commonly seen in dogs
• Uterine malformations mainly congenital malformations including Uterine Didelphys, bicornuate uterus
and septate uterus. It also includes congenital absence of the uterus Rokitansky syndrome
• Asherman's syndrome, also known as intrauterine adhesions occurs when the basal layer of the
endometrium is damaged by instrumentation (e.g. D&C) or infection (e.g. endometrial tuberculosis)
resulting in endometrial scarring followed by adhesion formation which partially or completely obliterates
the uterine cavity.
• Hematometra, which is accumulation of blood within the uterus.
• Transvaginal ultrasonography showing a uterine fluid accumulation in a postmenopausal woman.
• Myometritis, an infection of the uterine muscular layer
6. • Benign disease of the cervix and body of the uterus is
extremely common. Cervical ectropion and fibroids are
often present without symptoms, but are also common
problems encountered in almost every gynaecological
outpatient clinic.
7. ENDOMETRIUM
The uterine endometrium comprises glands and
stroma with a complex architecture, including blood
vessels and nerves. during the follicular phase of the menstrual
cycle,proliferation of tissue from the basal layer occurs, followedby
secretory changes under the influence of progesterone after ovulation and
finally shedding asprogesterone levels fall, with corpus luteum regression.
9. ENDOMETRIAL POLYPS
• Localized overgrowths of the endometrial glands and stroma projecting
beyond the endometrial surface
• Peak age incidence is at 40-49 years
• Cause is unknown
but in menapause common in women with HRT and patient take tomoxifen
for ca breast.
• Mostly are asymptomatic, mostly are detected by sonography.
10. • Common manifestation is inermenstrual bleeding in
perimenapaue or postmenapausal bleeding
• Has 3 histological components:
• Endometrial glands
• Endometrial stroma
• Central vascular channels
12. ENDOMETRIAL POLYPS
• Malignant transformation is estimated at 0.5%
• Differential diagnosis:
• Submucous leiomyoma
• Adenomyoma
• Retained products of conception
• Endometrial hyperplasia
• Endometrial carcinoma
• Uterine sarcoma
• Optimal management is removal by Hysteroscopy with D and
C
13. ASHERMAN'S SYNDROME
When the endometrium has been damaged, in particular
when it has been removed down to or beyond the basal
layer, normal regeneration does not occur, and instead
there is fibrosis and adhesion formation.
14. ASHERMAN'S SYNDROME
causes:
• Endometrial resection by using a diathermy loop or is
ablated with a laser.
• Consequence of excessive curettage, especially for retained
placental tissue or miscarriage or secondary postpartum
hemorrhage.
• tuberculosis and schistosomiasis.
17. MANAGEMENT
• resection of uterine synechia by Dand C or by hystroscope
then maintaining separation of the uterine walls by
insertion of a large inert IUCD such as
a Lippes loop
• Treatment of tuberculosis and
schistosomiasis.
18. CERVICAL STENOSIS
• Often occurs in the internal os
• Maybe congenital or acquired
• Symptoms differ depending on the menopausal status of the
woman
• Diagnosis is established by inability to introduce a cervical
dilator into the uterine cavity
• Management:
• Cervical dilatation under ultrasound guidance
• Laminaria tent or T-tube as stent for a few days
19. HEMATOMETRA
• Uterus is distended with blood secondary to gynatresia
• Common congenital causes:
• Imperforate hymen
• Transverse vaginal septum
• Common acquired causes:
• Senile atrophy of endocervical canal and endometrium
• Scarring of the isthmus by synechiae
• Cervical stenosis associated to surgery, radiation therapy, cryotherapy or
electrocautery, endometrial ablation
• Malignant disease of endocervical canal .
• premalignant disease of the cervix was treated by knife cone biopsy.
20. HEMATOMETRA
• Usually suspected by history of amenorrhea and cyclic abdominal
pain
• Diagnosis confirmed by :
• Ultrasonography
• Probe the cervix with dilator and with release of dark
brownish black blood
• Management
• Depends on the operative relief of lower genital tract obstruction ,
careful surgical dilatation of the cervix
and endometrial biopsy under antibiotic cover.
22. PYOMETRA
• In postmenopausal women, cervical
stenosis may give rise to pyometra, in which
accumulated secretions become a focus of infection.
Underlying malignancy may also lead to pyometra.
23. UTERINE FIBROIDS
• A fibroid is a benign tumour of uterine smooth
muscle,termed a leiomyoma.
24. LEIOMYOMA
• Benign tumors of muscle cell origin
• The most frequent pelvic tumor and the most common tumor in women
• Highest prevalence above the 3th
decade of woman’s life
• Found in 30-50% of perimenopausal women
• Symptomatic leiomyomas are the primary indication for approximately 30% of
all hysterectomies
• Risks factors:
- Increasing age - Early menarche
- Low parity -Tamoxifen use
- Obesity - High fat diet
- positive family history - African racial origin.
25. A LOWER RISK OF FIBROIDS
i. -Oral contraceptives
ii. -Athletic women may have,
iii. -Pregnancy and giving birth may have a protective effect,
26. LEIOMYOMA
• 3 most common types:
• Intramural
• Subserous
• Submucous
• Other types: Intraligamentary and Parasitic myomas
• Origin:
• Each tumor develops from a single muscle cell a progenitor myocyte
• Cytogenetic analysis demonstrated that myomas have multiple chromosomal
abnormalities affecting regulation of growth-inducing proteins and cytokines
29. LEIOMYOMA
• Current theory:
Neoplastic transformation from normal myometrium to leiomyomata is the
result of a somatic mutation in the single progenitor cell affecting cytokines that
affect cell growth.The growth may be influenced by estrogen and progesterone
levels.
• Clinical characteristics:
• Rare before menarche, diminish in size after menopause
• Enlarges during pregnancy and occasionally during OCP use
• Gross appearance:
• Lighter in color than the normal myometrium
• Cut surface: Glistening, pearl-white with smooth muscle arranged in trabeculated or
whorl configuration.
31. LEIOMYOMA
• Histologic appearance:
With proliferation of mature smooth muscle cells.The nonstraited muscle
fibers are arranged in interlacing bundles with variable amount of fibrous
connective tissue in-between.
• Types degeneration:
- Hyaline - Myxomatous
- Calcific - Cystic
- Fatty - Necrosis
- Red or Carneous
32. Red degeneration follows an acute disruption of the blood supply to the fibroid during
active growth, classically during pregnancy. This may present with the sudden
onset of pain and tenderness localized to an area of the uterus, associated with a
mild pyrexia and leukocytosis. The symptoms and signs typically resolve over a
few days and surgical intervention is rarely required.
Hyaline degeneration occurs when the fibroid more gradually outgrows its blood
supply, and may progress to central necrosis, leaving cystic spaces at
the centre, termed cystic degeneration.
As the final stage in the natural history, calcification of a fibroid may be detected
incidentally on an abdominal X-ray in a postmenopausal woman. Rarely, malignant or
sarcomatous degeneration has been occur.
33. LEIOMYOMA
• Malignant transformation is 0.3 to 0.7%, usually into a Sarcoma.
• Clinical Manifestations:
The great majority do not cause symptoms but may be identified coincidentally, for
example at the time of taking a cervical smear or performing laparoscopic sterilization.
Most common symptom:
• Pressure from an enlarging mass
• Pain including dysmenorrhea and red degenration during pregnancy or
twisted subsrosal type.
• Abnormal uterine bleeding(menorraghea).
• Sub fertility
• Recurrent pregnancy lose
• Malpresentation and postpartum hemorrhage
34. Rectosignoid compression with constipation or intestinal
obstruction
Prolapse of a pedunculated submucous tumor through the cervix
→ severe cramping and subsequent ulceration and
infection (uterine inversion has also been reported)
Venous stasis of lower extremities and possible thrombophlebitis
2nd
to pelvic compression
Polycythemia
Ascites
Rapid growth after menopause, consider Leiomyosarcoma
35. FIBROID LOCATION INFLUENCES
SIGNS AND SYMPTOMS
Submucosal fibroids. Fibroids that grow into the
inner cavity of the uterus it is responsible for
prolonged, heavy menstrual bleeding &
dysmenghroea.
Subserosal fibroids. Fibroids project to the outside
of the uterus press on bladder, causing urinary
symptoms.
If fibroids bulge from the back of uterus, they
occasionally can press on rectum, causing
constipation on spinal nerves, causing backache.
36. COMPLICATIONS OF FIBROIDS
1-Degenerations;Hylain ,necrosis, red degeneration
( pregnancy, menopause) ,calcifications .
2-Sarcomatous changes;<0.05%
3-Infection
4-Rare:
a-Parasitic attachment to omentum bowel to
gain blood supply,
b- metastasis through blood vessels to vessel
wall,
c-Polycythmia associated with broad ligament
fibroid
37. EFFECT OF PREGNANCY ON FIBROID
A. Subinvolution
B. Ascending infection
C. Torsion
38. EFFECTS OF FIBROID ON
PREGNANCY
1-Infertility
2-Abortion
3-PUC
4- preterm labor
5-Abruptio placentae
6-abnormal Lie & position
7-Increase rate of operative delivery
8-PPH (uterine atony) .
42. • Conservative management is appropriate where
asymptomatic fibroids are detected incidentally. It may
be useful to establish the growth rate of the fibroids by
repeat clinical examination or ultrasound after a 6-12-
month interval.
43. LEIOMYOMA
• Factors affecting the type of surgical approach:
• Age of the patient
• Parity
• Future reproductive plans
• Classic indications for Myomectomy:
• Persistent abnormal bleeding
• Pain or pressure
• Enlargement of an asymptomatic myoma to more than 8 cm in a
woman who has not completed chilbearing
44. LEIOMYOMA
• Contraindications to Myomectomy:
• Pregnancy
• Advanced adnexal disease
• Malignancy
• When enucleation of the myoma results in severe reduction of endometrial surface
that the uterus would not be functional
• Myomectomy maybe performed through:
• Laparoscopy
• Hysteroscopy
• Laparotomy
• Vaginally
45. LEIOMYOMA
• Indications for Hysterectomy:
• All indications for myomectomy,
plus:
• Asymptomatic myomas when the uterus that has reached the size of 14-16 weeks
gestation
• Rapid growth of myoma after menopause
46. MEDICAL TREATMENT
practical currently available medical treatment is ovarian
suppression using a gonadotrophin-releasing hormone
(GnRH) agonist. Unfortunately, ,,,,hile very effective in shrinking fibroids,
when ovarian function returns, the fibroids regrow to their previous
dimensions.Mifepristone (an antiprogestogen) has been
shovm to be effective in shrinking fibroids at a low dose,
but is not available for use in this indication.The optimaldose, duration of
treatment and long-term effects have yet to be established.
47. LEIOMYOMA
Advantages of Preoperative GnRH Agonist Treatment:
• Advantages Gained by Uterine-Fibroid Shrinkage
• May allow vaginal hysterectomy
• May decrease intra-operative blood loss
• May allow Pfannenstiel incision
• May facilitate endoscopic myomectomy
• Advantages Gained by Induction of Amenorrhea
• May correct hypermenorrhea-menorrhagia-associated anemia
• May improve ability to donate blood
• May decrease need for non-autologous blood transfusion
• May atrophy endometrium, facilitating hysteroscopic resection of submucosal
myoma
48. LEIOMYOMA
Disadvantages of Preoperative GnRH Agonist Treatment:
• Delay to final tissue diagnosis
• Degeneration of some myomas, necessitating piecemeal enucleation at
myomectomy
• Hypoestrogenic side effects.
• Trabecular bone loss
• Vasomotor symptoms: e.g. hot flushes
• Cost
• Need to self-administer or receive injections in many cases
• Vaginal hemorrhage in approximately 2% of patients
49. NEW DEVELOPMENTS
Endoscopic surgical treatments for fibroids have proved
Disappointing.
myolysis using a diathermy needle to destroy the tissue is followed by intense
adhesion formation.
interruption of the arterial supply to the tumour is atheoretically attractive
concept. In practice, this is feasible by the radiological technique of
percutaneous selective catheterization of the uterine arteries.
Microparticles are released into the vessel s, causing occlusion of both
uterine arteries.
50. LEIOMYOMA
Complications of Uterine Artey Embolization:
• Post-embolization fever
• Sepsis from infarction of the necrotic myometrium
• Ovarian failure
• Abdominal pain
52. GENERAL OVERVIEW OF
GYNECOLOGIC CANCERS
• 79,480 new cases/years of female genital system cancers in the
U.S.
• 28,910 deaths in U.S. from genital system cancers in 2005
• Diet, exercise and lifestyle choices play important roles in the
prevention of cancer
• Knowledge of family history also increases prevention and
early diagnosis rates
• Regular screening and self-examinations for appropriate
cancers early detection early intervention & therapy
53. ENDOMETRIAL CANCER
• Strong association with excess weight
• Obesity has been implicated in the development of
• Type 2 diabetes
• Heart disease
• Stroke
• Hypertension
• Gallbladder disease
• Osteoarthritis
• Sleep apnea
• Asthma
54. • Psychological disorders or difficulties
• Some cancers, including ovarian, cervical, breast, and endometrial
• Dyslipidemia
• Complications of pregnancy
• Hirsuitism
• Menstrual abnormalities
• Stress incontinence
• Increased surgical risk
55.
56. Important Definitions
• Obesity: having a very high amount of body fat in relation to
lean body mass, or Body Mass Index (BMI) of 30 or higher for
adults.
• Body Mass Index (BMI): a measure of weight in relation to
height, specifically weight in kilograms divided by the square of
his or her height in meters.
• Morbid Obesity-100 pounds above ideal weight or BMI over
40 (indication for bariatric surgery)
• Bariatric surgery is the term for operations to help promote
weight loss.
57. ENDOMETRIAL CANCER
• Cancer of the uterine endometrial lining
• Most common female reproductive cancer
• 40,000 new cases/year
• 7,000 deaths/year
• Most of these malignancies
• are adenocarcinoma
58. INCIDENCE AND PREVALENCE
• Most common gynecologic cancer
• 4th most common in women (US)
• 2nd most common in women (UK)
• 5th most common in women (worldwide)
• Western developed > Southeast Asia
• Increase in the 1970’s
• Increased use of menopausal estrogen therapy
59. RISK FACTORS FOR ENDOMETRIAL
CANCER
• Early menarche
• (<age 12)
• Late menopause
(>age 52)
• Infertility or nulliparous
• Obesity
• Treatment with tamoxifen for breast
cancer
• Estrogen replacement therapy (ERT)
after menopause
• Diet high in animal fat
• Diabetes
• Age greater than 40
• Caucasian women
• Family history of endometrial
cancer or hereditary
• nonpolyposis colon cancer
(HNPCC)
• Personal history of breast or
ovarian cancer
60. ENDOMETRIAL CARCINOMA
• Etiology
• Unnoposed estrogen hypothesis:
exposure to unopposed
estrogens
• Pathology
• Spreads through uterus, fallopian
tubes, ovaries and out into
peritoneal cavity
• Metastasizes via blood and
lymphatic system
61. SYMPTOMS OF
ENDOMETRIAL CANCER
• Symptoms
• Non-menstrual bleeding or discharge
• Especially post-menopausal bleeding
• Heavy bleeding
• Dysuria
• Pain during intercourse
• Pain and/or mass in pelvic area
• Weight loss
• Back pain
62. ENDOMETRIAL CANCER
• Diagnosis
• Pelvic examination
• Pap smear (detect cancer spread
to cervix)
• Endometrial biopsy
• Dilation and curettage
• Transvaginal ultrasound
• Treatment
• Surgery
• Hysterectomy
• Salpingo-oophorectomy
• Pelvic lymph node
dissection
• Laparoscopic lymph
node sampling
• Radiation therapy
• Chemotherapy
• Hormone therapy
• Progesterone
• Tamoxifen
63. ENDOMETRIAL HYPERPLASIA
• Overgrowth of the glandular epithelium of the endometrial
lining
• Usually occurs when a patient is exposed to unopposed
estrogen, either estrogenically or because of anovulation
• Rates of neoplasm
• simple hyperplasia: 1%.
• complex hyperplasia with atypia: 30%
64. ENDOMETRIAL HYPERPLASIA
• Complex hyperplasia with atypia
• One study found incidence of concomitant endometrial
cancer in 40% of cases
• Hysterectomy or high dose progestin tx
• Simple
• Often regress spontaneously
• Progestin treatment used for treating bleeding may help in
treating hyperplasia as well
65. • Estrogen dependent disease
• Prolonged exposure without the balancing effects of progesterone
• Premalignant potential
• Endometrial hyperplasia
• Simple => 1%
• Complex => 3%
• Simple with atypia => 8%
• Complex with atypia => 29%
66. REDUCED RISK
• Oral Contraceptives
• Combined OC => 50% reduced rate
• Actual reduction number small because uncommon in women of child
bearing age
• Long term offers protection
• Reduced risk presumably => progesterone
• Tobacco Smoking
• Some evidence that it reduces the rate
• Smokers have lower levels of estrogen and lower rate of obesity
67. PREVENTION AND SURVIVAL
• Early detection is best prevention
• Treating precancerous hyperplasia
• Hormones (progestin)
• D&C
• Hysterectomy
• 10 ~ 30% untreated develop into cancer
• Average 5 year survival
• Stage I => 72 ~ 90%
• Stage II=> 56 ~ 60%
• Stage III => 32 ~ 40%
• Stage IV => 5 ~ 11%
68. POTENTIALLY MODIFIABLE RISK
FACTORS
• Dietary factors
• Isoflavones:
• Phytoestrogens that have
properties similar to selective
estrogen receptor modulators
Soy, beans, chick peas…
69. DIETARY FIBER
• Increases estrogen
excretion and
decreases estrogen
reuptake: whole grains,
vegetables, fruits, and
seaweeds
70. SUMMARY POINTS
• Endometrial cancer is one of the leading gynecological
cancers in the US
• Obesity is one of the key factors involved in Endometrial
cancer development
• More research is needed to explore modifiable risk factors
in endometrial cancer development
