Abnormal Uterus, Endo, and Tubes!

What are Müllerian anomalies?

Structural abnormalities of the uterus caused by abnormal development of the Müllerian ducts.

What can cause Müllerian anomalies?

Failure of Müllerian duct fusion, failure of septum reabsorption, or arrested development.

What problems can Müllerian anomalies cause?

Infertility and recurrent miscarriage.

____% of people with infertility or recurrent pregnancy loss have some sort of mulerian anomaly.

25%

Which Müllerian anomaly is most common?

Septate uterus.

What is an arcuate uterus?

A fairly common, usually normal uterine variant with a slight fundal endometrial indentation less than 1 cm.

What does the outer serosa look like in an arcuate uterus?

Smooth with no indentation.

Is an arcuate uterus associated with fertility problems according to the slides?

No.

What causes a septate uterus?

Failure of the septum to reabsorb after the Müllerian ducts fuse.

What are the two forms of septate uterus described?

Deep complete septate or shallow subseptate.

What Müllerian anomaly is the most common cause of recurrent pregnancy loss?

Septate uterus.

What does the outer serosa look like with a septate uterus?

Smooth.

How can a septate uterus be treated?

The septum can be removed hysteroscopically.

What is a unicornuate uterus?

A uterus with only one developed horn/side.

What does the cavity of a unicornuate uterus typically look like?

Straight and narrow and may deviate.

How many fallopian tubes are usually present with a unicornuate uterus?

Usually one.

Can a person with a unicornuate uterus have both ovaries?

Yes.

What pregnancy complications are associated with a unicornuate uterus?

Higher miscarriage and growth-restricted babies.

What does a bicornuate uterus look like?

Heart-shaped.

What causes a bicornuate uterus?

Partial failure of Müllerian duct fusion.

What is the cervical/lower uterine configuration of a bicornuate uterus?

Usually a single cervix and lower uterine segment with separation in the fundal region.

How far apart are the two cornua often in a bicornuate uterus?

At least about 4 cm.

How does the outer serosa appear in a bicornuate uterus?

Indented more than 1 cm.

What causes uterine didelphys?

Complete failure of the Müllerian ducts to fuse.

What structures may be duplicated with uterine didelphys?

Two uteri, two cervices, and often two vaginal openings or one vagina with a septum.

Which Müllerian anomaly is the most rare?

Uterine didelphys.

What causes a T-shaped uterus?

DES exposure in the womb.

What is DES?

Diethylstilbestrol, a synthetic estrogen formerly prescribed from 1940-1971 to prevent pregnancy complications.

Why is DES important in GYN history?

It was associated with congenital reproductive tract abnormalities and increased reproductive cancer risk in exposed female offspring.

What are leiomyomas?

Benign uterine tumors arising from the muscular layers of the uterus.

What are other names for leiomyomas?

Fibroids or myomas.

What is the most common pelvic tumor?

Leiomyomas/fibroids.

How common are fibroids in women over 30 according to the slides?

About 30%.

What hormone are fibroids dependent on?

Estrogen.

When can fibroids grow more rapidly?

During pregnancy.

How can fibroids appear on ultrasound?

Myometrium-like with a capsule, heterogeneous, hypoechoic, calcified-rim, fatty/hyperechoic, or cystic/degenerating.

Can fibroids be single or multiple?

Either.

Where is an intracavitary fibroid located?

Within the endometrial canal.

Where is a submucosal fibroid located?

Beneath the endometrial canal and it displaces/distorts the endometrium.

Where is an intramural fibroid located?

Within the myometrium; it is the most common location.

Where is a subserosal fibroid located?

Projecting through the outer uterine wall/serosa into the pelvis.

What is a pedunculated fibroid?

An extrauterine pelvic mass connected to the uterus by a thin stalk.

What symptoms can fibroids cause?

Menorrhagia, dysmenorrhea, enlarged/irregular uterus, pelvic pain/pressure, bloating, and anemia.

What are treatments for fibroids?

Myomectomy, hysterectomy, Lupron, or uterine artery embolization.

How does Lupron treat fibroids?

It reduces estrogen to shrink the fibroids.

How does UAE treat fibroids?

Small particles are delivered through a catheter to block blood supply to parts of the uterus.

What is the most common cause of uterine calcifications?

Fibroids.

What is another cause of uterine calcifications?

Calcification of arcuate arteries around the uterine periphery.

What conditions can be associated with uterine vascular calcifications?

Diabetes and hypertension.

What lifestyle factor is associated with uterine calcifications?

Smoking.

When are uterine calcifications more common?

Postmenopause and advanced age.

What is adenomyosis?

Endometrial tissue invading the myometrium.

What happens to the basal layer with adenomyosis?

It is broken down as endometrium invades the myometrium.

Can adenomyosis be diffuse or focal?

Yes.

What uterine appearance is associated with adenomyosis?

A bulky, globular uterus, often involving the posterior uterus.

What ultrasound finding is associated with adenomyosis?

Venetian blind effect.

What other ultrasound findings can occur with adenomyosis?

Globular/focally enlarged areas, myometrial cystic areas, and an indistinct endometrial-myometrial border.

What symptoms can adenomyosis cause?

Dysmenorrhea, menorrhagia/prolonged periods, pelvic pain/pressure, and an enlarged uterus.

What is leiomyosarcoma?

A very rare malignant tumor of the uterus.

What percentage of uterine malignancies are leiomyosarcomas according to the slides?

About 1%.

Where can leiomyosarcoma originate?

The myometrium or endometrium.

How can leiomyosarcoma differ from a fibroid?

It can look similar initially but grows much faster and is less circumscribed.

Where is leiomyosarcoma more commonly located?

Fundal/intramural.

What age group is commonly affected by leiomyosarcoma?

About 40-60 years old.

What symptoms can leiomyosarcoma cause?

Abnormal uterine bleeding and pain.

What is a uterine AVM?

A rare vascular anomaly with abnormal artery-vein connections/fistulas and missing capillaries.

Where is a uterine AVM usually located?

In the myometrium, sometimes the endometrium.

Why is a uterine AVM dangerous?

It can cause potentially life-threatening hemorrhage, especially during surgery or birth.

Is a uterine AVM congenital or acquired?

It can be congenital but is more commonly acquired after uterine trauma or surgery.

How can a uterine AVM appear on grayscale?

Heterogeneous with small anechoic tubular structures in the myometrium.

What does a uterine AVM look like on color Doppler?

Turbulent mosaic flow.

What does spectral Doppler show with a uterine AVM?

High-velocity, low-resistance arterial flow and high-velocity venous flow with an arterial component.

How is a uterine AVM treated?

Angiography and embolization.

What is an endometrial polyp?

An overgrowth of glandular tissue in the endometrium.

How can an endometrial polyp attach?

By a stalk or broad base.

How do endometrial polyps usually compare with fibroids on ultrasound?

They are usually more echogenic than fibroids and similar to the endometrium.

What other ultrasound appearance can endometrial polyps have?

Cystic components.

What vascular finding is typical of an endometrial polyp?

Usually a single feeder vessel.

What percentage of endometrial polyps are rarely cancerous according to the slides?

About 2-4%.

What symptom is commonly associated with endometrial polyps?

Abnormal uterine bleeding or menorrhagia.

How are endometrial polyps removed according to the slides?

D&C.

What is a sonohysterogram/SIS/SOH?

A GYN procedure used to evaluate the endometrial canal.

What is used to distend the endometrial cavity during an SIS?

Sterile saline.

What abnormalities can SIS help visualize?

Endometrial polyps, intracavitary myomas, synechiae, and structural anomalies.

When is an SIS typically performed?

After menstrual bleeding, around days 7-12.

What is endometrial hyperplasia?

Abnormal overgrowth/thickening of the endometrium.

What is a common hormonal cause of endometrial hyperplasia?

Unopposed estrogen.

What conditions can cause unopposed estrogen?

HRT and anovulation/PCOS.

Why does lack of ovulation promote endometrial hyperplasia?

Without ovulation there is no progesterone, so the endometrium is not shed and continues growing under estrogen.

What conditions increase hyperplasia risk through increased estrogen?

Diabetes and higher BMI.

How is endometrial hyperplasia diagnosed?

Endometrial biopsy.

How can endometrial hyperplasia be treated?

D&C or hysterectomy.

What is the approximate normal maximum endometrial thickness in a premenopausal patient according to the slides?

Up to about 16 mm, depending on the cycle.

What is the asymptomatic postmenopausal endometrial thickness threshold listed?

Up to about 8-11 mm.

What endometrial thickness should be expected in a postmenopausal patient with bleeding?

Less than 5 mm.

What premenopausal thickness is considered abnormal in the slides?

Greater than 16 mm.

What postmenopausal thickness is abnormal without bleeding?

Greater than 11 mm.

What postmenopausal thickness is abnormal with bleeding?

Greater than 5 mm.

What are risk factors for endometrial hyperplasia?

Obesity, age ≥35, Caucasian race, diabetes, never being pregnant, family history of uterine/ovarian/colon cancer, BRCA/Lynch syndrome, and early menarche.

What is endometritis?

Infection/inflammation of the endometrium.