It is about common gynecological problems found in middle aged women and leading causes of abnormal. Uterine bleeding

1. POLYP (AUB P)
Athira Radhakrishnan
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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

12. 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

13. 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

14. Clinical features
• Usually parous
• Around 40 yrs
• Heavy menstrual bleeding
• Progressively increasing dysmenorrhoea
• Pelvic discomfort
• Backache
• Dyspareunia

15. • 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

16. • 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

17. • 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

18. • Ultrasound :
• ill defined hypoechoic areas
• Heterogeneous echoes in myometrium
• Asymmetrical uterine enlargement
• Subendometrial halo thickening
• Endometrial infiltration into
myometrium

20. • 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

21. Adenomyosis diagnostic criteria
• Presence of 2 or more of these criteria are highly associated with
a diagnosis of Adenomyosis

23. Management
• Consider
• Age
• symptomatology ( AUB, pain & infertility)
• Association with other conditions ( leiomyomas, polyps &
endometriosis)

24. • 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

25. • 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

26. THANK YOU