Fusion defects. Endometrial Polyps
Fusion defects include unicornuate uterus (AFS class II), uterus didelphys (AFS class III), bicornuate uterus (AFS class IV), and septate uterus (class V).
A unicornuate uterus has a single hemi-uterus that is attached to its fallopian tube. It may also be associated with a rudimentary cavity from the contralateral side. A didelphys uterus has two uterine cavities, and each has a separate cervix. The fundus of the uterus also has a deep cleft between the cavities. A bicornuate uterus has a single cervix, a heart-shaped fundus, and two uterine cavities separated by myometrium. Conversely, a septate uterus has a single cervix, a flat fundus, and two uterine cavities separated by relatively avascular scar tissue.
Two clinically relevant points for fusion defects are:
In a woman with a unicornuate uterus, a rudimentary horn can result in pain because of obstruction orretrograde flow, either of which may cause endometriosis or be a site of infection.
Fusion defects may be associated with reproductive problems, from recurrent miscarriage to premature labor. The incidence of these problems is uncertain, however, because in women who have had only uncomplicated pregnancies, anomalies may never have been noted.
Among patients with AFS class I to IV uterine anomalies, there is an increased incidence of renal anomalies, usually renal agenesis ipsilateral to the associated hypoplastic mullerian defect. Therefore, a search for uterine anomalies should be conducted in patients with renal agenesis, and pelvic pain, or reproductive dysfunction.
Advances in the Treatment of Endometrial Polyps
Endometrial polyps are benign tumors consisting of surface endometrium, fibrous stroma, and thick-walled, centrally positioned blood vessels. A clonal rearrangement of chromosome 6p21 is common in the mesenchymal (stroma) cells in the polyp. The endometrial cells do not have the chromosome 6 rearrangement. One possible explanation of these findings is that an endometrial polyp begins when a stromal cell undergoes a rearrangement in chromosome 6p21 resulting in an abnormal signal to grow. The stromal elements proliferate and bring the endometrial glands along as “innocent bystanders.”
Most endometrial polyps are solitary. In approximately 20% of cases multiple polyps are present. Polyps peak between ages 40 and 50 years, but many cases occur in menopausal women. In fewer than 1% of cases, polyps are associated with cancer. The usual presenting symptom is intermenstrual bleeding or menometrorrhagia.
Polyps are typically diagnosed by sonography (especially sensitive in the follicular phase), saline infusion hysterosonography, hysterosalpingography, hysteroscopy, or curettage. Curettage often fails to remove endometrial polyps because of the mobility of their body and tip. In menopausal women taking hormone replacement therapy who have abnormal uterine bleeding, polyps are commonly found by hysteroscopy. Multiple case reports indicate that tamoxifen treatment may stimulate the development and growth of endometrial polyps.
Other Benign Uterine Disorders
Adenofibromas are benign tumors of epithelium and stroma that contain fewer that 4 mitoses per 10 high-power fields. Women with adenofibromas usually are elderly. Abnormal vaginal bleeding is the most frequent presentation.
Uterine Conservation at the Time of Adnexal Removal
In women who desire future childbearing, every effort should be made to preserve ovarian tissue unless a cancer diagnosis necessitates the removal of both ovaries. Occasionally, the clinician is confronted with a large benign ovarian cyst and must decide whether to remove the entire ovary or perform a cystectomy. If the woman has a desire for more children, an effort should be made to perform a cystectomy and to leave as much ovarian tissue as possible.
For some conditions, both ovaries require surgical removal. The clinician then is confronted with the issue of uterine conservation. If the woman has clearly and consistently communicated that she has no interest in further pregnancies and does not desire to retain her uterus, the uterus can be removed. If the woman has clearly expressed an interest in future childbearing, the uterus may be left in place so she may be able to become pregnant through oocyte or embryo donation.