Benign Uterine Diseases and Endometriosis

Question 1

Endometrium and Estrogen

Answer 1

Estrogen is growth stimulatory, mitogenic: induces cell proliferation

Question 2

Endometrium and Progesterone

Answer 2

Progesterone is growth suppressive, antimitotic: suppresses epithelial proliferation but also induces stromal cell differentiation (decidualization).

Question 3

Answer 3

Normal uterine bleeding: The normal menstrual cycle results from a complex feedback system involving the hypothalamus, pituitary, ovary, and uterus. In a normal ovulatory cycle, the endometrium proliferates from estrogen stimulation, then undergoes secretory changes when exposed to progesterone, and ultimately breaks down upon withdrawal of ovarian steroid support. Cessation of bleeding depends, in part, on clot formation, but also on uterine factors, such as vasoconstriction and uterine contraction, which is regulated by local prostaglandins.

Question 4

Endometrial Disorders

Answer 4

• Dysfunctional uterine bleeding (DUB)
• Organic abnormalities
• Abnormal uterine bleeding (AUB)

Question 5

Abnormal Uterine Bleeding (AUB)

Answer 5

• the occurrence of bleeding at times other than expected menses. This is responsible for as many as one-third of all outpatient gynecologic visits, most commonly just after menarche or in the perimenopausal period.
• It can be caused by a wide variety of local and systemic diseases or related to medications. However, most cases are related to pregnancy, structural uterine pathology (eg, fibroids, polyps, adenomyosis), anovulation, disorders of hemostasis, or neoplasia.
• Trauma and infection are less common.

Question 6

Dysfunctional uterine bleeding (DUB)

Answer 6

• abnormal bleeding during or between menstrual periods that is caused by abnormalities in the menstrual cycle or systemic diseases, not caused by local organic abnormalities of the endometrium.
• DUB is a common encounter in clinic. Systemic causes include general bleeding disorders such as ITP, liver cirrhosis, leukemia, and hypothyroidism, etc.
• Most dysfunctional uterine bleeding (DUB) is related to anovulation, which could be related to a variety of factors affecting the hypothalamic pituitary axis or the ovary. Anovulation may be physiologic, such as in adolescence, perimenopause, or during pregnancy and lactation.
• Pathologic causes of anovulation include polycystic ovarian syndrome, hypothalamic dysfunction, hypothyroidism, hyperprolactinemia, pituitary disorders, premature ovarian failure, and iatrogenic causes like medication.

Question 7

Organic Abnormalities that Cause AUB

Answer 7

•chronic endometritis, leiomyoma, endometrial polyp, endometrial neoplasms.

Question 8

Amenorrhea

Answer 8

absence of bleeding for at least three usual cycles

Question 9

Oligomenorrhea

Answer 9

bleeding that occurs at an interval greater than 35 days

Question 10

Polymenorrhea

Answer 10

regular bleeding that occurs at an interval less than 24 days

Question 11

Menorrhagia

Answer 11

excessive or prolonged bleeding

Question 12

Menometrorrhagia

Answer 12

heavy bleeding at irregular intervals

Question 13

Organic Abnormalities that Cause AUB: Leiomyoma

Answer 13

• Benign smooth muscle tumor. Not restricted to the uterus but is stimulated by estrogen in this site.
• Incidence: The most common tumor in women; occur in 25% women during reproductive years; multiple lesions are common.
• Cause: Localized, heightened sensitivity to normal levels of estrogen.
• Effect: Asymptomatic, mass, abnormal bleeding (if submucosal), impaired fertility, dystocia (difficult labor), and rarely sarcoma.
• Morphology: Characteristic gross appearance (whorled, gray-white, sharp circumscription). Location intramural > subserous > submucous. Microscopic: mature smooth muscle with rare mitoses

. • Treatment: None unless symptomatic; myomectomy, hysterectomy.

• Clinical course: Develop and grow in reproductive years; degenerate and shrink after menopause if estrogen level is low.

Question 14

Answer 14

Question 15

Answer 15

Question 16

Answer 16

Question 17

Answer 17

Question 18

Leiomyoma: Indications for Hysterectomy or Myomectomy

Answer 18

• Excessive bleeding: anemia occurs after uncontrolled bleeding
• Sudden enlargement in a short period: to rule out malignancy such as leiomyosarcoma or endometrial stromal sarcoma, etc.
• Symptomatic problems such as pelvic pain or heaviness
• Myomectomy may be offered when fertility is desired

Question 19

Organic Abnormalities that Cause AUB: Endometrial Polyps

Answer 19

Question 20

Endometriosis

Answer 20

• The term endometriosis refers to the presence of endometrial glands or stroma outside the uterine cavity. The most common sites of involvement in descending order of frequency are: ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, laparotomy scars, and rarely the umbilicus, vulva, vagina, or appendix. This ectopic endometrial tissue remains hormonally responsive, at least partially, and undergoes cyclic menstrual changes with periodic bleeding.
• This is a disease of the reproductive years and is most commonly seen during the third and fourth decades of life. Approximately 10% of women suffer from this condition, whose clinical manifestations may include severe dysmenorrhea, menstrual irregularities, recurrent pelvic pain, and infertility in 30 to 40% of cases. Additional symptoms include pain on defecation and dysuria that occurs as a result of rectal and bladder involvement, respectively.

Question 21

Reurgitation Theory of Endometriosis

Answer 21

The regurgitation theory involves retrograde menstruation through the fallopian tubes.

Question 22

Metaplastic Theory of Endometriosis

Answer 22

The metaplastic theory involves de novo formation of endometrium from the coelomic epithelium.

Question 23

Vascular or Lymphatic Dissemination Theory of Endometriosis

Answer 23

The vascular or lymphatic dissemination theory involves dissemination through the pelvic veins and lymphatics and explains the presence of lesion in distant location such as lungs.

Question 24

Endometriosis Theories

Answer 24

• None of these theories can completely explain all cases of endometriosis, however. Genetic, hormonal, and immune factors are believed to promote the development of endometriosis. There appear to be both biochemical and genetic differences between endometriotic tissue and normal endometrium.
• Aromatase p450, an enzyme not present in normal endometrium, has been found in endometriotic tissue. In addition, endometriosis appears to be clonal in origin.

Question 25

Endometriosis Gross Appearance

Answer 25

• Grossly, the foci of endometriosis appear as red-blue to yellow-brown, subserosal nodules.
• In patients with extensive disease, organizing foci of hemorrhage can cause extensive fibrous adhesions between ovaries, tubes, and other intrapelvic structures. The ovaries may become markedly distorted by large hemorrhagic cysts (chocolate cysts).
• The microscopic diagnosis of endometriosis requires the demonstration of endometrial stroma, or in its absence, endometrial glands and hemosiderin pigment.

Question 26

Adenomyosis

Answer 26

• This condition is closely related to endometriosis and is characterized by the presence of endometrial tissue deep within the myometrial wall (at least 2-3 mm beneath the basalis endometrium). The foci of adenomyosis may be connected to the surface endometrium. This suggests that adenomyosis may represent down growth of the endometrium into the myometrium.
• This condition can be identified in up to 20% of uteri and its cause is unknown.
• Hemorrhage within these small adenomyotic nests results in menorrhagia, colicky dysmenorrhea, dyspareunia, and premenstrual pelvic pain.
• Gross examination of the uterus demonstrates variable thickening of the wall and numerous small hemorrhagic cysts.
• Microscopically, there is invagination of the basalis endometrium with irregular nests of endometrial stroma, with or without glands.