Chapter 41: Pathology of the Uterus Flashcards
What are the most common cystic lesions of the vagina?
Gartner’s duct cyst
What is the most common congenital abnormality of the female genital tract?
imperforate hymen resulting in obstruction
Obstructin of the uterus and vagina may result in:
accumulation of fluid (hydroculpos/hydrometra), blood (hematocolpos/hematometra), pus (pyocolpos/pyometra)
The upper size limit of a normal vaginal cuff is
2.1cm
How long does the cervix measure?
2-4cm
Most common presence of of the cervix is
nabothian cyst AKA epithelial inclusion cysts
How may polyps appear in the cervix?
pedunculated (projecting out of the cervix) or broad based
Who is more likely to develop cervical polyps?
late middle age
Leiomyoma AKA
fibroid
What is cervical stenosis
acquired condition with obstruction of the cervial canal at the internal or external os (may be asymptomatic but produce a distended fluid filled uterus)
What is the most common kind of cervical cancer?
squamous cell
What are precursors to squamous cell carcinomas?
cervical dysplasias classified as mild, moderate or severe
The uterine position changes with
degree of bladder and rectal distention
What are the most common gynecologic tumors?
leiomyomas or myomas or fibroids …occur in 20-30% of women over 30
T/F: fibroids are more common in white women?
false, african american women
Fibroids are composed of what?
spindle-shaped smooth muscle cells arranged in a whorl-like pattern
Tumor fibroids consist of what?
nodules or myometrial tissue and are usually multiple
The fibroid is encapsulated with
a pseudo capsule and separates easily from the surrounding myometrium
What may take place with degeneration of fibroids
liquefaction, necrosis, hemorrhage, and calcification
What is hyalinization?
development of an albuminoid mass in a cell or tissue..occurs most often, making the fibroid appear more lucent or hypoechoic than myometrium
What percent of fibroids contain calcification?
10%
What percent of fibroids have areas of hemorage?
10%
Fibroids are ______dependent
estrogen, may increase in size in pregnancy, though 50% don’t change in size
Do fibroids regularly develop in postmenopausal women?
no, most stabilize or decrease in size following menopause bc of lack of estrogen, unless the women is undergoing hormone replacement therapy
A rapid increase in fibroid size, esp in postmenopausal pt. should raise possibility of
sarcomatous change
What has been reported to cause growth in fibroids?
tamoxifen
How do fibroids present clinically?
cause uterine irregularity and enlargement with sensation of pelvic pressure and pain..patterns of irregular menstrual bleeding , heavy bleeding, or heavy and irregular bleeding
where are fibroids located to interfere with a normal vaginal delivery?
LOWER UTERINE SEGAMENT
what type of fibroid is most likely to cause irregular uterine bleeding?
submucosal fibroid
The submucosal fibroid is found to _______ or _______ the endometrial cavity and may erode into ?
deform or displace; endometrial cavity
Why is it important to diagnose submucosal fibroids?
because they are a well established cause of dysfunctional uterine bleeding, infertility and spontaneous abortion
The intramural fibroid is confined to?
myometrium and is the most common type
Subserosal fibroid project from the?
serosal surface of the uterus
what is the appearance of the subserosal fibroid?
becomes pedunculated and appear as an extrauterine mass
Uncommonly, a pedunculated fibroid develops?
a long stalk and is migratory
Fibroid can implant into the blood supply of ?
broad ligament, omentum or bowel mesentery
T or F ; fibroids have variable sonographic appearances
True
What is the earliest sonographic finding of fibroids?
uterine enlargement or irregular uterine wall contour with heterogenous myometrial texture pattern
What should you look for along the interface between the uterus and the bladder?
contour distortions
Sonographically discrete fibroids look?
hypoechoic but can be hyperechoic if they contain dense fibrous tissue
fibroids can look hyperechoic if they contain
dense fibrous tissue
fibroids that demonstrate an area of acoustic attenuation without a discrete mass make it hard to?
estimate the size
The uterus and adnexa may be difficult to image because of shadowing due to?
extensive calcification
what is the size of a fibroid?
.5cm
How can fibroids be detected
endovaginal sonogram
What do larger fibroids cause? and how are they better visualized?
heterogenous uterine enlargement and are better outlined transabdominally
What should you note when describing a fibroid?
texture, size and location
What is the most common cause of uterine calcification?
fibroids
what is the less common cause of uterine calcification
arcuate artery calcification in the periphery of the uterus
Calcifications may occur sonographically as?
focal areas of increased echogenicity with shadowing or as a curvilinear echogenic rim
what are some uterus fibroid treatments
- hormonal suppression
- endometrial ablation
- uterine artery embolization
- high intensity focused ultrasound
what is endometrial ablation?
uses radiofrequency microwaves. freezing or heating to ablate or remove the endometrium
what is uterine artery embolization?
uses small plastic particles injected into the blood supply to the myoma
What is high intensity focused ultrasound?
involves the application of therapeutic sound waves to the uterus and fibroid
What is the least common cause of uterine calcification?
arcuate artery calcification in the periphery of the uterus
what is adenomyosis?
ectopic occurrence of nest of endometrial tissue within the myometrium and is more extensive in the posterior wall
The tissue penetration of adenomyosis usually reaches a depth of?
2.5 mm from the basal layer of the endometrium
Because this ectopic tissue arises fro the ________ _________ component of the endometrium, it does not bleed in response to_________.
stratum basalis; cyclical hormone stimulation
what are the classifications of adenomyosis?
diffuse and focal forms
what is the more common form of classification of adenomyosis?
diffuse adenomyosis
focal adenmyosis is sometimes called?
adenomyoma
Adenomyosis represents a reactive hypertrophy of the _______ _______, which produces uterine ___________ but never to extend seen with________
myometrial muscle, enlargement, fibroids
focal adenomyosis lacks sonographically?
a hypoechoic border that is seen with fibroids
T or F: clinically, both adenomyosis and endometriosis are identical with respect to structure and function, but are usually regarded as separate and distince processes
True
Patients with adenomyosis are often?
multiparous and older than patients with endometriosis
A patient with adenomyosis presents with?
heavy, painful abnormal menses. three times normal size, globular in contour, boggy and somewhat tender
On a physical examination of adenomyosis the uterus is found to range from normal to?
three times normal size
______% of women with adenomyosis experience ______ or ________.
60%, menorrhagia, or metrorrhea
approximately 25% of patients with adenomyosis also suffer from?
dysmenorrhea
The most common finding of extensive adenomyosis is?
diffuse uterine enlargement
what appears as small hypoechoic myometrial cyst?
hemorrhage in the islands of the endometrial tissue
With the involved area being slightly more anechoic than the normal myometrium, there may be?
thickening of the posterior myometrium
what has been described as a swiss cheese or honeycomb patter?
hemorrhage in the islands of endometrial tissue (adenomyosis)
How do localized adenomas appear endovaginally?
inhomogenous, circumscribed areas in the myometrium , having indistinct margins and ontaining anechoic cavity
What is the best technique for presurgical diagnosis of adenomyosis
adenomyosis
Uterine arteriovenous malformations consist of what?
a vascular plexus of arteries and veins without an intervening capillary network
Most AVMS are teratogenic (acquired) due to
pelvic trauma, surgery, and gestational trophoblastic neoplasia
Leiomyosarcomas are rare, accounting for
1% of uterine malignancies
Leiomyosarcomas originate from the
myometrium or endometrial lining, are highly aggressive, and have a poor prognosis
What is the endometrial canal is the landmark for the ID’ing of the
long axis of the uterus
An abnormally thick endometrium results form a variety of conditions:
- early intrauterine pregnancy
- gestational trophoblastic disease
- endometrial hyperplasia
- secretory endometrium
- estrogen replacement therapy
- Polyps
- endometrial carcinoma
Disorders of the endometrium may occur in menopausal patients with
breast cancer who are receiving tamoxifen therapy
Patients with endometrial polyps usually are
asymptomatic, but some might be the cause of uterine bleeding
What are polyps histologically?
overgrowth of endometrial tissue covered by epithelium
Approximately __% of endometrial polyps are multiple
20%
In postmenopausal women, especially those being investigated for bleeding, the major differential considerations other than endometrial polyps are:
- hyperplasia
- submucosal fibroids
- less commonly endometrial carcinoma
What is the most common cause of abnormal uterine bleeding in both premenopausal and postmenopausal women?
endometrial hyperplasia
What does hyperplasia develop from?
unopposed estrogen stimulation
In premenopausal women, if the endometrium measures more than 14mm, ________ is suggested
hyperplasia
In asymptomatic postmenopausal women with endometrial hyperplasia, ___mm is the upper limit of normal
8mm
After progesterone is added, endometrial thickness will _____/
decrease
When should a woman using sequential hormones be studied for endometrial thickness, ideally?
at the beginning or end of hormone cycle
Hyperplasia is less common when?
during reproductive years
During reproductive years, hyperplasia of the endometrium may occur when?
- persistent anovulatory cycles
- polycystic ovarian disease
- obese women with increased production of endogenous estrogens
What is necessary for endometrial hyperplasia diagnosis?
endometrial biopsy
Describe endometrial hyperplasia
- endo is usually diffusely thick and echogenic with well-defined margins
- focal/asymmetrical thickening can occur
- small cysts representing dilated cystic glands may be seen within the endometrium
Endometrial polyps typically cause what?
diffuse or focal endometrial thickening
Endometrial polyps are more frequently seen in who?
perimenopausal and postmenopausal women
In menstruating women, endometrial polyps may be associated with
menometrorrhagia or infertility
Sonographically, polyps may initialy appear as
nonspecific echogenic endometrial thickening:
- polyp may be diffuse or focal and may also appear as a round echogenic mass within the endometrial cavity
- feeding artery may be seen in pedicle
- individual polyps are better visualized when outlined by intracavitary fluid
Endometrial thickening or fluid may indicate
endometritis
What is endometritis?
an infection within the endometrium of the uterus
Endometritis occurs most often in association with
- PID
- postpartum state
- following instrumentation invasion
Postpartum patients may dev. endometritis when?
- after prolonged labor
- vaginitis
- premature rupture of membranes
- retained products of conception
Sonographically, how does the endometrium appear with endometritis?
prominent, irregular or both, with a small amount of endometrial fluid
What can be found in women with posttraumatic or postsurgical histories (including uterine curettage)
intrauterine syncheiae
How does syncheiae appear sonographically?
bright echoes within the endometrial cavity, but diagnosis is difficult unless fluid is distending the endometrial cavity
What is the most common gynecological malignancy in North America, with an increase in incidences
endometrial carcinoma
Most endometrial malignancies are ______ occurring in postmenopausal patients
adenocarcinomas
What is the most common clinical presentation of endometrial carcinoma?
uterine bleeding
There is a strong association with endometrial carcinoma and
replacement estrogen therapy, also in the premenopausal woman, anovulatory cycles and obesity are also considered risk factors
The earliest change of endometrial carcinoma is a
thickened endometrium
What are correlated with more advanced stages of endometrial carcinoma?
enlargement with lobular contour of uterus and mixed echogenicity
What is a good way to screen for early changes of endometrial hyperplasia or carcinoma?
TV
Endometrial carcinoma may obstruct the endometrial canal, resulting in
hydrometra or hematometra
What is tamoxifen?
a nonsteroidal antiestrogen compound used for menopause therapy
What has been reported in patients on tamoxifen therapy?
increased risk of endometrial carcinoma, hyperplasia, and polyps
Small endometrial fluid collections occur when?
with ectopic pregnancies
- endometritis
- degenerating fibroids
- recent abortion
Before menstruation, the accumulation of secretions is
hydrometrocolpos
Following menstruation, the presence of retained menstrual blood results in
hematometrocolpos
Patients with large endometria fluid collections complain of
abdominal pain and have a globular abdominal mass..typically little or no vaginal bleeding
Presence of fever along with large endometria fluid collections suggest
infection of blood collection
What is likely to occur with uterine cancer?
pyometra
Sonography can demonstrate _______, ________,_________ of an IUD
malposition, perforation, incomplete removal
Eccentric position of an IUD from midline suggest
myometrial penetration
What is highly recommended for all IUD localization exams?
3D scanning
