CP6-2 uterine pathology and pcos Flashcards
What is endometriosis?
Presence of ectopic endometrial tissue
What is the epidemiology of endometriosis?
6-10% of women aged 30-40
10% of women in UK will suffer with endometriosis
10% of women worldwide have endometriosis
What are four theories for the aetiology of endometriosis?
Regurgitation theory
Metaplasia theory
Stem cell theory
Metastasis theory
How does endometriosis pathogenisize?
Endometrial bleeding into tissues can’t be removed so becomes fibrosed
How do patients with endometriosis present?
25% asymptomatic
Dysmenorrhea
Dyspareunia (pain before, during or after sex)
Pelvic pain
Subfertility
Pain in passing stool
Dysuria
What is the gold standard test for endometriosis?
Laparoscopy
What is first line treatment for endometriosis?
NSAIDs
With progesterone only or combined contraceptive pill
What is the definitive treatment of endometriosis?
Surgical ablation of lesions
What is the prevalence of endometriosis associated infertility?
30-50%
What are endometrial polyps?
Sessile/polypoid endometrial overgrowths
What is the pathogenesis of endometrial polyps?
Inappropriate reaction of foci of endometrium to oestrogenic stimulation
What is the epidemiology of endometrial polyps?
<10% of women aged 40-50
How do patients with endometrial polyps present?
Often asymptomatic
Intermenstrual/post menopausal bleeding
Menorrhagia
Dysmenorrhea
What percentage of women endometrial polyps will have abnormal uterine bleeding?
25%
Are polyps usually benign or malignant?
Benign
What are the two layers of the endometrium?
Stratum functionalis
Stratum basalis
What percentage of hysterectomies have endometrial polyps (not reason for hysterectomy)?
10-24%
What hormone stimulates growth of the endometrium?
Oestrogen
What hormone opposes oestrogen to control/stop endometrial growth?
Progesterone
What is endometrial hyperplasia?
Hyperplasia of the endometrium as a result of excess oestrogen
What can increase risk of excess oestrogen/endometrial hyperplasia?
Obesity due to excess adipose tissue
PCOS
Oestrogen secreting tumours (e.g. granulosa cell tumours)
Early menarche
Late menopause
Not giving birth
Oestrogen only HRT
Tamixofen
Mutation of the PTEN tumour suppressor gene
What can increase risk of excess oestrogen/endometrial hyperplasia?
Obesity due to excess adipose tissue
PCOS
Oestrogen secreting tumours (e.g. granulosa cell tumours)
Early menarche
Late menopause
Not giving birth
Oestrogen only HRT
Tamixofen
Mutation of the PTEN tumour suppressor gene
What is the epidemiology of endometrial hyperplasia?
Incidence increases by 3x in over 40 year olds
What is the pathogenesis of endometrial hyperplasia?
unopposed oestrogenic stimulation of the endometrium
How does a patient with endometrial hyperplasia present?
abnormal bleeding
What is simple hyperplasia?
When hyperplasia is present with a normal stroma to gland ratio
What is complex hyperplasia?
Hyperplasia with increase glands and decreased stroma
What is the risk of progression to endometrial cancer with simple and complex hyperplasia?
Simple = 1%
Complex = 5%
What percentage of simple and complex hyperplasia is associated with atypia?
Simple = 10%
Complex = 30%
How is endometrial hyperplasia treated?
Weight loss of obese
Stopping unopposed oestrogen therapy
Correcting anovulation e.g. treat PCOS
Give progesterone medications to counteract effect of oestrogen
Hysterectomy - remove uterus but often keep ovaries and Fallopian tubes
What are the two types of endometrial adenocarcinomas?
Type 1 - endometriosis adenocarcinoma
Type 2 - serous adenocarcinoma
What is the epidemiology of endometrial cancer?
most common cancer of female genital tract with 9200 new cases/year and 2500 deaths/year in the UK
What is the aetiology of endometrial cancer?
unnopposed E2 (aka estradiol) or mutation
What is the pathogenesis of endometrial cancer?
hyperplasia progression and IEC origin for type 2 (serous)
How do patients with endometrial cancer present?
similar to endometrial hyperplasia +/- symptoms of advanced metastatic disease e.g. weight loss, changes in bowel and bladder habits, loss of appetite, feeling full quickly, etc…)
What are the characteristics of type 1 endometrial cancer?
most common of two types (incidence = 75%)
effects pre- or perimenopausal women
derives from endometrial hyperplasia.
associated with PTEN and KRAS mutations
estradiol +ve
can be grade 1,2 or 3
What are the characteristics of type 2 endometrial cancer?
least common of two types (incidence = 25%)
effects postmenopausal women
derives from endometrial atrophy.
associated with P53 mutations
estradiol -ve
can only be grade 3
What are the stages of endometrial cancer?
Stage 1a or b - 1a = endometrial and 1b = myometrial
Stage 2 = cervical
Stage 3a, b or c - 3a = ovary, 3b = vagina, stage 3c = lymph nodes
Stage 4a or b - a = bladder or small bowel and b = liver
What is lynch syndrome?
aka hereditary non-polyposis colorectal cancer is an autosomal dominant inherited condition which predisposes an individual to colorectal, endometrial and ovarian cancer in their lifetime. It is a result of a mutation in mismatch repair genes.
What mutations are involved in Lynch syndrome?
Alteration in mist match repair genes e.g. MLH1, MSH2,
What are myometrial tumours?
Benign smooth muscle tumours of the myometrium
What is the epidemiology of myometrial tumours?
commonest gynaecological condition.
black women have an increased risk
What is the aetiology and pathogenesis of myometrial tumours?
Unknown aetiology but suspect due to E2/P4 stimulation resulting in benign monoclonal proliferation of smooth muscle cells
How do patients with myometrial tumours present?
majority asymptomatic
can present with: irregular bleeding, abdominal mass, bladder problems or abnormal uterine bleeding
What is PCOS?
Polycystic ovarian syndrome - an endocrine disorder characterised by hyperandrogenism, ovulatory dysfunction, menstrual irregularities +/- polycystic ovaries and insulin resistance.
What is the epidemiology of PCOS?
6-10% of women of reproductive age
What is the aetiology and pathogenesis of PCOS?
Aetiology unknown although ?genetic mutation resulting in dysfunction in the hypothalamic-pituitary-ovarian axis causing too much LH, and no LH surge leading to no ovulation
What are the symptoms of PCOS and what are they associated with?
Increased androstenedione causes hirsuitism, male pattern baldness and acne
Insulin resistance causes increased weight and acanthosis nigiricans
Infertility due to lack of ovulation causing amenorrhea or oligomenorrhea
How is PCOS diagnosed?
pelvic ultrasound to look for follicles and cysts
hormone tests to see if increased LH:FSH ratio and for increased androgen
How is PCOS treated?
Weight loss - reduces inclusion resistance
Metformin - increase insulin sensitivity
Oral contraceptive - regulate cycle
Clomiphene citrate - induces ovulation
Ovarian drilling - punctures cystic ovary to induce ovulation
Spironolactone - contraception required but treats hirsutism
