Endometrium + abnormalties Flashcards
Why study the endometrium? (2)
abnormalities = very common
all women will visit healthcare professions about their period
Layers of the Endometrium (4)
Layers 1-3: prolif stage (anchored in basal layer):
1) Compactum (bleed all away)
2) Spongiosum
3) Basalis (all epithelial)
- Junctional zone = extra layer b/w 3 and myometrium: unique because partly epithelial + myometrial
Menstruation effect of endo. MoA (6)
- Initiated by withdrawal of E and P (directs event but not direct cause)
- Local mediators PG’s, PAF (molecular cause of menses)
- # Spiral artery vasoconstriction
- # Ischaemia and tissue damage (= backache, nauseas discomfort- ischaemic pain)
- # Spiral artery relaxation
- Shedding of functional endometrium (majority)
Factors affecting Menstruation explained (7)
- Control E2 + P
- PGs (E + I vs F2a + Tx) : needs balance 1= vasodil + stop platelets @ endo layer, 2= vasocons. = platelets sticky = clot (F2a = dom.)
- Interleukins (IL – 8, 13 +16) - endo: brings other inflam cells = balance
- Tissue Necrosis Factor (TNF) + Platelet Aggregating Factor (PAF)
- Matrix metallo-proteinases: enzyme group = activation right time + amount
- Coagulation / fibrinolysis: needs balance - coag cascade - linked to inflam. cascade
- Junctional zone: intrinsic errors = bleeding probs + vascular properties = pinch vessels
What is needed for normal menstruation?
Correct balance and regulation of inflammation, coagulation and fibrinolysis
in the endometrium
What are the Clinical problems regarding the endometrium? (5)
- Anything different from usual pattern
- Too much bleeding - Menorrhagia (most common)
- Bleeding too often - Polymenorrhoea (Ovul + vol + reg. problems)
- IMB / PCB = period bleeding period (directly after, shortly after or during sex
- Chaotic bleeding ( unsched./ constant)
Nomenclature + classification of uterine bleeding - AUB, factors, Structural + non-Structural (4)
1) Abnormal Uterine Bleeding: Acute, Intermittent + chronic
2) Frequency, Regularity, Duration + Volume
Structural:
P olyp
A adenomyosis
L eiomyoma
M alignancy
Non- Structural:
C oagulopathy
O vulatory dysfunction
E ndometrial
I atrogenic
N ot otherwise classified
Causes of Abnormal vaginal bleeding (6)
‘Pathological causes’
* Fibroids – (submucous - tumours of smooth muscle (MYO))
* Adenomyosis
* Endometrial pathology – benign adenomas or polyps (ENDO)
- hyperplasia (PCOS)
- carcinoma
* Cervical pathology – polyps (twist it off)
- carcinoma
* Cervical Infection - Chlamydia (teenage/early 20’s - usually asymptom. erractic bleeding)
* Pregnancy!!!
DUB: Dysfun. uterine bleeding - diagnosis of exclusion
Importance of intrauterine
structural abnormalities - fibroids + polyps (3)
- Submucous fibroids (leiomyomas)
associated w/ 3x increased risk of abnormal bleeding – invariably menorrhagia - Endometrial Polyps (adenomas) are more
frequent in women with menstrual disorders (incidental finding) - Causal / casual – diagnostic bias??
Abnormal Bleeding - aims - (5)
1) Exclude pregnancy (test)
2) Exclude cervical pathology (look at cervix)
3) Exclude focal benign intracavity pathology
(polyps, submucous fibroids)
4) Consider other endometrial pathology (>
45) - hyperplasia/cancer
5) Use the least invasive method to achieve
this
Endometrial abnormalities (5)
- Dysfunctional uterine bleeding
- Endometrial polyps
- Endometrial hyperplasia benign vas atypical
- Endometrial hyperplasia with atypia (mild–severe)
- Endometrial adenocarcinoma
Why do you use diagnosis of exclusion?
Of women presenting with menorrhagia 50-
60% will have NO structural or obvious
pathological cause identifiable – it is a
problem at the molecular level i.e. cellular
dysfunction
=It is a diagnosis of exclusion
DUB - explained (2)
all factors: but mostly:
1) PGs: E+I imbalance
2) Fibrinolysis - excessive clot breaking not lack of making
Polyps (3)
- Benign endometrial adenomas
- Focal problem
- Rest of endometrium is normal
Abnormal Bleeding
History and Examination (8)
Points in history
– LMP – was it normal?
– Regular or irregular periods
* cycle control (ovulation vs anovulation)
* heavy- clots, flooding?
* with bleeding between (IMB)?
* post coital bleeding (PCB)?
* Pain
– Medication, smoker, smear, operations
– Contraception - hormonal vs non-hormonal
– BMI ( < = no period, > PCOS)
– Abdomen
* Distension, scars, pain, masses
– Bimanual
* Uterine size, adnexal masses, pain
– Cervix
* polyps, suspect lesions
Abnormal Bleeding
Investigation (5)
- Pregnancy test where appropriate
- Hb if heavy bleeding
- Swabs – endocervical (Chlamydia)
- Cervical smear – only if due
- Transvaginal ultrasound : main thing to do - but if sexual
+/- Endometrial sampling
+/- Hysteroscopy - in-patient or OPD
Transvaginal sonography
TVS- benefits (6)
- Can assess the relationship of fibroids to the cavity
- Has a high detection rate for polyps
- Assess function – anovulatory cycles
- Can reliably assess structures outside the uterus
(tubal and ovarian pathology) - Well accepted by patients
- Relatively cheap with few complications
1) TVS + endo. (3) - not or global but focal (hyperplasia)
- Periovulatory endometrium is hard to hide pathology in – or immediately post menstrual to
assess ET - Cut-off values for ET are arbitrary in premenopausal women - @ 6 mm post menstrual
or 12 mm anytime in cycle - Ultrasound is ideal for focal pathology but not
good for predicting endometrial pathology – a biopsy is still needed in many cases
2) Hysteroscopy
- If TVS abnormal
- Non-response to medical therapy
- Multiple risk factors for endometrial
pathology
Risk factors for significant
endometrial abnormality (6)
- Obesity!!!!!
- Nulliparity - no preg./contraception = protective - inc. turnover
- Early menarche / late menopause – length
of E2 exposure – weak factor - HT / DM - hypertension/diabetes
- Anovulation e.g. PCOS
- Genetics (5-10%) - FH breast / endometrial (30/40yrs) / colonic
cancer – Lynch syndrome (HNPCC - faulty mismatch repair function)
Endometrial hyperplasia causes/types (3)
- Simple - benign overgrowth (big women - adipose)
- Atypical - Unopposed E2
- Carcinoma - post-menopausal
Unopposed oestrogen risk explained- obesity(6)
- Obesity – peripheral conversion of androgen to oestrogen (aromatase) - abundant aromatase = T -> E2
- BMI most vital factor
- The more adipose tissue the more conversion
- Chronic anovulation e.g. PCOS (resist. to LH/FSH = no df)
- Follicular ovarian oestrogen production
continues - Progesterone only produced after ovulation
= Unopposed oestrogen =
Over years leads to hyperplasia/ sometimes cancer
Polyp treatment
only surgery - TCRP
Fibroid treatment (2)
medical: medical Mirena IUS/ Kyleena (coil) = stops bleeding (releas. P in cavity = switch off)
surgery: TCRF/myomectomy (if too big), hysterectomy (total/subtotal, vaginal)
Treatments q’s for DUB (3)
- Does she need or want treatment?
- Does she need contraception/desire
pregnancy? - How much is the problem affecting her
quality of life?
Non-hormonal treatments of DUB (6)
Fixing PG’s or Fibrinolysis!!
- Tranexamic acid - anti fibrinolytics 40-50%
reduction in blood loss - Corrects excessive fibrin breakdown in endometrium (affects plasminogen action)
- Mefanamic acid 30% reduction in blood loss
- NSAID – corrects PG imbalance to allow normal vasoconstriction
and platelet aggregation (inhib. COX or PG’s - wrong PG’s produced E/I) = restores ratio via vasodil. + cons.) - Good for pain also!
hormonal treatments of DUB (3)
- Mirena IUS – 90% reduction blood loss
- 30% amenorrheic
- Local high dose progestagen - thin endometrium (red. side effects because delivered in uterus)
- Kyleena new 4 year option
- COCP – 20 - 30% reduction in blood loss
- Removes cyclical events – thin endometrium
- Progestagens less beneficial for volume loss (higher than n levels to red. bleeding = inc. bloating, appetite + constipation)
- Use to control cycle length in anovulatory DUB
Options for treating DUB
Surgery – for failed medical treatment
– Endometrial resection/ablation
– Hysterectomy - Vaginal/abdominal
– Remove ovaries?
How to approach real cases - (6)
- How old is patient (< or >45)
- Is the cycle regular?
- Is there erratic bleeding?
- Do you need to investigate the
endometrium? - If so, how?
- Treatment?
Summary (4)
- Most menorrhagia is DUB and treatments
reflect the dysfunction - Exclude focal pathology – needs focal removal
- Beware erratic bleeding – pathology much more likely
- TVS and biopsy +/- hysterosocpy diagnosis in nearly all
