endometrium and its abnormalities

Question 1

what are the layers of the endometrium?

Answer 1

Compactum
Spongiosum
Basalis – once you menstruate, this is the layer you’re left (immediately above the myometrium)
Junctional zone – zone between the endometrium and myometrium

Proliferation of the endometrium = development of the spongiosum and compactum layers.

Question 2

How does menstruation and shedding of the functional endometrium occur?

Answer 2

1. Initiated by withdrawal of E2 and Prog (demise of CL).
2. As a result, we get increase in local mediators e.g. PGF2A which causes vasoconstriction of the spiral arteries = ischaemia and tissue damage, and PAF (platelet aggregating factor).
   a. These vessels also release proteolytic enzymes which aids in the breakdown.
3. Spiral arteries then suddenly dilate (PGE2) = menstruation and shedding of the functional endometrium.

Question 3

when you bleed during menstruation, your body will do 3 things to prevent it…what are they?

Answer 3

1. Vasoconstrict to restrict blood flow to the area.
2. Activate platelets.
3. Activate clotting factors.

= form a clot. However, we don’t want to clot the entire uterus, thus it’s tightly regulated with fibrinolysis.

= Therefore, for NORMAL MENSTRUATION need correct balance and regulation of inflammation, coagulation and fibrinolysis in the endometrium.

Question 4

name clinical problems

Answer 4

1. Anything different from usual pattern
2. Menorrhagia (too much bleeding)
3. Polymenorrhoea (bleeding too often)
4. Internal menstrual bleeding (ICB) or post coital bleeding (PCB)
5. Chaotic bleeding – constant bleeding

Question 5

what are the causes of abnormal vaginal bleeding?

Answer 5

1) Pathological causes:
a. Fibroids – benign tumours of the myometrium
b. Adenomyosis – endometrial tissue in the myometrium
c. Endometrial pathology – polyps, hyperplasia or carcinoma
d. Cervical pathology – polyps (bleed during sex) or carcinoma
e. Cervical Infection – Chlamydia
f. Pregnancy

2) DUB (dysfunctional uterine bleeding) – diagnosis of exclusion

Question 6

what are the aims of abnormal bleeding?

Answer 6

• Exclude pregnancy
• Exclude cervical pathology
• Exclude focal benign intracavity pathology (polyps, submucous fibroids)
• Consider other endometrial pathology (> 40) – use the least invasive method to do so

Question 7

name some endometrial abnormalities

Answer 7

1) Dysfunctional uterine bleeding (DUB)
2) Endometrial polyps – focal problem, rest of the endometrium is normal
3) Endometrial hyperplasia – all cells look the same
4) Endometrial hyperplasia with atypia – DNA errors accumulate so the cells look atypical
5) Endometrial adenocarcinoma

Question 8

what is dysfunctional uterine bleeding (DUB)?

Answer 8

• Large majority of women presenting with menorrhagia will have no structural or obvious pathological causes, it is a problem at the molecular level (cellular dysfunction). It is diagnosed through exclusion.
• The dysfunction is caused by an altered ratio and amount of PGs… and excessive fibrinolysis = excessive bleeding.

Question 9

what are the risk factors of abnormal bleeding?

Answer 9

1) Mediation e.g. warfarin.
2) Smoking.
3) Contraception – progesterone-only-pill is the biggest cause of erratic bleeding.
4) BMI – extreme weights affect the MC cycle. THIS IS THE BIGGEST FACTOR.
a. Anorexic = no fat tissue–> dysfunction of the HPG axis.
b. Obese = lots of adipose tissue–> androgens are converted to oestrogen in adipose tissue via aromatase = menstruation problems.
5) Polyps and lesions.
6) Surgery.
7) Nulliparity (never given birth) – more time HPG axis is activated for.
8) Early menarche or late menopause – increases time exposed to oestrogen.
9) Hypertension and diabetes.
10) Anovulation e.g. PCOS.
a. Constantly producing oestrogen from the arrested antral follicles, however, not enough to cause ovulation, therefore, anovulatory cycles–> little progesterone is produced.
b. = unopposed oestrogen-dependent proliferation of the endometrium = endometrial hyperplasia.
11) Genetics – Lynch syndrome.

Question 10

how is abnormal bleeding investigated?

Answer 10

1) Pregnancy test.
2) Hb if heavy bleeding – may potentially become anaemic.
3) Swabs – endocervical (Chlamydia).
4) Cervical smear (only if due).
5) Transvaginal ultrasound with hydrosonography – if abnormal, then do hysteroscopy.
a. Can check the uterus and ovaries at the same for structural pathologies (hydrosonography).
b. Relatively cheap.
If there is no intracavity pathology–> DUB.
 

Question 11

how are polyps treated?

Answer 11

surgery (transcervical resection of polyps)

Question 12

how are fibroids treated?

Answer 12

Small fibroids = Mirena IUCD

Large fibroids = Surgery TCRF/Myomectomy

Hysterectomy

Question 13

how is DUB treated?

Answer 13

Nothing

Medical:
Non-hormonal–>
1. Tranexamic acid (anti-fibrinolytics) which corrects the excessive fibrin breakdown in endometrium.
2. Mefanamic acid.
3. NSAIDs (blocks the COX pathway) – corrects PG imbalance to allow normal vasoconstriction and platelet aggregation.

Hormonal–>

1. Mirena IUCD (progesterone).
2. Local high dose progestagen (thins endometrium).
3. COCP.

Surgery (for failed medical treatment):

• Endometrial resection/ablation
• Hysterectomy
• Remove ovaries

Question 14

Abnormal Uterine Bleeding (AUB) is acute, intermittent or chronic. If intermittent then it is either due to a structural or non-structural problem.

Structural issues include: Polyps, Adenomyosis (endometrial tissue in myometrium), Leiomyoma (fibroids – benign tumors of smooth muscle from myometrial origin), malignancy (cervix or endometrium).

Non-Structural causes include: Coagulopathy, Ovulatory dysfunction e.g. PCOS, Endometrial e.g. DUB, Iatrogenic (Warfarin treatment) and Not otherwise classified.

Answer 14

endometrium