Endometrium & its Pathology I&II Flashcards
Endometrium Layers
Compactum
* Spongiosum
* Basalis
* Junctional zone
Menstrual Cycle
Bleed away endometrium in first half of the cycle
Secind half of the cycle is always 14days
Spiral arteries get muh more twisted- only supply there is (___)
Increased secretions (big inflammatory cells near day 22 when endometrium increases
Rapid drop in hormones triggers menstruation
How is menstruation initiated?
Menstruation initiated by withdrawal of E and P, local mediators = PGs, PAF (platelet aggregating factor)
Spiral artery vasoconstriction -> ischaemia and tissue damage -> spiral artery relaxation -> shedding of functional endometrium
PGs causes vasoconstriction in SMCs
Drop in steroids causes menstruation
Bleed down to the basal layer during menstruation
Endometrium becomes secretory during the follicular phase
Implant 5/max 6 days after ovulation- when endometrium is thickest
some of the spongiosum is also shed along with the compactum
Menstruation mediators
Controlled E2 and P
PGs (E and I vs F2alpha and thromboxane Tx)
E and I = SM relaxation/vasodilation and stop platelets working at the endothelial level (therefore you bleed)
F2a and Tx = vasoconstriction and make platelets clot (stop bleeding)
Interleukins (IL8, 13, 16): bring other inflammatory cells and have other effects
TNF and PAF (platelet aggregating factor)
Matrix metallo-proteinases (participate in the membrane shedding)
Involved in remodelling, so when activated they break down collagen
Coagulation/fibrinolysis (aid the clotting- needs to be balanced so antagonistic mechanisms)
Junctional zone
For normal menstruation: correct balance and regulation of inflammation, coagulation and fibrinolysis in the endometrium
Prostaglandins effect
ischemic pain- back pain, nausea
For normal menstruation
Correct balance and regulation of
inflammation, coagulation and fibrinolysis
in the endometrium is needed
Clinical problems- anything different from ususal pattern
(due to problems in ovulation)
Too much bleeding- menorrhagia
Bleeding too often- polymenorrhea
Inter Menstrual Bleeding/Post Coital Bleeding
Chaotic bleeding
Abnormal bleeding can either be
Structural (PALM)
polyp
adenomyosis
leiomyoma
malignancy (uncontrolled bleeding: cancer of the cervix or the cancer of the endometrium)
Non-structural (COIN)
coagulopathy
ovulatory dysfunction
endometrial
iatrogenic (relating to illness caused by medical examination or treatment.)
not otherwise classified
Pathological causes of abnormal bleeding
- Fibroids – submucous
- Adenomyosis
- Endometrial pathology – benign adenomas or polyps
- hyperplasia
- carcinoma - Cervical pathology – polyps
- carcinoma - Cervical Infection - Chlamydia (might present with erratic bleeding)
- Pregnancy!!!
DUB (diagnosis of exclusion)
Endometrial polyps
Endometrial polyps are benign endometrial adenomas; rest of endometrium is normal - Endometrial Polyps (adenomas) are more frequent in women with menstrual disorder
Fibroids
Fibroids often don’t cause abnormal uterine bleeding; however submucosal fibroids poke into uterine cavity and cause distortion and stretching of the uterine cavity; Submucous fibroids (leiomyomas) are associated with a threefold increased risk of abnormal bleeding – invariably menorrhagia
adenomyosis
Adenomyosis is when endometrial tissue is located within the myometrium – usually an artefact of childbirth and causes very heavy/painful periods
Importance of intrauterine structural abnormalities
Submucous fibroids (leiomyomas) are
associated with a threefold increased risk of
abnormal bleeding – invariably
menorrhagia
- indent the submucosal cavity (cause heavy bleeding: causal rather than casual)
Endometrial Polyps (adenomas) are more
frequent in women with menstrual disorders
Causal / casual – diagnostic bias??
Aims- abnormal bleeding
- Exclude pregnancy
- Exclude cervical pathology
- Exclude focal benign intracavity pathology
(polyps, submucous fibroids) - Consider other endometrial pathology (>
45) - Use the least invasive method to achieve
this
Endometrial abnormalities examples
- Dysfunctional uterine bleeding (MOST LIKELY)
- Endometrial polyps
- Endometrial hyperplasia
- Endometrial hyperplasia with atypia (mild –
severe) - Endometrial adenocarcinoma
Causes of endometrial abnormalities
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 (Where is the dysfunction)?
PGs (E + I vs F2a + Tx)
* Interleukins (IL – 8, 13 +16)
* Tissue Necrosis Factor (TNF) + Platelet
Aggregating Factor (PAF)
* Matrix metallo-proteinases
* Coagulation / fibrinolysis
* Junctional zone
2 areas above all else:
- PG’s (>E+I compared to F2a+Tx)
- Coagulation /(fibrinolysis in particular)
Heavy bleeding tend to be caused by increased fibrinolysis
Polyps
Benign endometrial adenomas
* Focal problem
* Rest of endometrium is normal
History and Examination (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
Points in examination
- BMI (overweight- testosterone to oestrogen (in men and women) )
– Abdomen - Distension, scars, pain, masses
– Bimanual - Uterine size, adnexal masses, pain
– Cervix - polyps, suspect lesions
Investigation
- Pregnancy test where appropriate
- Hb if heavy bleeding
- Swabs – endocervical (Chlamydia)
- Cervical smear – only if due
- Transvaginal ultrasound
+/- Endometrial sampling
+/- Hysteroscopy - in-patient or OPD
Transvaginal sonography TVS
- 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
TVS values
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
Hysteroscopy
If TVS abnormal
* Non-response to medical therapy
* Multiple risk factors for endometrial
pathology
