Female Genital Tract 2 Flashcards
What are the two layers of the uterus?
- endometrium
-lined by columnar epithelium and deep to that endometrial glands (glads change depending phase) and stroma
-normally some lymphocytes
A. functionalis-near the lumen, hormonally responsive
B. basalis-produces new cells to replace endometrium that was shed during menstruation - myometrium
- smooth muscle layer
What does normal postmenopausal endometrium look like?
atrophic endometrium
- glands diminished in number, thin epithelium
- stroma abundant collagen
Endometritis
Acute vs Chronic
Acute
-abnormal presence of neutrophils
-neutrophils normally present during menstruation
Chronic
-plasma cells diagnostic
-lymphocytes present in normal endometrium
What are causes of endometritis? What is the presentation? What are the long term complications?
Causes
1. Ascending infection from cervix
-std, pelvic inflammatory disease
-abortion, delivery, medical instrumentation
2. IUDs
3. Retained products of conception post delivery
Presentation
-fever, abdominal pain, menstrual abnormalities
Long term complications
-infertility
-ectopic pregnancy-if ascending to fallopian tube-scarring
What can cause PID? How does it present and look? What can it lead to?
STD
- chlamydia trachomatis
- neisseria gonorrhoea
- polymicrobial
Ascending infection
Cervicitis–Endometritis—Salpingitis–Tubo Ovarian abscess
present
-purulent cervical discharge, cervical motion tenderness
Fallopian tubes distorted
Fimbriated ends adherent
Serosa hyperemic
Exudate
–infertility and ectopic pregnancy
Endometriosis?
Presence of endometrial glands and stroma outside the endometrium
- ovaries, uterine ligaments, fallopian tubes, pouch of douglas, rectovaginal septum
- less frequently peritoneal cavity, periumbilical tissues
- uncommonly lungs, heart, lymph nodes
What are the three theories of endometriosis?
- Regurgitation (favored)
- menstrual flow back through fallopian tubes leads to implantation - Metaplastic
- endometrial differentiation of multipotential coelomic epithelium - Vascular or Lymphatic dissemination
- explains extrapelvic intranodal implants
What is the pathogenesis of endometriosis?
- Increased inflammatory mediators
- High aromatase activity of stromal cells, increasing estrogen production
- Activated macrophages contribute to establishment, maintenance
- Decreased immune clearance
What must be present histologically for endometriosis?
- Endometrial glands
- Endometrial stroma
- Hemosiderin pigment
Chocolate cyst ovary
What are the symptoms of endometriosis, which affects 10% of women?
- infertility ~50%
Depends on site of implants - severe dysmenorrhea–intrapelvic bleeding
- pelvic pain, increased risk of ectopic pregnancy, infertility–result of scarring
- pain with defecation
- pain with urination
Adenomyosis
Presence of endometrial glands and stroma within the myometrium
- cause unknown
- uterus may enlarge-result of myometrial hypertrophy
- clinically asymptomatic to irregular bleeding to pelvic pain
What is endometrial hyperplasia and what causes it? HOw does it present?
Exaggerated endometrial proliferation
glands>stromal hyperplasia
Result of ESTROGEN EXCESS -exogenous estrogen -estrogen producing ovarian lesions PCOS Granulosa theca cell tumor -obesity -failure of ovulation Perimenopause
Presents
-postmenopausal uterine bleeding
How does non atypical vs atypical hyperplasia affect the risk of endometrial cancer?
Non atypical
-short term risk of endometrial cancer is LOW
Atypical
-marked increased risk of endometrial cancer
Atypical Hyperplasia Histology
Low power: glandular crowding
High power: cytologically atypical rounded, vesicular nuclei with prominent nucleoli
What causes atypical endometrial hyperplasia?
PTEN tumor suppressor gene mutation
- phosphatase protein product involved in the regulation of the cell cycle
- hyperplastic glands may ultimately proliferate autonomously
Endometrial Intraepithelial Neoplasm= neoplastic growth genetically altered cells with greatly increased risk o becoming endometrioid type of endometrial carcinoma
What are the two types of endometrial cancer? What is the presentation?
Postmenopausal women
Post menopausal bleeding
1. endometrioid
2. serous type
What is the difference between endometrioid and serous endometrial carcinoma?
- Arise
Endometrioid: from endometrial hyperplasia
Serous: sporadic- no defined precursor lesion-arises from atrophic endometrium - Risk factors
Endometrioid: Obesity, exogenous estrogen, early menarche, late menopause, DM, HTN, infertility with anovulatory cycles - Presentation
Endometrioid: 60yrs
Serous: 70 yrs - Histology
Endometrioid: appears reminiscent of “normal” endometrium
Serous: papillary structures - Mutations
Endometrioid: PTEN, early inactivation of DNA mismatch repair genes
Serous: p53 mutations - Behavior
Serous: aggressive behavior
What happens with endometrial carcinoma?
- invade myometrium, uterus may affix to surrounding structures
- Invade vascular spaces
- Metastasize to regional lymph nodes, distant sites
Endometrial polyp
Usually in fundus Monoclonal stromal cells + endometrial glands -perimenopause -bleeding -association with tamoxifen
Leiomyoma “fibroids”
most common benign tumor females
- arise from myometrial smooth muscle cells
- whorled appearance
- Monoclonal
- Chromosomal abnormalities
- 6, 12 rearrangements
- others - almost never transform to malignancy
What causes Leiomyomas? What is the presentation?
Estrogens stimulate growth
- common in premenopausal women
- growth in pregnancy
- shrink postmenopausal
30-50% women
blacks> whites
Presentation :
- asymptomatic
- abnormal bleeding
- pelvic mass
- pain
- infertility
Leiomyosarcoma
- malignant
- arise de novo from mesenchymal cells of myometrium
- do NOT arise from benign leiomyomas - Postmenopausal women
- Clinical Course:
- recur after removal
- metastasize-often to lungs - 5 Year survival 40%
Histology
- necrosis
- cytologic atypia
- mitosis
What causes abnormal uterine bleeding for each age group?
Prepuberty
-Precocious puberty
Adolescence
-Anovulatory Cycle
Reproductive Age
-Complications of pregnancy, proliferations (leiomyoma, adenomyosis, polyps)
Peri menopause
-Anovulatory cycle proliferation (polyps, hyperplasia, carcinoma)
Postmenopause
-Carcinoma, hyperplasia, polyps
Failure of ovulation- anovulatory cycle- what happens?
- endometrium does not progress to normal progesterone driven secretory phase
- endometrium prone to breakdown–abnormal bleeding
- lack of progesterone leads to abnormal development of endometrial arteries
Abnormal uterine bleeding can be caused by uterine organic lesions, systemic abnormalities or absence of distance uterine lesion, what are some examples of these things?
Uterine organic lesion -polyp Systemic abnormalities -exogenous hormones, coagulopathies, thyroid disorders Absence of distinct uterine lesion -dysfunctional uterine bleeding
