Intro to Gynae Pathology Flashcards
What happens in the menstrual phase?
○ Functional layer of the uterine wall is sloughed off with the menstrual flow
○ Lasts 4-5 days
○ After menstruation, endometrium should be thin
What happens in the proliferative phase?
○ Lasts approximately 9 days
○ Coincides with growth of ovarian follicles
○ Controlled by the estrogen secreted by the follicles
○ Increase in thickness of endometrium (4-8mm)
What happens in the secretory phase?
○ Lasts approximately 13 days
○ Coincides with formation, functioning and growth of corpus luteum
○ Progesterone produced by the corpus luteum stimulates the glandular epithelium to secrete a glycogen-rich material
○ Endometrium thickens due to influence of progesterone and estrogen from the corpus luteum
What happens if fertilisation does not occur?
○ CL degenerates
○ Estrogen and progesterone levels fall and the secretory endometrium enters an ischaemic phase
○ Menstruation occurs
What is the ischaemic phase?
○ Occurs when oocyte is not fertilised
○ Decreased secretion of hormones, primarily progesterone, by the degenerating corpora lutea
○ Results in stoppage of glandular secretion, loss of interstitial fluid and a marked shrinking of the endometrium
○ The entire compact layer and most of the spongey layer of the endometrium are discarded in menses
What happens if fertilisation occurs?
○ Formation of blastocyst begins
○ Blastocyt begins to implant in the endometrium on approximately the 6th day of the luteal phase
○ hCG keeps the CL secreting estrogen and progesterone
○ Luteal phase and menstruation do not occur
Describe the appearance of the endometrium in the menstrual phase.
thin, single echogenic line 0.5-1mm
Hypoechoic central line representing blood and tissue surrounded by a hyperechoic endometrial echo
Late menstruation: hypoechoic echo that represents blood disappears and the endometrium appears as a thin single line
Describe the appearance of the endometrium in the proliferative phase.
hypoechoic thickening, 4-8mm
§ Endometrium appears as a single thin stripe that represents the cavity with a hypoechoic halo encompassing the triple stripe appearance. Thin surrounding hyperechoic layer represents the basalis
§ Late proliferative/early secretory: endometrium increases in thickness and echogenecity representing the basalis that progresses and inundates the entire endometrium
Describe the appearance of the endometrium in the secretory phase.
hyperechoic thickening, 7-14mm
Greatest thickness and echogenecity
Why does menopause result in endometrial atrophy?
Menopause results in hypooestrogenism which results in endometrial atrophy
What is the post-menopausal appearance of the endometrium when the patient is not on HRT?
Atrophic, single echogenic line, <4mm
What is the post-menopausal appearance of the endometrium when the patient is on HRT?
Single, echogenic line <8mm
Name some causes of endometrial thickening in pre-menopausal women.
○ Submucosal fibroid ○ Endometrial polyp ○ Endometrial hyperplasia ○ Trophoblastic disease ○ Uterine synechiae ○ Adhesions ○ Early intrauterine pregnancy ○ Collections of blood or pus due to infection, cervical cancer, cervical stenosis
Name some causes of endometrial thickening in post-menopausal women
Endometrial hyperplasia and endometrial carcinoma
Describe the premenopausal appearance of the ovaries
○ Follicular phase: many follicles (5-11), increase in size until day 8-9 then one follicle becomes dominant and grows 1-2mm a day. All others become atretic
○ Pre-ovulatory: follicle measuring 20-25mm
○ Luteal phase: corpus luteum, 20mm irregular, hypoechoic or isoechoic cyst often containing low-level echoes. There can be a typical ring of colour flow
Describe the postmenopausal appearance of the ovaries
With or without HRT: atrophic, no follicles
Describe changes that occur with the OCP
- OCP has a main contraceptive effect
- Progestogen in the combined pill also creates a thin endometrial lining that resists implantation and thickens cervical mucus, retarding sperm entry into the upper female reproductive tract
○ Make pregnancy unlikely if ovulation occurs - Ovary will be imaging as a homogeneous structure without a dominant follicle
- Sometimes patients will ovulate despite OCP use
What are some side effects of the OCP?
- People on OCP are less common to have ectopic pregnancy and ovarian cysts
- Decreased incidence of PID
- Iron deficiency anaemia is decreased
Prolonged use of OCP reduces risk of developing uterine fibroids and ovarian and endometrial cancers
What is tamoxifen?
Orally administered, non-steroidal, anti-oestrogen agent that treats breast cancer and can prevent breast cancer in some high risk populations
Weak oestrogen agonist in post-menopausal endometrial tissue
What are endometrial side-effects associated with tamoxifen?
○ Benign cystic hyperplasia- u/s appearance of cystic endometrial hyperplasia
○ Increased incidence of benign endometrial polyps, endometrial proliferation and hyperplasia
§ More likely to have endometrial pathology with the tamoxifen if had pathology before
○ Increase risk of endometrial adenocarcinoma in post-menopausal tamoxifen
What are uterine side effects of tamoxifen usage?
Small increase in risk of uterine sarcoma
Why might a patient go on HRT?
○ Disturbances in menstrual pattern:
§ Anovulation
§ Reduced fertility
§ Decreased flow or hypermenorrhoea
§ Irregular frequency of menses
○ Vasomotor instability (hot flushes and sweats)
○ Psychological symptoms such as anxiety, increased tension, mood depression, irritability
○ Atrophic conditions such as skin atrophy, urinary problems, vulvar, introial and vaginal atrophy leading to pruritus (severe itching) and dyspareunia
○ Osteoporosis
○ Cardiovascular disease
Why is HRT given?
HRT is used to give oestrogen in order to reduce all effects of oestrogen deprivation especially osteoporosis and cardiovascular disease as it has a major impact on long-term health
What is the downside of oestrogen only HRT?
Oestrogen ONLY dramatically increases the risk of endometrial cancer
Risk is eliminated by the addition of progestogen
