Intro to Gynae Pathology

Question 1

What happens in the menstrual phase?

Answer 1

○ Functional layer of the uterine wall is sloughed off with the menstrual flow
○ Lasts 4-5 days
○ After menstruation, endometrium should be thin

Question 2

What happens in the proliferative phase?

Answer 2

○ 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)

Question 3

What happens in the secretory phase?

Answer 3

○ 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

Question 4

What happens if fertilisation does not occur?

Answer 4

○ CL degenerates
○ Estrogen and progesterone levels fall and the secretory endometrium enters an ischaemic phase
○ Menstruation occurs

Question 5

What is the ischaemic phase?

Answer 5

○ 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

Question 6

What happens if fertilisation occurs?

Answer 6

○ 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

Question 7

Describe the appearance of the endometrium in the menstrual phase.

Answer 7

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

Question 8

Describe the appearance of the endometrium in the proliferative phase.

Answer 8

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

Question 9

Describe the appearance of the endometrium in the secretory phase.

Answer 9

hyperechoic thickening, 7-14mm

Greatest thickness and echogenecity

Question 10

Why does menopause result in endometrial atrophy?

Answer 10

Menopause results in hypooestrogenism which results in endometrial atrophy

Question 11

What is the post-menopausal appearance of the endometrium when the patient is not on HRT?

Answer 11

Atrophic, single echogenic line, <4mm

Question 12

What is the post-menopausal appearance of the endometrium when the patient is on HRT?

Answer 12

Single, echogenic line <8mm

Question 13

Name some causes of endometrial thickening in pre-menopausal women.

Answer 13

○ 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

Question 14

Name some causes of endometrial thickening in post-menopausal women

Answer 14

Endometrial hyperplasia and endometrial carcinoma

Question 15

Describe the premenopausal appearance of the ovaries

Answer 15

○ 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

Question 16

Describe the postmenopausal appearance of the ovaries

Answer 16

With or without HRT: atrophic, no follicles

Question 17

Describe changes that occur with the OCP

Answer 17

• 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

Question 18

What are some side effects of the OCP?

Answer 18

• 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

Question 19

What is tamoxifen?

Answer 19

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

Question 20

What are endometrial side-effects associated with tamoxifen?

Answer 20

○ 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

Question 21

What are uterine side effects of tamoxifen usage?

Answer 21

Small increase in risk of uterine sarcoma

Question 22

Why might a patient go on HRT?

Answer 22

○ 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

Question 23

Why is HRT given?

Answer 23

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

Question 24

What is the downside of oestrogen only HRT?

Answer 24

Oestrogen ONLY dramatically increases the risk of endometrial cancer
Risk is eliminated by the addition of progestogen

Question 25

Does HRT affect the myometrium and ovaries?

Answer 25

No, HRT influences the thickness of the post-menopausal endometrium but not the myometrium or ovary. Duration of HRT usage does not influence the thickness