Pathology Flashcards
Which phase of the menstrual cycle can vary in length
Proliferative phase
This is why women have different cycle lengths
Which hormones maintain the endometrium during pregnancy
Progesterone
HCG
Which cells within the ovary secrete hormones
The granulosa cells which surround the oocyte
Presence of what on histology suggest the endometrium is in the proliferative phase
Mitotic figures
Presence of what on histology suggest the endometrium is in the secretory phase
Glands become more complex
More tortuous/wiggly and later fill with secretions
How does obesity increase your risk of endometrial cancer
Higher levels of circulating oestrogen
Fat cells can produce it
List some indications for endometrial sampling
Abnormal bleeding Infertility Abortion - spontaneous and therapeutic Endometrial ablation Endometrial cancer screening
What is considered post-menopausal bleeding
if there has been no bleeding for a year and then it starts up again
What are the common causes of abnormal uterine bleeding
DUB due to anovulatory cycles Pregnancy and miscarriage Endometritis– inflammation of the endometrium Bleeding disorders Cancer
What is adenomyosis
Where you get glands and stroma in the muscular wall of the uterus which will cycle as normal
Leads to menorrhagia and dysmenorrhoea
Very painful condition and sometimes the only way to manage is hysterectomy
What is a leiomyoma
A very common smooth muscle tumour which can occur anywhere
Often called a fibroid
Which drugs can lead to abnormal uterine bleeding
Anything with exogenous hormones
HRT and tamoxifen
What endometrial thickness would be considered abnormal in post-menopausal women
Greater than 4mm
This is an indication for biopsy
How can you sample the endometrium
Endometrial pipelle - limited sample but easier/safer
Dilatation and curretage
Which phase in the menstrual cycle is worst for taking an endometrial sample
During menstruation
The architecture is hard to analyse as it is in the process of breaking down
Can exclude malignancy but nothing else
What is dysfunctional uterine bleeding
Irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining
No organic cause for bleeding
When is DUB most common
Either end of reproductive life
How can you recognise anovulation on histology
Gland will be disordered
Will have just kept proliferating
What is the function of the cervical mucous plug
Protects the endometrium from ascending infection
Changes with the cycle - easy for sperm to enter when fertile, harder when not
What is endometritis
Inflammation of the endometrium
Which microorganisms can cause endometritis
Neisseria Chlamydia TB - uncommon in UK CMV HSV
What are some non-microbiological of endometritis
IUD - copper
Post-partum or post-abortal
Leiomyomas or polyps
Granulomas - sarcoid
If you can see plasma cells in the endometrium what is the diagnosis
Chronic plasmacytic endometritis
Shouldn’t have plasma cells in the endometrium
Caused by an infection unless proven otherwise - associated with PID
How do endometrial polyps present
Usually asymptomatic but may present with bleeding or discharge
Common around or after the menopause
What might be seen in a sample from a miscarriage
Foetal RBC
Chorionic villi
Need to take a sample to exclude molar pregnancy
What is a molar pregnancy
When a non-viable fertilised egg implants in the uterus or tube
What is a complete mole
When one or two sperm combine with an egg which has lost its DNA
Only has the father’s DNA
Will form placenta and some structure but never a foetus
What is a partial mole
An egg fertilised by 2 sperm or a 1 sperm which reduplicates itself
It will have 2 copies of dad and one of mum
Leads to a crazy placenta and some foetal parts
What is the risk of leaving a complete mole behind
High risk of it developing into a choriocarcinoma
How can leiomyomas of the uterus present
Menorrhagia
Infertility
Mass effect
Pain
What drives the growth of leiomyomas
Oestrogen
How is CT used in gynae patients
Can be used to assess post-surgical complications
Staging of gynaecological malignancy, especially ovarian and endometrial
Assessing response to treatment in patients after chemotherapy +/- radiotherapy
How are MRI scans used in gynae patients
Cancer staging – especially cervical cancer
Further evaluation and characterisation of adnexal and uterine masses
Evaluation of patients with sub-fertility - looks for anatomical issues
Scan pituitary in suspected prolactinoma
What makes up a dermoid cyst
They contain tissue derived from ectoderm, mesoderm and endoderm
Therefore have a mixture of many types of tissue, particularly fat
Often lined with epithelial tissue and hence may contain hair, teeth.
What is hysterosalpingography
X-ray procedure where cervix is cannulated and radiopaque contrast instilled to fill the uterine cavity
For assessment of tubal patency in patients with infertility
How does endometriosis present on MRI
Endometriosis deposits contain altered blood and haemoglobin degradation products
These have characteristic MR signals - high on T1 (looks white)
How does ovarian cancer spread
Disseminates by peritoneal spread
Ascites, omental and peritoneal nodules are common. Sub-diaphragmatic deposits and deposits on the surface of the liver are also seen
How do you diagnose ovarian cancer
US usually makes the initial diagnosis - ovarian mass
CT is used for staging
How do you diagnose endometrial cancer
TV US - looks for abnormally thickened endometrium
MRI used to assess myometrial invasion
CT used to look for mets
What are the two types of US used in gynae
Transabdominal
Transvaginal
Which type of US scan needs a full bladder
Transabdominal -distended bladder displaces gas-filled bowel loops out of the pelvis
Transvaginal needs an empty bladder
How is a transabdominal US carried out
The pelvic organs are scanned through the anterior abdominal wall
What is the benefit of transvaginal; US
ultrasound probe is as close as possible to the pelvic organs
Gives better spatial resolution
What is female genital mutilation
All procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons
FGM is recognised internationally as a violation of the human rights of girls and women
What are the impacts of obesity in O andG
Increased infertility
Decreased effectiveness of IVF
Increased risk of miscarriage
Increased risk of pregnancy complications
What are the risks of smoking in pregnancy
Risk of stillbirth, premature birth, sudden infant death syndrome
Describe a follicular ovarian cyst
Very common
Thin-walled, lined by granulosa cells
Follicle grows into a cyst - can be several cm
Usually resolve over a few months
What are the different types of ovarian cyst
Follicular e.g. polycystic ovaries) Luteal - benign and form from the CL Theca luteal Endometriotic - filled with blood Epithelial - can be benign or malignant Mesothelial
What features of a cyst would make you consider malignancy
If has a solid component with a high CA125
What is endometriosis
Endometrial glands and stroma outside the uterine body - in the wrong place
Causes inflammation in the area leading to pain and infertility
What are the signs/symptoms of endometriosis
Pain is the significant symptom - severe and chronic pelvic pain
Heavy and painful periods
Painful sex - often deep
Infertility
Fatigue
Cyclical bowel issues
Adhesions or scarring in the reproductive tract
Which sites are commonly affected by endometriosis
Ovary (‘chocolate’ cyst) Pouch of Douglas Peritoneal surfaces, including uterus Cervix, vulva, vagina Bladder, bowel etc
What are the signs of endometriosis in the ovaries
Metaplasia of mesothelium
Adhesions on the ovary (from inflammation)
Chocolate cysts
Haemorrhage, inflammation, fibrosis
What are the complications of endometriosis
Pain Cyst formation Adhesions Infertility Ectopic pregnancy Malignancy (endometrioid carcinoma)
What is salpingitis
Inflammation of the fallopian tubes
Often due to infections
What is an ectopic pregnancy
Implantation of a conceptus outside the endometrial cavity
Often ruptures
May cause fatal haemorrhage
Where can an ectopic pregnancy occur
Commonest site is Fallopian tube
May occur in ovary or peritoneum
What are the differentials for a pelvic mass
Constipation! Caecal carcinoma Appendix abscess Diverticular abscess Urinary retention Pregnancy Uterine mass - benign or malignant Adnexal mass - benign or malignant
What family history is significant in a pelvic mass
Lynch Syndrome
BRCA (ovarian breast and prostate cancer)
HLRCC (renal cancer with fibroids)
Which blood tests should you do in a pelvic mass case
Young women: LDH, AFP, HCG
Older: Ca125
How do you assess pelvic malignancy risk
Risk of Malignancy Index (RMI)
Involves menopausal status, US features, Serum CA125
If someone has a high risk of pelvic cancer, what further investigations would you do
CT - check surrounding organs for involvement
MRI - Better view of the lesion itself
Hysteroscopy
Diagnostic laparoscopy
What are the most common benign ovarian tumours
Functional cysts
Epithelial tumours - serous, clear cell etc
Teratoma - germ cell tumour
Stromal tumours
What are functional cysts
Ovarian cysts that are related to ovarian cycle
Can be follicular or luteal
Usually resolve spontaneously after a few cycles and are asymptomatic
May bleed or rupture and cause pain
Most common type of ovarian cyst
What type of ovarian cysts can be caused by endometriosis
Endometriotic cysts - also called chocolate cysts
Blood filled cysts
Typically tender mass with ‘nodularity’ and tenderness
What cell types can be found in a dermoid cyst
It has totipotential
Commonly hair, teeth, sebaceous material and thyroid tissue
May present with thyrotoxicosis
What are the signs of ovarian torsion
Acute colicky pain associated with nausea, vomiting and distress
Can occur as a result of a benign cyst
How can you manage fibroids
CONSERVATIVE
MEDICAL – Mirena (1st line), GnRH analogues, Progestins
SURGICAL – Laparoscopic/Laparotomy
Myomectomy (Hysteroscopic or abdominal)
Subtotal Hysterectomy
Total hysterectomy
How does position of the transformation zone change throughout life
It has a physiological response to:-
menarche
pregnancy
menopause
what is the transformation zone of the cervix
Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia
What is cervical erosion
When exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
What inflammatory conditions can affect the cervix
Cervicitis – Often asymptomatic but can lead to infertility
Non-specific acute/chronic inflammation.
Follicular cervicitis
Chlamydia Trachomatis
Herpes Simplex Viral Infection
How does vulvar Paget’s disease present
Crusting rash.
Tumour cells in epidermis, contain mucin.
What is Paget’s disease of the vulva
A tumour which arises from sweat gland in skin.
usually no underlying cancer
What is the definition of primary amenorrhea
Failure of menstruation to start by the age of 16
