Pathology Of Abnormal Uterine Bleeding Flashcards
Profuse or prolonged bleeding at the time of the period
Menorrhagia
Irregular bleeding between periods
Metrorrhagia
Menstrual cycle at intervals of less than 21 days
Polymenorrhea
Menstrual cycle length that is greater than 37 days
Oligomenorrhea
Absence of menses by 16 years of age (primary) or no menses for > 6 months (secondary)
Amenorrhea
Bleeding that happens more than 12 months after menopause
Post menopausal bleeding
What are the organic causes of abnormal uterine bleeding?
They are reproductive tract disease: (4)
- Non-neoplasticism disorders of endometrium
- Premalignant: endometrial hyperplasia
- Malignant neoplasms
- Pregnancy -related:
- Miscarriage
- Ectopic
- Trophoblast disease
What are the non-organic or dysfunctional or hormonal causes of abnormal uterine bleeding?
- Anovulatory or dysfunction ovulation
- Iatrogenic —> IUD/ Drugs
- Systemic diseases —>
A. Coagulopathy —> e.g Von willberand disease
B. Ovarian —> PCOS, functional tumors
C. Endocrine: thyroid, adrenal, pituitary
D. Metabolic: obesity
What are the causes of adolescents AUB?
- Anovulatory cycle
2. Coagulation disorders
What are the causes of postmenopausal AUB?
- Endometrial atrophy
2. Anatomical lesions (carcinoma, hyperplasia,polyps)
What are the causes of AUB according to FIGO?
They are collected with mnemonic palm Coein
P—> polyp
A—> adenomyosis
L—> leiomyosis
M—> malignancy
C—> coagulopathy
O—> ovulatory dysfunction
E—> endometrial
I—> iatrogenic (for example, an intrauterian system)
N —> not otherwise specified (for example caesarean scar defects)
What is the main cause of prepubertal AUB?
Precocious puberty (hypothalamic, pituitary , or ovarian origin)
What is the cause of AUB in perimenapausal ?
- Dysfunctional uterine bleeding
- Anovulatory cycle
- Anatomical lesions (carcinoma, hyperplasia, polyps)
What is the cause of AUB in reproductive age?
- Complications of pregnancy (abortion, trophoblastic disease, ectopic pregnancy)
- Anatomical lesions (leiomyoma, adenomyosis, polyps, endometrial hyperplasia, carcinoma)
- Dysfunctional uterine bleeding
- Anovulatory cycle
- Ovulatory dysfunctional bleeding —> e.g inadequate luteal phase)
Mention the steps that lead to bleeding in anovulatory cycles?
- Hormonal imbalances, alterations in hypothalamus-pituitary-ovarian axis
- no positive estrogen feedback —> no LH midcycle surge
- No ovulation —> no corpus luteum —> no progesterone —> no secretory changes in endometrium
- Unopposed estrogen production continues —> overgrowth of endometrium —> thickened endometrium is fragile and bleeds easily
- In absence of progesterone —> defective vasoconstriction, hypoxia response, Hemostasis, and repair
What do u see in anovulatory endometrium on biopsy?
- Stomal condensation
- Irregular proliferation
- Lack secretory changes
- Disordered proliferation endometrium
- Glands dilation
- Breakdown and hemorrhage
Is a complex endocrine disorder characterized by?
- Hyperandrogenism
- Menstrual abnormalities
- Polycystic ovaries
- Chronic anovulation
- Decreased fertility
Polycystic ovarian syndrome
What are the characteristics of polycystic ovarian syndrome?
- Hyperandrogenism
- Menstrual abnormalities
- Polycystic ovaries
- Chronic anovulation
- Decreased fertility
With what is PCOS associated?
- Obesity
- Type 2 DM
- Premature atherosclerosis
What is the cause of PCOS?
Etiology remains incompletely understood: a dysrrgulation of enzymes involved in androgen biosynthesis and excessive androgen production
What is the pathophysiology of PCOS leading to symptoms?
Increase LH —> stimulation of ovarian theca cells (hyperthecosis) —> increase androgens production —> hyperandrogenicity (hirsutism)
Decrease FSH relative to LH —>decrease granulosa cell aromatization of androgens to estrogens (normally a function of FSH
What is a feature in histology that indicates:
Polycystic ovarian syndrome
Subcorticle follicle cysts that enlarges the ovaries —(due to)—> follicular arrest (lack of further maturation of follicle) leads to formation of these cysts
PCOS features:
- Empty fluid filled cysts
- Attenuated granulosa - theca cells —covered by a dense fibrous capsule—
- Corpora lutea and corpora albicantia are absent because of lack of ovulation
What are the non-organic causes of AUB in note they are 2
- PCOS
2. Granulosa cell tumor
What happens in granulosa cell tumor?
May elaborate large amounts of estrogen
What is happening in precocious girls (juvenile granulosa cell tumor) ?
Precocious sexual development
What occurs in granulosa cell tumors in adults?
- Associated with proliferation breast disease
- Endometrial hyperplasia
- Carcinoma
What are the organic causes of bleeding mentioned in the notes?
- Hydatiform mole
- Ectopic pregnancy
- Miscarriage
- Leiomyoma
- endometrial hyperplasia and carcinoma
- endometriosis
- adenomyosis
- Chronic endometriosis
- Endometrial polyp
Are exophytic masses of variable sizes that project into the endometrial cavity
Endometrial polyps (can be asymptomatic or may cause bleeding if they ulcerate or undergo necrosis)
What AUB is associated with tamoxifen?
Endometrial polyp
What is tamoxifen?
It is a therapy of hormone- positive breast cancer due to its anti-estrogen in activity
With what is endometrial polyps associated?
- Tamoxifen
- HRT
- Lynch syndrome
What we do to endometrial polyp?
We do polypectomy
What we see in microscopy of endometrial polyp?
- Dilated glands
2. Thick vessels
What is a disease that cause AUB and is associated with pelvic inflammatory disease?
Chronic endometriosis
What are the bacteria most commonly cause chronic endometritis?
- Neisseriae gonorrheae
2. Chlamydia trachomatis
How we diagnose chronic endometrititis?
The diagnosis rests on the identification of inflammatory cells in the stroma particularly plasma cells —> which are not seen in normal endometrium
What is a thing that could injure the endometrium and induce chronic endometritis?
Intrauterine device
Presence of endometrial tissue within the uterine wall (myometrium)?
Adenomyosis
Is the presence of ectopic endometrial glands and stroma outside the uterus?
Endometriosis
A patient comes with? Dysmenorrhea Pelvic pain Infertility Menstrual irregularities
Endometriosis
Does endometriosis involve certain structures?
Frequently involves pelvic structures” Ovaries Pouch of dougles Uterine ligament Tubes
Endometriosis is a precursor to what?
May be precursor to ovarian carcinoma —> endometoid and clear cell types
What is a feature of endometriosis?
Endometrial gland and stroma outside the endometrium
What causes endometrial bleeding?
Endometrial lesions bleed periodically in response to both ovarian hormones and intrinsic hormonal production
This bleeding produces nodules with a red-blue to yellow - brown appearance.
With time organizing hemorrhage causes extensive fibrous adhesions between tubes, ovaries and other structures
Scaring my block the tubes and cause infertility
What are the theories behind endometriosis?
- Regurgitation theory:
Currently favored, proposes that menstrual back flow through the Fallopian tubes leads to implantation - Benign metastasis theory:
Holds that endometrial tissue from the uterus can spread to distant sites via blood vessels and lymphatics - Meta plastic theory:
Proposes that coelomic epithelium of (mesothelioma of pelvis and abdomen from which endometrium originates) undergoes endometrial differentiation - Extra uterine stem/progenitor cell theory:
Proposes that circulating stem / progenitor cells from the bone marrow differentiate into endometrial tissue
When the dr keep the parts of miscarriage?
The diagnosis of retained products of conception is made by the pathologist when he/she identifies placental tissue +/- fetal parts
What is hematosplanix?
Blood-filled Fallopian tube
What is the most common cause of blood filled Fallopian tube?
Tubal pregnancy
What causes bleeding in ectopic tubal pregnancy?
With time the growth of gestational sac distended the Fallopian tube, causing thinning of the wall and rupture
The rupture results in massive intraperitoneal hemorrhage
Swollen graplike chorionic villi
Hydatiform mole
