Pathology of the Female Reproductive Tract Part 2​

Question 1

Menses refers to blood and other matter being discharged from the uterus at menstruation. What is the normal durational range for menses?

1 - 10-15 days
2 - 20-25 days
3 - 24-35 days
4 - 30-35 days

Answer 1

3 - 24-35 days

- not normal if you fluctuate from 25 in one cycle then 35 in another cycle

Question 2

What is the cycle and what is the normal cycle length (regularity) of menses?

Answer 2

• number of days from 1st day of bleeding in one menstrual cycle
• <7-8 days

Question 3

What is the normal duration of bleeding?

1 - 1-3 days
2 - 1-5 days
3 - <7-8 days
4 - 3-10 days

Answer 3

3 - <7-8 days

Question 4

What is the definition of normal and abnormal bleeding as part of a menstrual cycle?

Answer 4

• normal = blood flow that doesn’t affect normal life

- abnormal = blood flow that impacts on normal life, clots of flooding

Question 5

What marks the beginning of a new menstrual cycle?

Answer 5

• 1st day of bleeding

- ovulation occurs 14 days prior to the next beginning of a cycle

Question 6

What is inter-menstrual bleeding?

Answer 6

• inter = between

- bleeding inappropriately between cycles

Question 7

What is post coital bleeding?

Answer 7

• coitus is latin for coming together (sex)

- spotting or bleeding that occurs after intercourse

Question 8

What is menopause?

Answer 8

• woman no longer has any eggs so no longer has periods
• duration of >1 year
• normally around 50 y/o

Question 9

What is acute and chronic abnormal uterine bleeding (AUB)?

Answer 9

• abnormal with no pattern bleeding not associated with anything
• acute = <6 months
• chronic = >6 months

Question 10

What is the International Federation of Gynaecology and Obstetrics (FIGO)?

Answer 10

• international classification of abnormal uterine bleeding

Question 11

The International Federation of Gynaecology and Obstetrics (FIGO) is the international classification of abnormal uterine bleeding (AUB). What does the PALM, which relates to the cause of AUB acronym as part of the FIGO classification of PALM-COEIN refer to?

1 - polyps, adenomyosis, leiomyoma, malignancy and hyperplasia
2 - polyps, adenomyosis, lymphoma, malignancy and hyperplasia
3 - polyps, adrenal, leiomyoma, malignancy and hyperplasia
4 - polyps, adenomyosis, lymphoma, malignancy and hyperplasia

Answer 11

1 - polyps, adenomyosis, leiomyoma, malignancy and hyperplasia

• P = polyps
• A = adenomyosis (adeno = gland, myo = muscle and osis means condition)
• L = leiomyoma (leio = smooth, myo = muscle = fibroids)
• M = malignancy and hyperplasia

Question 12

The International Federation of Gynaecology and Obstetrics (FIGO) is the international classification of abnormal uterine bleeding (AUB). What does the COEIN acronym, which relates to refers to the non-structural causes of AUB, as part of the FIGO classification of PALM-COEIN refer to?

1 - coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, neoplasia
2 - coagulopathy, ovulatory dysfunction, endometrial, intrauterine, not yet classified
3 - cancer, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
4 - coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified

Answer 12

4 - coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified

Question 13

What are the top 3 causes of bleeding in post-menopausal bleeding in women?

1 - tubal malignancy, submucosal fibroids, endometrial atrophy
2 - ovarian malignancy, submucosal fibroids, endometrial atrophy
3 - polyps, submucosal fibroids, endometrial atrophy
4 - polyps, endometrial carcinoma, endometrial atrophy

Answer 13

3 - polyps, submucosal fibroids, endometrial atrophy

Question 14

The International Federation of Gynaecology and Obstetrics (FIGO) is the international classification of abnormal uterine bleeding (AUB). The PALM acronym as part of the FIGO classification of PALM-COEIN refers to structural changes causing AUB:

• P = polyps
• A = adenomyosis (adeno = gland, myo = muscle and osis means condition)
• L = leiomyoma (leio = smooth, myo = muscle = fibroids)
• M = malignancy and hyperplasia

How can these changes be assessed?

Answer 14

• imaging and histology

Question 15

What are the 5 clinical features of a red flag that suggest gynaecological caner?

Answer 15

• Post coital Bleeding (after sex)
• Postmenopausal Bleeding (following menopause)
• Intermenruel bleeding (between periods) that is recurrent
• pelvic mass
• cervix lesion
• abnormal bleeding when on hormone therapy
• failure of treatment after 3 months

Question 16

Assessment of the uterine and endometrium is conducted in women at high risk of benign or malignant genital tract pathology. This essentially comprises of three components, what are the 3 components?

1 - blood test, ultrasound, endometrial biopsy
2 - hysteroscopy, ultrasound, endometrial biopsy
3 - blood test, hysteroscopy, endometrial biopsy
4 - hysteroscopy, ultrasound, endometrial biopsy

Answer 16

2 - hysteroscopy, ultrasound, endometrial biopsy

Question 17

What is the difference between colposcopy and hysteroscopy?

Answer 17

• colposcopy = imaging device to study cervix

- hysteroscopy = imaging device to study uterine walls

Question 18

Postmenopausal bleeding is bleeding, generally in older adults following the cessation of their periods. What % of the bleeding is due to a thickened endometrium and endometrial cancer measured via transvaginal ultrasound?

1 - 10%
2 - 30%
3 - 60%
4 - 96%

Answer 18

4 - 96% of endometrial cancer is due to endometrial thickening
- 10-12% then become cancerous but all need investigating

Question 19

Postmenopausal bleeding is bleeding, generally in older adults following the cessation of their periods. 96% of the bleeding is due to a thickened endometrium because of endometrial cancer. What thickness would then trigger the need to perform a hysteroscopy in post menopausal women?

1 - 1- 2mm
2 - >4mm
3 - 2-4mm
4 - >6mm

Answer 19

2 - >4mm

Question 20

What are the main causes of postmenopausal bleeding?

Answer 20

• polyps = 30%
• submucosal fibroids = 20%
• endometrial atrophy = 30%
• hyperplasia = 8–15%
• endometrial carcinoma = 8–10%
• ovarian, tubal, cervical malignancy = 2%

Question 21

If a woman has begin taking hormone replacement therapy and and she continues to have postmenopausal bleeding, what needs to be done?

1 - monitor by GP
2 - prescribe vaginal progesterone
3 - referred for further investigation
4 - refer for hysterectomy

Answer 21

3 - referred for further investigation

Question 22

What is Tamoxifen?

Answer 22

• medication for breast cancer

- increases risk of developing endometrial hyperplasia or cancer

Question 23

Tamoxifen is a medication for breast cancer, but is associated with increased risk of developing endometrial hyperplasia or cancer. If a patient is taking Tamoxifen and has unscheduled bleeding while on HRT beyond 3 months of starting should receive what?

1 - nothing as not serious
2 - GP to monitor
3 - refer for further investigation
4 - switch breast cancer medication

Answer 23

3 - refer for further investigation

Question 24

What are fibroids?

Answer 24

• leiomyomas (leio = smooth, myo = muscle)
• smooth muscle tumours (myometrium layer of endometrium)
• <1% become malignant

Question 25

Fibroids, also called - leiomyomas are benign smooth muscle tumours (myometrium layer of endometrium). What % of these can become malignat?

1 - 1%
2 - 5%
3 - 10%
4 - 20%

Answer 25

1 - 1%

Question 26

Fibroids are leiomyomas (leio = smooth, myo = muscle), smooth muscle tumours where <1% become malignant. Which population are these most common in?

1 - caucasian
2 - African-Caribbean women
3 - Scandinavian
4 - asian/indian

Answer 26

2 - African-Caribbean women

Question 27

Fibroids are leiomyomas (leio = smooth, myo = muscle), smooth muscle tumours where <1% become malignant. How do we known if the fibroid has potentially become malignant (sarcoma - cancer in connective tissue)?

Answer 27

• if patient has pain
• if patient has abnormal bleeding
• exponential fibroid growth

Question 28

Fibroids are leiomyomas (leio = smooth, myo = muscle), smooth muscle tumours where <1% become malignant. They tend to reduce in size during menopause. Why is this?

1 - muscle tends to atrophy with age
2 - uterus is not needed anymore
3 - drop in estrogen and progesterone
4 - no contraception anymore

Answer 28

3 - drop in estrogen and progesterone

- both hormones can stimulate growth

Question 29

What is the most common gynaecological cancer in the UK?

1 - breast
2 - cervical
3 - ovarian
4 - endometrial

Answer 29

4 - endometrial

- around 34% incidence

Question 30

What is a lesion?

Answer 30

• damage or abnormal change in the tissue of an organism

- usually caused by disease or trauma

Question 31

What is a pre-invasive lesion of the endometrium?

1 - growth of a fibroid on endometrium
2 - growth of a polyp on endometrium
3 - histological and molecular alterations of the endometrium
4 - post menopausal bleeding with pain

Answer 31

3 - histological and molecular alterations of the endometrium
- related to high-risk of uterine carcinoma development

Question 32

A pre-invasive lesion of the endometrium is a histopathological and molecular alteration to the endometrium, which is related to high-risk of uterine carcinoma development. What happens to the gland to stroma ratio in the endometrium? (normal endometrium can be seen in the image below)

Answer 32

• gland:ratio increases
• it is endometrial glands that are associated with endometrial cancer-

Question 33

What is endometrial hyperplasia?

1 - thinning of the endometrium
2 - thickening of the endometrium
3 - abnormal cells develop on the endometrium

Answer 33

2 - thickening of the endometrium
- hyperplasia means to increase cell number

Question 34

Endometrial hyperplasia is thickening of the endometrium. When unopposed, which hormone drives endometrial hyperplasia?

1 - estrogen
2 - progesterone
3 - human chorionic gonadotrophin hormone
4 - testosterone

Answer 34

1 - estrogen
- unopposed continues secretion

Question 35

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed estrogen. There are 2 types of endometrium hyperplasia, what are they?

Answer 35

1 - simple hyperplasia = proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

2 - complex hyperplasia = proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands

Question 36

Endometrial hyperplasia is thickening of the endometrium, driven primarily by estrogen. There are 2 types of endometrium hyperplasia:

1 - simple hyperplasia = proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

2 - complex hyperplasia = proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands

What is the single most important prognostic factor for progression to carcinoma?

1 - cytology looking for aytipia (abnormal cells)
2 - blood sample
3 - colposcopy
4 - muscle biopsy

Answer 36

1 - cytology looking for aytipia (abnormal cells)
- most important prognostic factor for progression to carcinoma

Question 37

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. Would the combined pill cause endometrial hyperplasia?

Answer 37

• no
• estrogen is not unopposed as there is progesterone as well

Question 38

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. There are 2 types of endometrial hyperplasia:

1 - simple hyperplasia = proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

2 - complex hyperplasia = proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands

If a patient has simple non-atypical endometrial hyperplasia, which has a progression rate of 1–3%, what treatment could you provide?

1 - estrogen
2 - GnRH
3 - high dose progesterone
4 - high dose androgens

Answer 38

3 - high dose progesterone

Question 39

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. How can the thickness of the endometrium be measured?

1 - ultrasound
2 - MRI
3 - CT scan
4 - transvaginal ultrasound

Answer 39

4 - transvaginal ultrasound

Question 40

What are some of the main risk factors for developing endometrial hyperplasia and endometrial cancer?

Answer 40

• age
• obesity/diabetes
• polycystic ovary syndrome (unopposed estrogen and obesity)
• hypertension
• family history

Question 41

Why is obesity associated with endometrial hyperplasia?

1 - total cholesterol contributes to cell hyperplasia
2 - insulin like growth factor is raised in obesity and causes hyperplasia
3 - increased gluconeogenesis occurs in obesity and is linked with cellular hyperplasia
4 - adipocytes convert the precursor of estrogen, esteron into estrogen

Answer 41

4 - adipocytes convert the precursor of estrogen, esteron into estrogen
- adipose tissue converts estrone sulfate to estrone, and estrone to estradiol
- essentially too much estrogen again

Question 42

How is polycystic ovary syndrome (PCOS) associated with endometrial hyperplasia?

1 - increase LH, increased androstenedione converted into estrogen
2 - insulin like growth factor is raised in obesity and causes hyperplasia
3 - increased gluconeogenesis occurs in obesity and is linked with cellular hyperplasia
4 - adipocytes convert excess

Answer 42

1 - increase LH, increased androstenedione converted into estrogen

• PCOS associated with low FSH and increased LH
• increased LH causes theca cells to express too much androstenedione
• androstenedione moves into adipocytes and is converted to estrone and then estradiol
• excessive unopposed estrogen increases the risk of endometrial hyperplasia

Question 43

What is the gold standard for diagnosing endometrial hyperplasia and endometrial cancer?

1 - hysteroscopy and endometrial biopsy
2 - ultrasound
3 - MRI
4 - colposcopy

Answer 43

1 - hysteroscopy and endometrial biopsy

- confirmed with histology with a 97% detection rate

Question 44

The gold standard for diagnosing endometrial hyperplasia and endometrial cancer is hysteroscopy and endometrial biopsy. What method should be used to assess the level the cancer has invaded if cancer is confirmed?

1 - X-ray
2 - ultrasound
3 - MRI
4 - colposcopy

Answer 44

3 - MRI

Question 45

There are 2 types of endometrial cancer, type 1 and type 2. Which is most common?

Answer 45

• type 1 = 80-90% of endometrial cancers

- type 2 = 10-20% of endometrial cancers

Question 46

There are 2 types of endometrial cancer, type 1 and type 2. Are they both associated with excessive estrogen levels?

Answer 46

• type 1 = linked to estrogen

- type 2 = not linked to excess oestrogen

Question 47

There are 2 types of endometrial cancer, type 1 and type 2. Which groups of people are type 1 and 2 likley to affect?

1 - type 1 = older women, type 2 = peri/postmenopausa
2 - type 1 = young women, type 2 = older women
3 - type 1 = peri/postmenopausal, type 2 = older women
4 - type 1 = peri/postmenopausal, type 2 = young women

Answer 47

3 - type 1 = peri/postmenopausal, type 2 = older women

Question 48

There are 2 types of endometrial cancer, type 1 and type 2. Which type has a high grade and prognosis?

1 - type 1 = low grade+bad prognosis, type 2 = low grade+good prognosis
2 - type 1 = low grade+good prognosis, type 2 = high grade+bad prognosis
3 - type 1 = low grade+good prognosis, type 2 = high grade+good prognosis
4 - type 1 = high grade+bad prognosis, type 2 = low grade+good prognosis

Answer 48

2 - type 1 = low grade+good prognosis, type 2 = high grade+bad prognosis

Question 49

There are 2 types of endometrial cancer, type 1 and type 2. Which types of tumours does each type form?

1 - type 1 = endometriod adenocarcinoma, type 2 = uterine serous, clear cell
2 - type 1 = endometriod adenocarcinoma, type 2 = cervical cells
3 - type 1 = uterine serous, clear cell, type 2 = endometriod adenocarcinoma
4 - type 1 = endometriod adenocarcinoma, type 2 = ovarian

Answer 49

1 - type 1 = endometriod adenocarcinoma, type 2 = uterine serous, clear cell
- endometriod adenocarcinoma are cancers that affect glands

Question 50

The gold standard for diagnosing endometrial hyperplasia and endometrial cancer is hysteroscopy and endometrial biopsy. If cancer has been confirmed then lymphadenopathy should be performed. What 2 areas in the body should be scanned if the patient has type 1 cancer (estrogen related)?

1 - head and chest
2 - chest and pelvis
3 - abdomen and pelvis
4 - abdomen and head

Answer 50

3 - abdomen and pelvis

Question 51

The gold standard for diagnosing endometrial hyperplasia and endometrial cancer is hysteroscopy and endometrial biopsy. If cancer has been confirmed then lymphadenopathy should be performed. The pelvis and abdomen are the 1st 2 areas to scan, but what other area in the body should also be scanned if the patient has type 2 cancer (non estrogen related)?

1 - head
2 - chest
3 - abdomen
4 - pelvis

Answer 51

2 - chest

Question 52

There are 2 types of endometrial cancer:

• type 1 = endometrial adenocarcinomas linked to estrogen
• type 2 = not linked to excess oestrogen

Which is more dangerous?

Answer 52

• type 2 cancers

Question 53

In stage 1 of endometrium cancer where does the cancer remain?

Answer 53

• myometrium invasion

- generally good survival if detected here (95%)

Question 54

A 51-year-old woman presents with a 2 month history of postmenopausal bleeding. Her periods stopped last year and she has been using continuous combined hormone replacement therapy for 9 months. A transvaginal ultrasound scan revealed a normal-size anteverted uterus with normal ovaries and an endometrial thickness of 3 mm. Clinical examination was unremarkable.
What is the most appropriate management?

1 - cervical smear
2 - endometrial biopsy
3 - change to cyclical hormone replacement therapy and further investigation
4 - inpatient hysteroscopy
5 - cease hormone replacement therapy and investigate further if symptoms persist beyond 6 weeks

Answer 54

5 - cease hormone replacement therapy and investigate further if symptoms persist beyond 6 weeks

Question 55

A 50-year-old patient with a BMI of 20 and one episode of postmenopausal bleeding presents to the clinic. She is otherwise asymptomatic. Abdominal and pelvic examination is unremarkable and the endometrial thickness is 6 mm. An outpatient hysteroscopy and biopsy is arranged and the cavity is noted to be 8 cm in length and an adequate sample is taken. The endometrium was noted to be atrophic at hysteroscopy and the cavity normal. At 2 weeks later, the histology report reads “some inactive endometrium but sample insufficient for diagnostic purposes”. On reading the histology report, what would be the most appropriate action?

1 - Arrange MRI of pelvis
2 - Arrange an urgent hysteroscopy and curettage under general anaesthesia
3 - Discharge the patient from the clinic and ask the GP to re-refer them should they have a further episode of bleeding
5 - Recommend the GP start hormone replacement therapy
6 - Review the patient in clinic in 6 months and repeat endometrial sampling

Answer 55

3 - Discharge the patient from the clinic and ask the GP to re-refer them should they have a further episode of bleeding
- if bleeding persisted then GP would need to refer back

Question 56

Endometrial hyperplasia is thickening of the endometrium, driven primarily by estrogen. There are 2 types of endometrium hyperplasia, what are they?

Answer 56

1 - simple hyperplasia = proliferative lesion of glands of irregular size and shape and increases gland:stroma ratio

2 - complex hyperplasia = proliferative lesion of glands with severe glandular complexity and crowding as well as minimal stroma between glands

Question 57

What would be the treatment for a patient with endometrial cancer stage 1 grade 1 and stage 2 grade 2?

1 - MRI and monitor
2 - colposcopy
3 - total abdominal hysterectomy and oophprectomy with pelvis examination
4 - hysterectomy

Answer 57

3 - total abdominal hysterectomy and oophprectomy with pelvis examination

Question 58

What would be the treatment for a patient with endometrial cancer stage 1 grade 3?

1 - MRI and monitor
2 - colposcopy
3 - radical hysterectomy and oophprectomy with pelvis examination
4 - radical hysterectomy, oophprectomy, pelvic and para lymph node dissection and radiotherapy

Answer 58

4 - radical hysterectomy, oophprectomy, pelvic and para lymph node dissection and radiotherapy