Pathology of the Female Reproductive Tract Part 2 Flashcards
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
3 - 24-35 days
- not normal if you fluctuate from 25 in one cycle then 35 in another cycle
What is the cycle and what is the normal cycle length (regularity) of menses?
- number of days from 1st day of bleeding in one menstrual cycle
- <7-8 days
What is the normal duration of bleeding?
1 - 1-3 days
2 - 1-5 days
3 - <7-8 days
4 - 3-10 days
3 - <7-8 days
What is the definition of normal and abnormal bleeding as part of a menstrual cycle?
- normal = blood flow that doesn’t affect normal life
- abnormal = blood flow that impacts on normal life, clots of flooding
What marks the beginning of a new menstrual cycle?
- 1st day of bleeding
- ovulation occurs 14 days prior to the next beginning of a cycle
What is inter-menstrual bleeding?
- inter = between
- bleeding inappropriately between cycles
What is post coital bleeding?
- coitus is latin for coming together (sex)
- spotting or bleeding that occurs after intercourse
What is menopause?
- woman no longer has any eggs so no longer has periods
- duration of >1 year
- normally around 50 y/o
What is acute and chronic abnormal uterine bleeding (AUB)?
- abnormal with no pattern bleeding not associated with anything
- acute = <6 months
- chronic = >6 months
What is the International Federation of Gynaecology and Obstetrics (FIGO)?
- international classification of abnormal uterine bleeding
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
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
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
4 - coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
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
3 - polyps, submucosal fibroids, endometrial atrophy
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?
- imaging and histology
What are the 5 clinical features of a red flag that suggest gynaecological caner?
- 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
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
2 - hysteroscopy, ultrasound, endometrial biopsy
What is the difference between colposcopy and hysteroscopy?
- colposcopy = imaging device to study cervix
- hysteroscopy = imaging device to study uterine walls
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%
4 - 96% of endometrial cancer is due to endometrial thickening
- 10-12% then become cancerous but all need investigating
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
2 - >4mm
What are the main causes of postmenopausal bleeding?
- polyps = 30%
- submucosal fibroids = 20%
- endometrial atrophy = 30%
- hyperplasia = 8–15%
- endometrial carcinoma = 8–10%
- ovarian, tubal, cervical malignancy = 2%
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
3 - referred for further investigation
What is Tamoxifen?
- medication for breast cancer
- increases risk of developing endometrial hyperplasia or cancer
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
3 - refer for further investigation
What are fibroids?
- leiomyomas (leio = smooth, myo = muscle)
- smooth muscle tumours (myometrium layer of endometrium)
- <1% become malignant
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%
1 - 1%
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
2 - African-Caribbean women
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)?
- if patient has pain
- if patient has abnormal bleeding
- exponential fibroid growth
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
3 - drop in estrogen and progesterone
- both hormones can stimulate growth
What is the most common gynaecological cancer in the UK?
1 - breast
2 - cervical
3 - ovarian
4 - endometrial
4 - endometrial
- around 34% incidence
What is a lesion?
- damage or abnormal change in the tissue of an organism
- usually caused by disease or trauma
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
3 - histological and molecular alterations of the endometrium
- related to high-risk of uterine carcinoma development
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)
- gland:ratio increases
- it is endometrial glands that are associated with endometrial cancer-
What is endometrial hyperplasia?
1 - thinning of the endometrium
2 - thickening of the endometrium
3 - abnormal cells develop on the endometrium
2 - thickening of the endometrium
- hyperplasia means to increase cell number
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
1 - estrogen
- unopposed continues secretion
Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed estrogen. There are 2 types of endometrium hyperplasia, what are they?
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
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
1 - cytology looking for aytipia (abnormal cells)
- most important prognostic factor for progression to carcinoma
Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. Would the combined pill cause endometrial hyperplasia?
- no
- estrogen is not unopposed as there is progesterone as well
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
3 - high dose progesterone
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
4 - transvaginal ultrasound
What are some of the main risk factors for developing endometrial hyperplasia and endometrial cancer?
- age
- obesity/diabetes
- polycystic ovary syndrome (unopposed estrogen and obesity)
- hypertension
- family history
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
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
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
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
What is the gold standard for diagnosing endometrial hyperplasia and endometrial cancer?
1 - hysteroscopy and endometrial biopsy
2 - ultrasound
3 - MRI
4 - colposcopy
1 - hysteroscopy and endometrial biopsy
- confirmed with histology with a 97% detection rate
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
3 - MRI
There are 2 types of endometrial cancer, type 1 and type 2. Which is most common?
- type 1 = 80-90% of endometrial cancers
- type 2 = 10-20% of endometrial cancers
There are 2 types of endometrial cancer, type 1 and type 2. Are they both associated with excessive estrogen levels?
- type 1 = linked to estrogen
- type 2 = not linked to excess oestrogen
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
3 - type 1 = peri/postmenopausal, type 2 = older women
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
2 - type 1 = low grade+good prognosis, type 2 = high grade+bad prognosis
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
1 - type 1 = endometriod adenocarcinoma, type 2 = uterine serous, clear cell
- endometriod adenocarcinoma are cancers that affect glands
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
3 - abdomen and pelvis
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
2 - chest
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?
- type 2 cancers
In stage 1 of endometrium cancer where does the cancer remain?
- myometrium invasion
- generally good survival if detected here (95%)
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
5 - cease hormone replacement therapy and investigate further if symptoms persist beyond 6 weeks
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
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
Endometrial hyperplasia is thickening of the endometrium, driven primarily by estrogen. There are 2 types of endometrium hyperplasia, what are they?
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 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
3 - total abdominal hysterectomy and oophprectomy with pelvis examination
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
4 - radical hysterectomy, oophprectomy, pelvic and para lymph node dissection and radiotherapy
