Pathology of the uterine body and endometrium

Question 1

What are developmental abnormalities of the uterus due to?

Answer 1

Fusion of the mullerian ducts

Question 2

What is the basic histology of the endometrium

Answer 2

Consists of glands and stroma and has a variety of normal appearances depending on the phase of the menstrual cycle, menopausal status etc.

Question 3

Describe the basic histology of the myometrium

Answer 3

Smooth muscle comprising much of the uterus

Question 4

Which hormone results in the thickening of the endometrial lining?

Answer 4

Oestrogen

Question 5

Describe the endometrium during the proliferative phase

Answer 5

• Gland to stroma ratio is low
• Glands have a tubular appearance
• Cells within glands are cuboidal and have ovoid nuclei
• Presence of mitotic

Question 6

Describe the endometrium during the secretory phase

Answer 6

• Glands have a coiled appearance
• No mitotic activity
• Gland to stroma ratio is low
• Nuclei are close to the basement membrane but small gap in which there are vacuoles (which disappear as move through phase)

Question 7

Describe the endometrium in the menstrual phase

Answer 7

• Lots of blood
• Fragmentation of the endometrium, condensed stroma
• Presence of apoptosis

Question 8

Describe the endometrium in menopause

Answer 8

• Cystic atrophy
• More thin
• Still low gland to stroma ratio
• Low cytoplasm

Question 9

What is endometriosis?

Answer 9

The presence of endometrial tissue outside of the uterus

Question 10

What is adenomyosis?

Answer 10

The presence of endometrial tissue within the myometrium

Question 11

What are the clinical symptoms of endometriosis?

Answer 11

• Dysmenorrhoea
• Pelvic pain
• Infertility

Question 12

What is the metastatic theory of endometriosis?

Answer 12

Retrograde menstruation or surgical procedures introduce endometrium to sites outwit the uterine cavity

Question 13

What is the metaplastic theory of endometriosis?

Answer 13

Endometrium arises directly from the coelomic epithelium (i.e. peritoneum) of the pelvis as this is where the endometrium originates from during embryological development

Question 14

Describe endometrial polyps

Answer 14

Exophytic masses of variable size which project into the endometrial cavity

Question 15

What drug are endometrial polyps associated with?

Answer 15

Tamoxifen

Question 16

How can endometrial polyps present?

Answer 16

Abnormal bleeding

Question 17

How are endometrial polyps treated?

Answer 17

Hysteroscope in the outpatient clinic

Question 18

Describe the histology of endometrial polyps

Answer 18

• Haphazardly arranged glands with preservation of a low gland to stroma ratio
• Often thick walled blood vessels and fibrous stroma
• Glands are usually inactive but can show proliferation, secretory changes or metaplasia
• Occasionally cytological atypia or frank adenocarcinoma

Question 19

What is the relationship between endometrial hyperplasia and adenocarcinoma?

Answer 19

They are on the same spectrum, hyperplasia is often first and then can transform into adenocarcinoma

Question 20

What are endometrial hyperplasia and adenoma associated with?

Answer 20

Prolonged oestrogen stimulation of the endometrium

Question 21

What are the possible underlying causes of endometrial hyperplasia and adenocarcinoma?

Answer 21

• Anovulatory cycle
• Endogenous sources of oestrogen - obesity, PCOS, oestrogen secreting ovarian tumours
• Exogenous sources of oestrogen such as oestrogen only HRT (not really given now)

Question 22

What are the symptoms of endometrial hyperplasia and adenocarcinoma?

Answer 22

Usually postmenopausal bleeding or in premenopausal women irregular/continuous/heavy bleeding

Question 23

What is the histological characteristic of endometrial hyperplasia and adenocarcinoma?

Answer 23

There is an increase in the gland to stroma ratio

Question 24

What is the management of endometrial hyperplasia?

Answer 24

• Progesterone therapy e.g. mirena IUS

* Hysterectomy

Question 25

What is the management of endometrial adenocarcinoma?

Answer 25

Hysterectomy with subsequent management depending on tumour grade and stage

Question 26

What is a leiomyoma?

Answer 26

Bengin smooth muscle tumour of the myometrium, it is very common (at least 25% of women have it and 70% of over 50s do)

Question 27

What are the symptoms of leiomyoma?

Answer 27

• Can be asymptomatic
• Abnormal bleeding
• Urinary frequency if large
• Impaired fertility

Question 28

Describe the histology of leiomyoma

Answer 28

Completely resembles normal smooth muscle

Question 29

What do leiomyomas look like macroscopically?

Answer 29

Sharply demarcated round grey white tumours with a whorled cut surface

Question 30

What is the management of leiomyoma?

Answer 30

• Varies depending on the number, size, and symptoms
• Medical: progesterone secreting IUS, hormonal therapies, tranexamic acid, GnRH agonists
• Surgical - uterine artery embolisation, myomectomy, hysterectomy

Question 31

What is a leiomyosarcoma?

Answer 31

Malignant smooth muscle tumour of the myometrium (uncommon)

Question 32

What is the peak incidence of leiomyosarcoma?

Answer 32

Age 40-60, can be pre or post menopausal

Question 33

What are the symptoms of leiomyosarcoma?

Answer 33

Initially none, then bleeding or pain

Question 34

Describe the macroscopic appearance of leiomyosarcoma

Answer 34

bulky invasive masses or polyploid, haemorrhage, necrosis

Question 35

Describe the microscopic appearance of leiomyosarcoma

Answer 35

• Overt cytological atypia
• Necrosis
• Mitotic activity
• Infiltrative margin

Question 36

What is the typical prognosis of leiomyosarcoma?

Answer 36

• Spread to lungs, liver and brain

* 40% 5 year survival