Pathology of the uterus Flashcards
What are the three stages in the ovarian cycle?
Follicular phase Ovulation Luteal phase
What are the three stages in the uterine cycle?
Menstrual phase proliferative phase secretory phase
When does the proliferative phase of the uterine cycle occur? What hormone influences it? What effect does it have?
D1 -14 Oestrogen Growth
When does the secretory phase of the uterine cycle occur? What hormone influences it? What effect does it have?
D16-28 Progesterone Secretion
When does the menstrual phase of the uterine cycle occur? What hormone influences it? What effect does it have?
D1-3 Withdrawal Necrosis
What phase does the endometrium enter if there has been implantation? What hormone influences it and what is the effect?
Fertilised Progesterone & HCG Hypersecretion Decidualisation
What stage in the endometrial cycle is shown?
Proliferative phase
Which phase in the menstrual cycle is shown and how can you tell?
Secretory phase
Increasing tortuosity
Why is the endometrial biopsy difficult to interpret?
Constant physiological changes before, during and after reproductive life
Changes due to hormone therapy
Lack of clinical data
List the indications for endometrial sampling?
- Abnormal uterine bleeding
- Investigation for infertility
- Spontaenous and therapeutic abortion
- Assessment of response to hormonal therapy
- Endometrial ablation
- Work up prior to hysterectomy for benign indications
- Incidental finding of thickened endometrium on scan
- Endometrial cancer screening in high risk patients
What does menorrhagia mean?
Prolonged and increased menstrual flow
What does metrorrhagia mean?
Regular intermenstrual bleeding
What does polymenorrhoea mean?
Menses ocurring at <21 day interval
What does polymenorrhagia mean?
Increased bleeding and frequent cycle
What does menometorrhagia mean?
Prolonged menses and intermenstrual bleeding
What does amenorrhoea mean?
Absence of menstruation > 6 months
What does oligomenorrhoea mean?
Menses at intervals of >35 days
What is dysfunctional uterine bleeding
Abnormal uterine bleeding with no organic cause
Define post-menopausal bleeding
Abnormal uterine bleeding >1 year after cessation of menstruation
What are the common causes of abnormal uterine bleeding in adolescence/early reproductive life?
- anovulatory cycles
- pregnancy/miscarriage
- endometritis
- bleeding disorders
What are the causes of abnormal uterine bleeding during reproductive life/perimenopause?
- pregnancy/miscarriage
- DUB: anovulatory cycles, luteal phase defects
- Endometritis
- Endometrial/endocervical polyp
- Leiomyoma
- Adenomyosis
- exogenous hormone effects
- bleeding disorders
- hyperplasia
- neoplasia: cervical, endometrial
What are the causes of abnormal uterine bleeding post-menopause?
- atrophy
- endometrial polyp
- exogenous hormones: HRT, tamoxifen
- endometritis
- bleeding disorders
- > hyperplasia*
- > endometrial carcinoma*
- > sarcoma*
Endometrial thickness of ____ in postmenopausal women (____ in premenopausal) is generally taken as an indication for biopsy
Endometrial thickness of >4mm in postmenopausal women (16mm in premenopausal) is generally taken as an indication for biopsy
How can the endometrium be sampled?
Endometrial pipelle
Dilatation and curettage
Describe an endometrial pipelle
- 3.1mm diameter, no dilatation needed
- no anaesthesia
- outpatient procedure
- very safe
- limited sample
Describe dilatation and curettage
- most common operation performed on women
- most thorough sampling method
- can miss 5% hyperplasias/cancers
What history is required for interpreting an endometrial sample
- age
- date of LMP and length of cycle
- pattern of bleeding
- hormones
- recent pregnancy
- do not need to know number of pregnancies, drugs withough hormonal influences*
What is considered in histological assessment of endometrial samples for abnormal uterine bleeding
- is the sample adequate/representative for the given clinical scenario
- is there evidence of fresh/old breakdown/haemorrhage
- is there an organic benign abnormality? (polyp, endometritis, miscarriage)
- is there evidence for dysfunctional bleeding?
- is there hyperplasia (atypical/non atypical) or malignancy?
In which phase of the menstrual cycle is the endometrial sample the least informative?
Menstrual phase
Define 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 the bleeding)
What is dysfunctional uterine bleeding normally caused by?
Anovulatory cycles
Describe an anovulatory cycle
Commonest at either end of reproductive life
Corpus luteum does not form
Continuous growth of functionalis layer
What can cause anovulatory cycles?
PCOS
hypothalamic dysfunction
thyroid disorders
hyperprolactinaemia
What is luteal phase deficiency
Insufficient progesterone or poor response by the endometrium to progesterone. Abnormal follicular development (inadequate FSH/LH)- poor corpus luteum
What organic causes from the endometrium can cause abnormal uterine bleeding?
Endometritis
Polyp
Miscarriage
What organic pathologies in the myometrium can result in AUB?
Adenomyosis
Leiomyoma
How is endometritis diagnosed histologically?
By recognising an abnormal pattern of inflammatory cells
What is the role of the cervical mucous plug in protecting the endometrium?
Protects from ascending infection
What makes the endometrium relatively resistant to infection?
Cyclical shedding
Which micro-organisms can cause endometritis?
Neisseria
Chlamydia
TB
CMV
Actinomyces
HSV
What can cause endometritis without specific organisms?
IUCD
Postpartum
Postabortal
Post curettage
Chronic endometritis- NOS
Granulomatous (sarcoid, foreign body post ablation)
Associated with leiomyomata or polyps
What is chronic plasmacytic endometritis?
Infectious unless proven otherwise
Associated with PID (neisseria gonorrhoea, chlamydia, enteric organisms)
How may endometrial polyps present?
Usually asymptomatic but may present with bleeding or discharge
When do endometrial polyps occur?
Often occur around and after the menopause
What is the prognosis of endometrial polyps
Almost always benign
BUT endometrial carcinoma can present as a polyp
What may be seen on a miscarriage specimen
Products of conception
- chorionic villi
- foetal RBCs
What is a molar pregnancy?
Abnormal form of pregnancy in which a non-viable fertilised egg implants in the uterus (or tube)
Molar pregnancy is a gestational _____________ disease which grows as a mass characterised by swollen _______ _____. Categorised as ______ ______ or _______ _____.
Molar pregnancy is a gestational trophoblastic disease which grows as a mass characterised by swollen chorionic villi. Categorised as partial moles or complete moles.
What causes a complete mole?
Caused by one or two sperm combining with an egg that has lost its DNA.
How does a complete mole form?
The sperm reduplicates forming a complete 46 chromosome set but only paternal DNA is present
When does a partial mole occur?
When an egg is fertilised by two sperm or by one sperm which reduplicates itself yielding the genotypes of 69 XXY (triploid)
Which type of molar pregnancy has the greatest potential to become choriocarcinoma?
Complete hydatidiform moles
What is adenomyosis?
Endometrial glands and stroma within the myometrium
How does adenomyosis present?
Causes menorrhagia/dysmenorrhoea
What is a leiomyoma
Benign tumour of smooth muscle, may be found in locations other than the uterus
How may a leiomyoma present?
Menorrhagia/infertility/mass effect, pain
Single or multiple, may distort uterine cavity
What is the growth of leiomyomas dependent upon?
Oestrogen
