Pathology of the Uterus Flashcards
What are the phases of the ovarian cycle?
Follicular phase, ovulation and luteal phase
What are the phases of the uterine cycle?
Menstrual cycle, proliferative phase and secretory phase
What are some features of the proliferative phase?
Lasts 1-14 days
Oestrogen is involved
Causes growth
What are some features of the secretory phase?
Lasts 16-28 days
Progesterone is involved
Causes secretion
What are some features of the menstrual cycle?
Lasts 1-3 days
Hormones withdrawn
Causes necrosis
What are some features of the fertilised phase?
Continues from the secretory phase onwards
Progesterone and HCG involved
Causes hypersecretion and decidualisation
What are the indications for endometrial sampling?
Abnormal uterine bleeding
Investigations for infertility
Spontaneous and therapeutic abortion
Assessing response to hormonal therapy
Endometrial ablation
Endometrial cancer screening if high risk
Work up prior to hysterectomy for benign indications
Incidental finding of thickened endometrium on scan
What are the types of abnormal uterine bleeding (AUB)?
Menorrhagia, metrorrhagia, polymenorrhoea, polymenorrhagia, menometrorrhagia, amenorrhoea, oligomenorrhoea
What is menorrhagia?
Prolonged and increased menstrual flow
What is metrorrhagia?
Regular intermenstrual bleeding
What is polymenorrhoea?
Menses occurring at <21 day intervals
What is polymenorrhagia?
Increased bleeding and frequent cycle
What is menometrorrhagia?
Prolonged menses and intermenstrual bleeding
What is amenorrhoea?
Absence of menstruation >6 months
What is oligomenorrhoea?
Menses at intervals of >35 days
What is dysfunctional uterine bleeding (DUB)?
Abnormal uterine bleeding with no organic cause
What is PUB?
Abnormal uterine bleeding > 1 year after cessation of menstruation
What are the causes of AUB in adolescence?
DUB usually due to anovulatory cycles
Pregnancy or miscarriage
Endometritis and bleeding disorders
What are the causes of AUB during reproductive life and perimenopause?
Pregnancy or miscarriage
Endometritis and bleeding disorders
Leiomyoma, hyperplasia, cervical/endometrial cancer
DUB = anovulatory cycle, luteal phase defect
Endometrial/endocervical polyp
Adenomyosis or exogenous hormone effects
What are the causes of AUB post menopause?
Atrophy, hyperplasia or endometritis
Endometrial polyp or bleeding disorder
Endometrial carcinoma or sarcoma
Exogenous hormones = HRT, tamoxifen
What endometrial thickness would be an indication for a biopsy?
Thickness >4mm in post-menopausal women
Thickness >16mm in pre-menopausal women
What are the methods for assessing the endometrium?
TVUS or hysteroscopy
What are the methods for sampling the endometrium?
Endometrial pipelle
Dilatation and curettage
What are some features of an endometrial pipelle?
3.1mm diameter = no dilatation or anaesthesia needed
Outpatient procedure
Very safe but limited sample obtained
What are some features of dilatation and curettage?
Most common operation performed on women
Most thorough sampling method
Can miss 5% of hyperplasia/cancer
What should be covered in the required history of a patient with AUB?
Age, date of last period and length of cycle, pattern of bleeding, hormones, recent pregnancy
What questions are asked when histologically assessing a sample for AUB?
Is the sample adequate for the given scenario?
Is there evidence of fresh/old breakdown or bleed?
Is there an organic benign abnormality?
Is there evidence for dysfunctional bleeding?
Is there hyperplasia or malignancy?
What is DUB?
Irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining
What is the most common cause of DUB?
Anovulatory cycle
What are some features of anovulatory cycles?
Most common at beginning or end of reproductive life
Corpus luteum doesn’t form
Continued growth of functionalis layer
What are some causes of anovulatory cycles?
PCOS, hypothalamic dysfunction, thyroid disorders, hyperprolactinaemia
What is another cause of DUB?
Luteal phase deficiency
What are some features of luteal phase deficiency?
Insufficient progesterone or poor response by endometrium to progesterone
Abnormal follicular development (inadequate FSH/LH) = poor corpus luteum
How is endometritis diagnosed histologically?
By recognising an abnormal pattern of inflammatory cells
Why is the endometrium resistant to infection?
Cervical mucous plug protect from ascending infection
Cyclical shedding of endometrium occurs
What are some micro-organisms that can cause endometritis?
Neisseria, chlamydia, TB, CMV, actinomyces, HSV
What are some causes of endometritis?
Intra-uterine contraceptive device, postpartum, post-abortal, post-curettage, chronic endometritis NOS, granulomatous, leiomyomata, polyps
What are some features of chronic plasmacytic endometritis?
Infectious unless proven otherwise
Associated with PID = neisseria gonorrhoea, chlamydia, enteric organisms
What are some features of endometrial polyps?
Common and almost always benign
Usually asymptomatic = may present with bleeding or discharge
Often occur around or after menopause
What can endometrial carcinoma present as?
Polyps
What is a molar pregnancy?
Abnormal form of pregnancy in which a non-viable fertilised egg implants in the uterus (or tube)
What is molar pregnancy a form of?
Gestational trophoblastic disease = grows as a mass characterised by swollen chorionic villi
What are molar pregnancies categorised as?
Partial or complete moles
What are causes complete moles?
Caused by single (90% incidence) or two (10% incidence) sperm combining with an egg which has lost its DNA
What are some features of complete moles?
Sperm replicates to form a complete 46 chromosome set = mole only contains paternal DNA
What are some features of partial moles?
Occurs when egg is fertilised by two sperm or by one sperm which reduplicates itself = yields genotype of 69XXY (triploid), have both maternal and paternal DNA
What do complete moles carry a risk of?
Have higher risk of developing into choriocarcinoma
What are myometrial causes of AUB?
Adenomyosis and leiomyoma
What is adenomyosis?
Endometrial glands and stroma within myometrium = causes menorrhagia/dysmenorrhoea
What are leiomyoma?
Benign tumours of smooth muscle = may be found in locations other than uterus
How may leiomyoma present?
Menorrhagia, infertility, mass effect or pain
What are some features of leiomyoma?
Single or multiple = may distort uterine cavity
Growth is oestrogen dependent
Interlacing smooth muscle cells seen microscopically
What may leiomyoma progress to?
Leiomyosarcoma
