Pathology of the Uterus and Endometrium

Question 1

how are the uterus and fallopian tubes formed embryologically?

Answer 1

From the coelomic lining epithelium which forms the lateral mullerian ducts. The ducts fuse with the urogenital sinus to form the uterus, and the unfused part becomes the fallopian tubes.

Question 2

What is the endometrial cavity and peritoneal lining formed from embryologically?

Answer 2

Coelomic lining epithelium.

Question 3

An issue in what causes abnormalities of the uterus?

Answer 3

Mullerian duct fusion.

Question 4

What are the 2 most common uterine abnormalities?

Answer 4

Septate uterus

Bicornuate uterus.

Question 5

Define endometriosis?

Answer 5

Presence of endometrial tissue outside the uterus.

Question 6

Define adenomyosis?

Answer 6

Presence of endometrial tissue in the myometrium.

Question 7

List some common sites of endometriosis?

Answer 7

Bowel
Peritoneum 
Ovaries 
Mucosa of cervix, vagina, fallopian tubes
Laparotomy scars

Question 8

Describe the pathogenesis of endometriosis?

Answer 8

2 theories

• Metastatic theory: Retrograde menstruation through fallopian tubes or surgical procedure introduces endometrial tissue to a new site.
• Metaplastic theory: Endometrial tissue arises from coelomic epithelium (aka peritoneum).

Question 9

What is an endometrial polyp?

Answer 9

An exophytic lesion of variable size projecting into the endometrial cavity.

Question 10

What are the symptoms of endometriosis?

Answer 10

Pelvic pain
Infertility
Dysmennorhoea

Question 11

How are endometrial polyps treated?

Answer 11

With a hysteroscope in an outpatient clinic.

Question 12

What does microscopy of an endometrial polyp show?

Answer 12

Haphazardly arranged glands with preservation of glands:stroma ratio.
Thick walled vessels.
Fibrous stroma.
Occasionally can see cytological atypia or adenocarcinoma.

Question 13

What can cause endometrial hyperplasia and adenocarcinioma?

Answer 13

Prolonged oestrogen stimulation of the endometrium.
May be due to
- anovulatory changes
- endogenous oestrogen e.g. PCOS, obesity, ovarian tumour
- Exogenous oestrogen e.g. HRT

Question 14

What is endometrial hyperplasia?

Answer 14

Categorised by an increase in the gland:stroma ratio.

Can be with or without cytological atypia.

Question 15

What kind of endometrial hyperplasia is a precursor of endometrioid carcinoma?

Answer 15

Atypical endometrial hyperplasia.

Question 16

How is endometrial hyperplasia mangaged?

Answer 16

Progesteron therapy such as mirena IUD or hysterectomy.

Question 17

How is endometrioid adenocarcinoma managed?

Answer 17

Hysterectomy with subsequent management based on stage.

Question 18

What is a leiomyoma?

Answer 18

A benign smooth muscle tumour of the myometrium.

Question 19

What are the symptoms of leiomyoma?

Answer 19

Asymptomatic
Abnormal bleeding
Urinary frequency (if large and presses bladder)
Impaired fertility

Question 20

Describe the appearance of leiomyomas?

Answer 20

Well demarkated with no necrosis or haemorrhagic areas. White tumours with whorled cut surface.
Microscopically resembles normal smooth muscle.

Question 21

What is the medical management of leiomyomas?

Answer 21

Progesterone secreting IUS
Hormonal therapies
Transexamic acid
GnRH agonists.

Question 22

What is the surgical management of leiomyomas?

Answer 22

Uterine artery embolisation (blocks the artery that feeds it)
Myomectomy
Hysterectomy

Question 23

What is a Leiomyosarcoma?

Answer 23

An uncommon malignant tumour of the myometrium

Question 24

What is the peak incidence of leiomyosarcoma?

Answer 24

40-60

Question 25

What are the symptoms of leiomyosarcoma?

Answer 25

Initially none, then bleeding and pain.

Question 26

Describe the pathology of a leiomyosarcoma?

Answer 26

Can be a bulky invasive mass or a polypoid mass with necrosis, haemorrhagic areas.
Microscopically has cytological atypia, necrosis, mitotic activity, infiltrative margin.

Question 27

Where does leiomyosarcoma commonly metastasise to?

Answer 27

Liver lungs and brain.

Question 28

What is an Endometrial Stromal Sarcoma (ESS)?

Answer 28

A group of tumours in the endometrial stroma. Very rare, can be low grade or high grade.

Question 29

Describe the pathology of ESS?

Answer 29

Both have diffuse infiltrative worm like growths. Many mitoses.

Question 30

What is gestational trophoblasstic disease?

Answer 30

An umberela term for several conditions including hydatidiform moles (partial and complete), and malignant tuours such as choriocarcinoma.

Question 31

How do hydatidiform moles presents?

Answer 31

Either as spontaneous miscarriage or abnormalities detected on ultrasound.

Question 32

What is a partial hydatidiform mole?

What does microscopy show?

Answer 32

One egg fertilised by 2 sperm, resulting in a triploid karyotype.
Microscopy shows oedematous villi and trophoblast proliferation. There is a risk of the mole invading and destroying the uterus.

Question 33

What is a complete hydatidiform mole?

What does microscopy show?

Answer 33

One egg with no genetic material being fertilised by one sperm that duplicates its genetic material, OR 2 sperm.
Diploid karyotype usually 46XX.
Microscopy: Large oedematous villi with central cisterns and circumferential trophoblast proliferation.
Risk of invasive mole or choriocarcinoma.

Question 34

How do we diagnose moles and choriocarcinoma?

Answer 34

Send products of conception to pathology. They can confirm placentally derived chorionic villi or an implantation site.