Pathology of Uterine Structures Ch 43 Flashcards
Most common congenital abnormality of female genital tract is
imperforate hymen resulting in obstruction.
Obstruction of uterus and/or vagina may result in:
- hydrometra
- hematometra
- pyometra
Hydrometra
accumulation of fluid
Hematometra
accumulation of blood
Pyometra
accumulation of pus
Solid masses are
rare in vagina
Most common vaginal masses are
adenocarcinoma and rhabdomyosarcoma
Solid mass with possible areas of
necrosis
adenocarcinoma and rhabdomyosarcoma are best seen with
translabial scanning approach
Vaginal cuff seen in
post-surgical hysterectomy patients.
Upper size limit of normal vaginal cuff is
2.1 cm.
If cuff is larger or contains well-defined mass or areas of high echogenicity,
it should be regarded with suspicion for malignancy, especially in patient who
has previous history of cancer.
Nodular areas in vaginal cuff may be due to
postirradiation fibrosis.
Rectouterine Recess (Posterior Cul-De-Sac) AKA
Pouch of Douglas
Rectouterine Recess (Posterior Cul-De-Sac) frequent site for
intraperitoneal fluid collections
Fluid in cul-de-sac is a
normal finding in asymptomatic women and can be seen
during all phases of menstrual cycle.
Pathologic fluid collections may be associated with
ascites, blood resulting from
ruptured ectopic pregnancy, hemorrhagic cyst, or pus resulting from infection.
Pelvic abscesses and hematomas can also occur in the
cul-de-sac.
Benign Cervical Pathology
- Nabothian cysts
- cervical polyps
- Leiomyoma (Fibroid)
- Cervical Stenosis
Cervical polyps arises from
hyperplastic protrusion of epithelium of endocervix or ectocervix
Cervical polyps may be
pedunculated, projecting from cervix, or broad-based
Cervical polyps ultrasound does not
always detect
cervical polyps more prevalent in
late middle-aged women
Leiomyoma (Fibroid) small percentage occur in
cervix
U/S may assist in determining
location, size, etc.
Sonohysterography with leiomyoma (fibroid) may enhance
visualization
Cervical Stenosis
a cquired condition
cervical stenosis obstruction of cervical canal at internal or external os resulting from
- Radiation therapy
- Previous cone biopsy
- Postmenopausal cervical atrophy
- Chronic infection
- Laser or cryosurgery
- Cervical carcinoma
intracavitary fluid collections can be
readily seen on ultrasound and may be indirect indicator of cervical stenosis.
Menopausal patient with cervical stenosis may be
asymptomatic even though stenosis can produce a distended, fluid-filled uterus
Premenopausal patients with cervical stenosis may experience
abnormal bleeding, oligomenorrhea,
amenorrhea, cramping, dysmenorrhea, or
infertility.
Squamous cell carcinoma is the most common type of
cervical cancer.
Cervical Carcinoma precursors are
cervical dysplasias (mild, moderate, severe)
When full thickness of epithelium composed of undifferentiated neoplastic cells, lesion referred to as
carcinoma in situ
Detection of these abnormalities attributed to screening with
Papanicolaou (Pap) smears because most early lesions are asymptomatic
Advanced cervical cancer usually evident
clinically
cervical carcinomas affects
women of menstrual age
Clinical findings of cervical carcinoma
vaginal discharge or bleeding
Sonographic findings of cervical carcinoma
retrovesical mass, obstruction of ureters, invasion of bladder
Translabial or Transperineal Sonography
- 5.0- to 7.5-MHz sector or curvilinear transducer is covered with sterile
probe cover and applied to vestibule of vagina in sagittal plane. - Partial bladder filling may assist visualization of cervical area.
- Sagittal and Transverse
- Positioning patient with hips elevated, as in transvaginal approach, helps
displace pelvic gas and identify anatomy.
normal variations of uterus
- Bicornuate
- Didelphic
- Septate
- Arcuate
- Unicornuate
most common normal variations of uterus is
- Bicornuate
- Didelphic
- Septate
Leiomyomas (Fibroids) occurring in
about 20-30% of women over the age
of 30.
Leiomyomas (Fibroids) more prevalent in
African American women.
Leiomyomas (Fibroids) variable amounts of
fibrous connective tissue
degeneration occurs when a fibroid
outgrows their blood supply, calcifications may be seen
Clinical Findings of fibroids
enlarged uterus, patterns of irregular bleeding or heavy menstrual bleeding, pain, sensation of pelvic pressure
fibroids may contribute to infertility by
distorting fallopian tube or endo cavity
Most Common gynecological tumor,
Leiomyomas (Fibroids)
Myomas are
estrogen-dependent
fibroids may
increase in size during pregnancy.
fibroids rarely develop in
postmenopausal women; most stabilize or decrease in size following
menopause because of lack of estrogen stimulation
fibroids may increase in size for patients
undergoing hormone replacement therapy
fibroids rapid increase in fibroid size may be
suspicious for neoplasm, especially in postmenopausal women
Uterine Locations of Myomas
- Submucosal
- Intramural
- Subserosal
- Pedunculated
- Intracavitary
Submucosal
displacing or distorting endometrial cavity with subsequent irregular or heavy menstrual bleeding
Intramural
confined to myometrium; most common type
Subserosal
projecting from peritoneal surface of uterus, may enlarge and cause pressure on adjacent organs
Pedunculated
can appear as extrauterine masses with stalk arising from uterus
Intracavitary
usually pedunculated and confined to endometrium
In cases of infertility and submucosal myomas,
myomectomy (surgical removal
of fibroid) is often the preferred treatment.
In cases of menorrhagia, possible treatments of fibroids are
- Least invasive treatment is hormonal suppression to stop the bleeding
- Endometrial ablation
- Uterine artery embolization (UAE)
- High intensity focused ultrasound (HIFU)
most common cause of uterine calcifications.
fibroids
Less common uterine calcifications
arcuate artery calcification at periphery of
uterus
uterine calcifications are thought to occur as
consequence of calcific sclerosis within these vessels
uterine calcifications can indicate
underlying disease, such as diabetes mellitus,
hypertension, or chronic renal failure
Adenomyosis is the
ectopic occurrence of endometrial tissue within myometrium; more common in posterior aspect
Adenomyosis is
- Benign disease
- Diffuse or focal
Adenomyosis sonographically presents as
- bulky enlarged uterus without focal mass
- heterogeneous uterus
- thickening of posterior myometrium
- myometrial cysts
Hemorrhage in islands of endometrial tissue appears as
small hypoechoic myometrial cysts.
Fluid nature of lesions produces
increased posterior acoustic enhancement rather than the degree of attenuation normally seen posterior to uterus.
Focal adenomyosis sometimes called
adenomyoma, referring to isolated implants that typically cause reactive
hypertrophy of surrounding myometrium
implants produce
diffuse uterine enlargement
estimated 60% women with adenomyosis experience
- Abnormal excessive uterine bleeding (hypermenorrhea)
- Prolonged/profuse uterine bleeding (menorrhagia)
- Irregular, acyclic bleeding (metrorrhea)
Approximately 25% of patients with adenomyosis also suffer from
pelvic pain during menstruation
(dysmenorrhea).
Uterine arteriovenous malformations
(AVMs) consist of
vascular plexus of arteries and veins.
Arteriovenous Malformations
Rare; usually involving myometrium and
rarely endometrium
Arteriovenous Malformations are
Congenital or acquired due to pelvic trauma,
surgery, or gestational trophoblastic
neoplasia
Clinically Arteriovenous Malformations women of childbearing years have
metrorrhagia with blood loss and anemia.
Arteriovenous Malformations diagnosis critical because
dilation and curettage may lead to catastrophic hemorrhaging.
Arteriovenous Malformations:
Sonographic Findings
- Tortuous, anechoic structures seen within the pelvis.
- Uterine AVMs may appear as subtle myometrial inhomogeneity, tubular spaces within myometrium, intramural uterine mass, endometrial or cervical mass, and sometimes as prominent parametrial vessels.
- Color Doppler is diagnostic to show blood flow within anechoic structures.
- May be florid-colored mosaic pattern with apparent flow reversals and areas of color aliasing.
- Spectral Doppler shows high-velocity, low-resistance arterial flow coupled with high-velocity venous flow with arterial component.
Uterine Leiomyosarcoma
Rare, solid tumor arising from myometrium or endometrium
Uterine Leiomyosarcoma commonly in
fundus of uterus
Uterine Leiomyosarcoma most common in
women 40 to 60 years of age
Uterine Leiomyosarcoma has
Rapid growth
Sarcoma botryoides:
very rare condition in children characterized by grapelike clusters of tumor mass
Uterine Leiomyosarcoma: Sonographic Findings
- Leiomyosarcoma may resemble myomas or
endometrial carcinoma with features of solid
or mixed-solid and cystic texture. - Clinically, rapid enlargement of solid uterine
mass in perimenopausal or postmenopausal
patient raises concern about development of
malignancy.
Tamoxifen is a
partial estrogen receptor antagonist used in postmenopausal women with estrogen
receptor positive breast cancer.
Abnormally thick endometrium could result
from:
- Early intrauterine pregnancy
- Gestational trophoblastic disease
- Endometrial hyperplasia
- Secretory endometrium
- Estrogen replacement therapy
- Polyps
- Endometrial carcinoma
Many endometrial pathologies, such as
hyperplasia, polyps and carcinoma, can cause
abnormal bleeding, especially in
postmenopausal patient.
Endometrial canal is landmark for
identification of long axis of uterus.
Echogenicity of endometrial tissue compared with
homogeneous, medium-level echogenicity of middle layer of myometrium.
Fluid, if present, should not be
included in endometrial measurements.
Disorders of endometrium may also occur in
menopausal patients with breast cancer receiving tamoxifen therapy.
Endometrial Hyperplasia follows
prolonged estrogenic stimulation
Endometrial Hyperplasia May be precursor
of endometrial cancer
Endometrial Hyperplasia Sonographic findings:
abnormal thickening of
endometrium
Endometrial Hyperplasia majority of women with postmenopausal uterine bleeding are
experiencing endometrial atrophy.
Endometrial Hyperplasia on transvaginal sonography,
atrophic endometrium
is thin, measuring <5 mm.
If postmenopausal patient has irregular bleeding and thickened endometrium,
may warrant sonohysterography procedure and/or endometrial biopsy
Patients with endometrial polyps may be
asymptomatic or present with uterine bleeding.
Histologically, polyps are overgrowths of
endometrial tissue covered by epithelium.
Endometrial Polyps may be
pedunculated, broad-based, or have a thin stalk.
Endometrial Polyps typically cause
diffuse or focal endometrial thickening; more frequently seen in perimenopausal and postmenopausal women.
Endometrial Polyps in menstruating women, may be associated with
menometrorrhagia or infertility.
Endometrial Polyps: Sonographic Findings
- Represented by hypoechoic or isoechoic
region within hyperechoic endometrium - Initially may appear as nonspecific
echogenic endometrial thickening - May be diffuse or focal and may also
appear as round echogenic mass within
endometrial cavity
Endometritis is
an infection within endometrium of the uterus.
Endometrial thickening or fluid may indicate
endometritis.
Endometritis it occurs most often in association
with PID, in postpartum state, or
following instrumentation of uterus, and may be seen with an IUD.
With a pelvic infection,
uterus is conduit for infectious spread to
tubes and adnexa.
Clinically endometritis patient has
intense pelvic pain; low back pain and fever;
dysmenorrhea; menorrhagia; sterility; constipation
Endometritis: Sonographic Findings
- Endometrium appears prominent, irregular, or both, with small amount of endometrial fluid.
- Pus may be demonstrated in cul-de-sac as echogenic particles or debris.
- Enlarged ovaries with multiple cysts and indistinct margins may be seen secondary to periovarian inflammation.
Common condition in which functioning
endometrial tissue is present outside the uterus.
Ectopic tissue can be found almost anywhere in pelvis, including
- ovary
- fallopian tube
- broad ligament
- external surface of uteru
- scattered over peritoneum
- cul-de-sac
- bladder
Endometrial tissue cyclically
bleeds and proliferates.
Endometriosis rarely diagnosed by
sonography
Intrauterine synechiae
(endometrial adhesions, seen with Asherman’s syndrome)
Synechiae found in women with
posttraumatic or postsurgical histories
Synechiae includes
uterine curettage and may be cause of infertility or recurrent pregnancy loss
synechiae sono findings -
- Bright echoes within endometrial cavity
- Diagnosis difficult unless fluid distending endometrial cavity
- Is best seen during secretory phase when endometrium more hyperechoic
- more easily seen in gravid uterus where they appear as hyperechoic band traversing uterus
from anterior to posterior
demonstration of
myometrial invasion clear evidence for endometrial carcinoma
TVS demonstrates
myometrial invasion as thickening and irregularity of central endometrial interface with echogenic or hypoechoic patterns combined with infiltration of hyperdense structures in myometrium.
endometrial carcinoma may
obstruct endometrial canal, resulting in hydrometra or hematometra
endometrial carcinoma intactness of subendometrial halo (inner layer of myometrium) usually indicates
superficial invasion.
endometrial carcinoma obliteration of halo indicative of
deep invasion
estrogen stimulation associated with
estrogen stimulation
endometrial carcinoma has
secondary effects on endometrium
endometrial carcinoma clinical
postmenopausal bleeding
endometrial carcinoma sonographic findings
- Prominent endometrial complex; enlarged uterus with irregular areas of low-level echoes
Small fluid collections can occur
with ectopic pregnancy, endometritis,
degenerating myomas, and recent
abortion.
Large fluid collections should be
regarded with suspicion
Before menstruation,
accumulation of secretions referred to as hydrometrocolpos.
Following menstruation,
hematometrocolpos results from presence of
retained menstrual blood.
Pyometra more likely to occur with
uterine cancer.
Large Endometrial Fluid Collections Clinical Findings:
- Abdominal pain with possible enlarged abdominal mass
- May or may not have vaginal bleeding
- Presence of fever suggests infection
- Lab results show elevated WBC
Large Endometrial Fluid Collections Sonographic Findings
- Large endometrial cavity fluid collection is that of centrally cystic, round, moderately enlarged uterus
- May contain echogenic material if pus or blood present
IUD sonographically
Appear as highly echogenic linear structure within endo canal
Beneficial Effects of Hormones Estrogen
- Alleviates menopausal symptoms (hot flashes, night sweats, painful intercourse)
- Reduces risk of osteoporosis, vertebral and
hip fractures - Reduces risk of heart attacks, strokes
Beneficial Effects of Hormones Progesterone
- Produces endometrial atrophy
- Reduces risk of endometrial
hyperplasia/cancer
Negative Effects of Hormones Estrogen
- Increases risk of endometrial hyperplasia/cancer
Negative Effects of Hormones Progesterone
- Increases risk of breast cancer
- Causes irritability, depression, breast tenderness in some women
Differential Diagnoses Enlarged Uterus
- Pregnancy
- Postpartum
- Leiomyoma
- Adenomyosis
- Bicornuate or didelphic uterus
Differential Diagnoses Uterine Tumor
- Leiomyoma
- Carcinoma
Differential Diagnoses Endometrial Fluid
- Endometritis
- Retained products of conception
- Pelvic inflammatory disease
- Cervical obstruction
Differential Diagnoses Endometrial Shadowing
- Gas (abscess)
- Intrauterine device
- Calcified myomas or vessels
- Retained products of conception
Differential Diagnoses Thickened Endometrium
- Early intrauterine pregnancy
- Endometrial hyperplasia
- Retained products of conception or incomplete abortion
- Trophoblastic disease
- Endometritis
- Adhesions
- Polyps
- Inflammatory disease
- Endometrial carcinoma
