T6-L2: Uterine Pathology

Question 1

For endometriosis give:

(a) Epidemiology
(b) Aetiology
(c) Pathogenesis
(d) Clinical features

Answer 1

Endometriosis is a condition in which there is ectopic endometrial tissue.

(a) 6-10% of women aged 30-40 years.
(b) Many theories regurgitation, metaplastic theory, stem cell theory and metastasis theory.
(c) Each month these tissues react in the same way as those in the uterus - building up, break down and bleeding.
(d) 25% asymptomatic, dysmenorrhea, dyspareunia, pelvic pain, pain during intercourse, subfertility, dysuria and pain on passing faeces

Question 2

What condition results due to inappropriate reaction of foci of endometrium to oestrogen stimulation?

Answer 2

Endometrial Polyps - This is a sessile/polypoid endometrial overgrowth which projects into the uterine cavity. It Is attached by a pedicle. Sessile (broad based) or pedunculated (narrow base). There can be multiple or single.

Affects less than 10% between 40-50 years. Incidence raises with age. 1 in 10 will have one in their lifetime.

Clinical features: Often asymptomatic, intermenstrual/post menopausal bleeding, menorrhagia, dysmenorrhoea. In 25% they are responsively for uterine bleeding.

Question 3

What layers make up the endometrium?

Answer 3

The outer Stratum Basalis and inner Startum Functionalis. The inner functional layer made of glands and supportive stroma. The outer thin basal layer is what regenerates to form the functional layer after each menstrual cycle.

Question 4

Which cells in the ovary secrete androgens?

Answer 4

Theca cells

Question 5

Which cells in the ovary secrete oestrogen?

Answer 5

Granuloma cells

Question 6

What is endometrial hyperplasia?

Answer 6

This is a condition of hyperplasia of the endometrium - most often occurs when the endometrium is exposed to high levels of oestrogen for a long period of time. There is a high growth of the glands relative to the stroma. This is often accompanied by low levels of progesterone. It is generally seen in women above 40. There is a three time more incidence compared to endometrial cancer.

Question 7

Give examples of causes of excess oestrogen.

Answer 7

• Obesity
• Drugs such as tamoxifen
• Contraceptive pills
• PCOS - high levels of androgens that get converted to oestrogen
• Tumours
• Endometrial hyperplasia
• Nulloparous women
• Early monarchy and late menopause

Question 8

How is the gene PTEN involved in endometrial hyperplasia?

Answer 8

Some patients develop endometrial hyperplasia independent from oestrogen production. Often seen in association with mutation in PTEN. When the gene PTEN (brake for the cell cycle) the cell become defective - the cells grow and proliferate out of control.

Question 9

What is the link between endometrial hyperplasia and endometrial cancer?

Answer 9

If there is increased thickening of the endometrium we say there is an endometrial change. If the gland to stromal ratio is maintained we say there is simple hyperplasia. However there is increased glandular growth compare to stroma we say there is complex hyperplasia. The risk of progression to endometrial cancer is 1% in simple hyperplasia but rises to 5% in complex hyperplasia.

If the nuclei in columnar cells look atypical - dark, large etc. - and there is simple hyperplasia, the risk increases to 10%. If there is nuclear atypia with complex hyperplasia the risk increases to 30%.

Question 10

What are the two types of endometrial cancer?

Answer 10

Type 1 - endometroid adenocarcinoma. Natural progression of endometrial hyperplasia to malignancy. Usually affects pre-and peri-menopausal ladies.

Features: Some patients present with PTEN or KRAS mutation; it is dependent on an oestrogen drive.

Type 2 - serous - this is independent of background endometrial hyperplasia. It is due to a background atrophy. It is seen in 25% of endometrial cancer patients. This affects mostly postmenopausal ladies.

Patients present with P53 mutation and It is independent of an oestrogen drive.

It is always a high grade tumour - it includes clear cell and serous.

Question 11

What are the clinical features of endometrial cancer?

Answer 11

Clinical features: similar to endometrial hyperplasia (particularly in type 1) and sometimes present with features of advanced metastatic disease (abdominal or pelvic pain, bloating, feeling full quickly when eating, and changes in bowel or bladder habits,weight loss, pallor, loss of appetite, etc.).

Question 12

What cancers does Lynch Syndrome increase the risk of?

Answer 12

• Colorectal cancer
• Endometrial Cancer
• Ovarian cancer
• Stomach Cancer

Question 13

What is a myometrial tumour?

Answer 13

These are smooth muscle tumour of the myometrium - second layer of the uterus. These are also called fibroid tumours.

Epidemiology: Most common gynecologically disease and most common benign tumours of the female genital tract. Black women have an increased risk of developing leiomyomas. 

Clinical features: more common in those with later reproductive life, low parity, vast majority are asymptomatic, - if large they can lead to irregular bleeding,  abdominal mass, bladder problems (pressure) or abnormal uterine bleeding.

Question 14

What is PCOS characterised by?

Answer 14

• Insulin intolerance
• High androgens
• Ovulary dysfunction
• Menstrual irregularities
• +/- Ovarian cysts

Question 15

What is epidemiology of PCOS?

Answer 15

6-10% of women of reproductive age