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reproduction > The endometrium & its pathology I&II > Flashcards

The endometrium & its pathology I&II Flashcards

1
Q

What are the layers of endometrium?

A
  • compactum
  • spongiosum
    -basalis
    -junctional zone
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2
Q

what is the role of inflammatory cells?

A

inflammatory cells helps with implantation and menstruation

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3
Q

junctional layer

A

between basalis and myometrium
one cell thick
bimordial pattern of behaviour - partly basal and partly myometrial

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4
Q

What layers do you lose during ovulation?

A
  • compactum
  • spongiosum
    -basalis - anchors everything, you lose everything above it.
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5
Q

What causes bleeding?

A

drop in oesterogen and progesterone leads to bleeding in menustration

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6
Q

Menstruation

A
  • initiated by withdrawl if E and P
    -local mediators PG’s and platelet aggregating factor (PAF)
    -spiral artery vasoconstriction
  • ischaemia and tissue damage
  • spiral artery relaxation
    -shedding of functional endometrium
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7
Q

What brings blood to endometrium?

A

Spiral artery
during menstruation they constrict and this prevents blood getting into the endometrium so layers start to shed

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8
Q

What are different factors involved to control bleeding?

A

PGs = E and I relaxes SM and F2a and Tx constricts
interleukins = IL -8 , 13, 16 bring in other inflammatory cells
-tissue necrosis factors TNF + platelet aggregating factors stops bleeding
-matrix metallo - proteinases - help re - build tissue
-coagulation/ fibrinolysis
-junctional zone - intrinsic error that can cause bleeding

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9
Q

For normal menstruation you need a balance and regulation between ….

A
  • inflammatory cascade
  • coagulation cascade
  • fibrinolysis cascade
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10
Q

menorrhagia

A

too much bleeding

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11
Q

polymenorrhoea

A

bleeding too often more than one cycle every month

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12
Q

amenorrhoea

A

not regular monthly periods

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13
Q

Intermenustrual bleeding (IMB)

A

bleeding in between periods

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14
Q

Post -cotial bleeding (PCB)

A

bleeding straight after intercourse

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15
Q

What are types of abnormal uterine bleeding(AUB)?

A
  1. acute
  2. intermittent
  3. chronic
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16
Q

What are different factors of AUB?

A
  • frequency
    -regularity
  • duration
    -volume
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17
Q

what are examples of structural problems of the endometrium that cause abnormal uterine bleeding?

A
  • polyp
    -adenomyosis
    -leiomyoma
    -malignancy
    (PALM)
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18
Q

what are examples of non- structural problems of the endometrium that cause abnormal uterine bleeding?

A
  • coaggulation
  • ovulatory dysfunction
    -endometrial
  • latrogenic
    -not otherwise classified
    (COIN)
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19
Q

What are some pathological causes of abnormal vaginal bleeding?

A
  • fibroids - submucous
  • adenomyosis
  • endometrial pathology - benign adenomas or polyps , hyperplasia , carcinoma
  • cervical pathology - polyps, carcinoma
  • cervical infection - chlamydia
  • pregnancy!!!
    => if its none of above, it is dysfunctional uterine bleeding (DUB)
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20
Q

What are some intrauterine structural abnormalities and why are they important?

A

-submucous fibroids (leiomyomas) are associated with a threefold increased risk of abnormal bleeding - invariably menorrhagia
- endometrial polyps (adenomas) are more frequent in women with menustrual disorders
- casual/ causal - diagnostic bias?

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21
Q

Abnormal bleeding -aims

A
  • exclude pregnancy
  • exclude cervical pathology
    exclude focal benign intracavity pathology (polyps, submucous fibroids)
  • consider other endometrial pathology (>45)
  • use the least invasive method to achieve this
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22
Q

Endometrial abnormalities

A
  • dysfunctional uterine bleeding
  • endometrial polyps
    -endometrial hyperplasia
  • endometrial hyperplasia with atypia (mild to severe)
  • endomterial adenocarcinoma
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23
Q

What can it be if a woman presenting with menorrhagia and doesnt have obivous pathological or structural cause?

A

-molecular level problem , cellular dysfunction
- it is a diagnosis of exclusion (DUB)

24
Q

Where does DUB occur?

A

PGs = E and I relaxes SM and F2a and Tx constricts
interleukins = IL -8 , 13, 16 bring in other inflammatory cells
-tissue necrosis factors TNF + platelet aggregating factors stops bleeding
-matrix metallo - proteinases - help re - build tissue
-coagulation/ fibrinolysis
-junctional zone - intrinsic error that can cause bleeding

25
Q

What are polyps?

A
  • benign (adenomas are malignant)
  • focal/ individual problem
    -rest of endometrium is normal
26
Q

Clinical examination - points in history:

A

Last menustrual period - was it normal?
regular or irregular periods
- cycle control (ovulation vs anovulation)
- heavy -clots, flooding?
-with bleeding between (IMB)?
-PCB
-pain
medication , smoker, smear, operations
contraception - hormonal vs non hormanl

27
Q

Why do you experience pain in periods?

A
  • ischemia
  • prostaglandins involved
28
Q

overweight - why is too much oestrogen a problem?

A

testosterone -> oestrogen in fat tissue leads to breast development in males
peripheral conversion (from ovaries) testosterone converted to oestrogen

29
Q

clinical examination

A
  • BMI
    -abdomen : distension, scar, pain, masses
  • bimanual : uterine size, adnexal masses, pain
  • cervix : polyps, suspect lesions
30
Q

abnormal bleeding investigation

A
  • pregnancy test where appropriate
    -Hb if heavy bleeding
  • swabs - endocervical (chylamydia)
  • cervical smear - only if due
  • transvaginal ultrasound
    +/- endometrial sampling
    +/- hysteroscopy - in patient or OPD
31
Q

When do you perform hysteroscopy?

A
  • putting camera in the uterus - put in saline to open up the walls of uterus
  • if TVS abnormal
  • Non - response to medical therapy
  • multiple risk factors for endometrial
32
Q

positives of transvaginal sonography (TVS)

A
  • can asses the relationship of fibroids to the cavity
  • has a high detection rate for polyps
    -assess function - anovulatory cycles
  • can reliably assess structures outside the uterus ( tubal and ovarian pathology)
  • well accepted by patients
  • relatively cheap with few complications
33
Q

negatives of TVS

A
  • periovulatory endometrium is hard to hide pathology in or imediately post menstrual to asses ET
    -cut off values for ET are arbitary in premenopausal women - @ 6mm post menstrual or 12 mm anytime in cycle
  • ultrasound is ideal for focal pathology but not good for predicting endometrial pathology - a biopsy is still needed in many cases
34
Q

what is the difference between polyps and fibroids?

A

polyps - epithelial , lighter in colour
fibroids - muscular, darker in colour

35
Q

What are risk factors for significant endometrial abnormality?

A
  • obesity (peripheral oestrogen production)
  • nullipartity - not having children
    -hormonal contraception
    -early menarche/ late menopause - length of E2 exposure - weak factor
    -Hypertension /Diabetes
    -anovulation , eg. PCOS
  • Genetics - FH breast/ endometrial/ colonic cancer - Lynch syndrome (HNPCC) , 5% genetic , 95% sporadic
36
Q

endometrial hyperplasia

A

too much tissue growth - overgrowth and bleed alot more - initially simple but slowly becomes atypical with
unopposed E2 then becomes a carcinoma

36
Q

endometrial hyperplasia

A

too much tissue growth

37
Q

unopposed oestrogen in obesity?

A
  • aromatase enzyme in adipose tissue which converts testosterone -> oestrogen so BMI is vital factor , the more adipose tissue the more conversion
  • so aromatase blocking medicine helps
38
Q

Why is unopposed oestrogen bad?

A

endometrial cancer risk is increased by exposure to endogenous and exogenous oestrogen
- obesity – peripheral conversion of androgen to oestrogen (aromatase)
- BMI is the most vital factor
- The more adipose tissue the more conversion
-chronic anovlation eg. PCOS
-follicular ovarian oestrogen production continues
-progesterone only produced after ovulation
-unopposed oestrogen
- over years leads to hyperplasia and sometimes cancer

39
Q

what factors do you need to consider when giving treatments for DUB?

A
  • does she need or want treatment?
  • does she need contraception/desire pregnancy?
    -how much is the problem affecting her quality of life?
40
Q

What are non-hormonal options for treating DUB?

A

=> non-hormonal needed for pregnant women bc hormones affects fetus,
1. tranexamic acid
- anti fibronyltic 40-50% reduction in blood loss
-corrects excessive fibrin breakdown in endometrium (affects plamsinogen action)
2. mefanamic acid 30% reduction in blood loss
- NSAID : corrects PG imbalance to allow normal vasoconstriction and PG imbalance to allow normal vasoconstriction and platelet aggregation
- Good for pain also!

41
Q

What are hormonal options for treating DUB?

A
  • Mirena IUS - 90% reduction blood loss
  • 30% amenorrheic
  • local high dose progestagen - thin endometrium
  • Kyleena new 4 year option

-COCP - 20 -30% reduction in blood loss
- Removes cyclincal events - thin endometrium

-Progestagens less beneficial for volume loss
- use to control cycle length in anovulatory DUB

42
Q

What are some treatment options for DUB?

A
  • surgery - for failed medical treatment
    -Endometrial resection/ ablation
  • Hysterectomy : vaginal/ abdominal
  • Remove ovaries?
43
Q

Menorrhagia management

A

See image

44
Q

Treatments for polyps and fibroids

A

polyps: surgery TCRP
Fibroids:
- medical Mirena IUS or Kyleena
-surgery TCRF/ Myomectomy
- Hysterectomy : total/ subtotal abdominal, vaginal

44
Q

Treatments for polyps and fibroids

A

polyps: surgery TCRP
Fibroids:
- medical Mirena IUS or Kyleena
-surgery TCRF/ Myomectomy
- Hysterectomy : total/ subtotal abdominal, vaginal

44
Q

What is the method of examining real cases?

A
  • How old is patient (<or> 45)
    -is the cycle regular?
    -is there erratic bleeding?</or>
  • Do you need to investigate the endometrium?
  • if so, how?
    -Treatment?
45
Q

Real cases

A
  • 41 year old - heavy periods for 9 months
  • bleeds for 9 days evry 28 reg (K= 9/28)
  • Affecting ability to go work

-NO IMB or PCB
- Smear 2 years ago - normal
- contraception - condoms
- no other relevant medical or family history

is she likely to have significant endometrial abnormality?
Any other likely diagnoses?

46
Q

Case 1- TVS normal, no polyps or fibroids , no contraception interfering with cycle

A

Diagnosis : DUB

47
Q

case 1 : treatment

A

volume control
- tranexamic acid
- mefanamic acid
- mirena IUS

48
Q

Case 2: <45 y/o, TVS normal, no polys or fibroid, heavy period, 65 days cycle

A

Diagnosis : DUB , abnormal cycle so anovulatory bc of 65 days cycle

49
Q

case 2: treatment

A
  • volume and cycle control
    volume:
    -tranexamic acid
  • mefanamic acid
    -mirena IUS
    cycle control :
    -combined oral contraceptive pill
50
Q

Case 3: 45 year old, IMB for last 6 months, K = 5/29 regular, contraception condoms , smear 1 year ago - normal , no other medical history notes

A
  • TVS
  • polyps : that could be causing the IMB for last 6 months
  • hysteroscopy - to remove the polyp
51
Q

Case 4: 51 y/o, heavy bleeding most days last 3 months, cycles used to be irregular (every 2-6 months), Gynae history of PCOS, Nulliparous, contraception - condoms, medical - obesity /NIDDM/ High BP

A

TVS - thickened endometrium - no discrete polyp seen
Endometrial biopsy

52
Q

Endometrial abnormalities

A
  • most menorrhagia is DUB and treatments reflect the dysfunction
  • exclude focal pathology - needs focal removal
  • beware erractic bleeding - pathology much more likely
  • TVS and biopsy +/- hysteroscopy diagnosis in nearly all

reproduction (29 decks)

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