The endometrium & its pathology I&II Flashcards
What are the layers of endometrium?
- compactum
- spongiosum
-basalis
-junctional zone
what is the role of inflammatory cells?
inflammatory cells helps with implantation and menstruation
junctional layer
between basalis and myometrium
one cell thick
bimordial pattern of behaviour - partly basal and partly myometrial
What layers do you lose during ovulation?
- compactum
- spongiosum
-basalis - anchors everything, you lose everything above it.
What causes bleeding?
drop in oesterogen and progesterone leads to bleeding in menustration
Menstruation
- 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
What brings blood to endometrium?
Spiral artery
during menstruation they constrict and this prevents blood getting into the endometrium so layers start to shed
What are different factors involved to control bleeding?
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
For normal menstruation you need a balance and regulation between ….
- inflammatory cascade
- coagulation cascade
- fibrinolysis cascade
menorrhagia
too much bleeding
polymenorrhoea
bleeding too often more than one cycle every month
amenorrhoea
not regular monthly periods
Intermenustrual bleeding (IMB)
bleeding in between periods
Post -cotial bleeding (PCB)
bleeding straight after intercourse
What are types of abnormal uterine bleeding(AUB)?
- acute
- intermittent
- chronic
What are different factors of AUB?
- frequency
-regularity - duration
-volume
what are examples of structural problems of the endometrium that cause abnormal uterine bleeding?
- polyp
-adenomyosis
-leiomyoma
-malignancy
(PALM)
what are examples of non- structural problems of the endometrium that cause abnormal uterine bleeding?
- coaggulation
- ovulatory dysfunction
-endometrial - latrogenic
-not otherwise classified
(COIN)
What are some pathological causes of abnormal vaginal bleeding?
- 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)
What are some intrauterine structural abnormalities and why are they important?
-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?
Abnormal bleeding -aims
- 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
Endometrial abnormalities
- dysfunctional uterine bleeding
- endometrial polyps
-endometrial hyperplasia - endometrial hyperplasia with atypia (mild to severe)
- endomterial adenocarcinoma
What can it be if a woman presenting with menorrhagia and doesnt have obivous pathological or structural cause?
-molecular level problem , cellular dysfunction
- it is a diagnosis of exclusion (DUB)
Where does DUB occur?
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
What are polyps?
- benign (adenomas are malignant)
- focal/ individual problem
-rest of endometrium is normal
Clinical examination - points in history:
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
Why do you experience pain in periods?
- ischemia
- prostaglandins involved
overweight - why is too much oestrogen a problem?
testosterone -> oestrogen in fat tissue leads to breast development in males
peripheral conversion (from ovaries) testosterone converted to oestrogen
clinical examination
- BMI
-abdomen : distension, scar, pain, masses - bimanual : uterine size, adnexal masses, pain
- cervix : polyps, suspect lesions
abnormal bleeding investigation
- 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
When do you perform hysteroscopy?
- 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
positives of transvaginal sonography (TVS)
- 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
negatives of TVS
- 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
what is the difference between polyps and fibroids?
polyps - epithelial , lighter in colour
fibroids - muscular, darker in colour
What are risk factors for significant endometrial abnormality?
- 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
endometrial hyperplasia
too much tissue growth - overgrowth and bleed alot more - initially simple but slowly becomes atypical with
unopposed E2 then becomes a carcinoma
endometrial hyperplasia
too much tissue growth
unopposed oestrogen in obesity?
- 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
Why is unopposed oestrogen bad?
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
what factors do you need to consider when giving treatments for DUB?
- does she need or want treatment?
- does she need contraception/desire pregnancy?
-how much is the problem affecting her quality of life?
What are non-hormonal options for treating DUB?
=> 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!
What are hormonal options for treating DUB?
- 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
What are some treatment options for DUB?
- surgery - for failed medical treatment
-Endometrial resection/ ablation - Hysterectomy : vaginal/ abdominal
- Remove ovaries?
Menorrhagia management
See image
Treatments for polyps and fibroids
polyps: surgery TCRP
Fibroids:
- medical Mirena IUS or Kyleena
-surgery TCRF/ Myomectomy
- Hysterectomy : total/ subtotal abdominal, vaginal
Treatments for polyps and fibroids
polyps: surgery TCRP
Fibroids:
- medical Mirena IUS or Kyleena
-surgery TCRF/ Myomectomy
- Hysterectomy : total/ subtotal abdominal, vaginal
What is the method of examining real cases?
- 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?
Real cases
- 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?
Case 1- TVS normal, no polyps or fibroids , no contraception interfering with cycle
Diagnosis : DUB
case 1 : treatment
volume control
- tranexamic acid
- mefanamic acid
- mirena IUS
Case 2: <45 y/o, TVS normal, no polys or fibroid, heavy period, 65 days cycle
Diagnosis : DUB , abnormal cycle so anovulatory bc of 65 days cycle
case 2: treatment
- volume and cycle control
volume:
-tranexamic acid - mefanamic acid
-mirena IUS
cycle control :
-combined oral contraceptive pill
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
- TVS
- polyps : that could be causing the IMB for last 6 months
- hysteroscopy - to remove the polyp
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
TVS - thickened endometrium - no discrete polyp seen
Endometrial biopsy
Endometrial abnormalities
- 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
