Theme 6: Uterine pathology and polycystic ovarian syndrome Flashcards
What is endometriosis?
- ectopic endometrial tissue
- normal tissue in an abnormal location
- most commonly in pelvis but can be found in chest cavity/lungs
- extra-uterine endometrial tissue can occur virtually anywhere
Who gets endometriosis?
6-10% of women aged 30-40 years
What is the aetiology behind endometriosis?
unknown but:
-regurgitation theory –> during the menstrual cycle, tissue is shed through the fallopian tubes into the pelvic cavity
- metaplasia theory - normal tissue undergoes metaplastic transformation
- stem cell theory - stem cells at different locations differentiate into endometrial tissue
- metastasis theory - spreads along lymphatic system
What is the pathogenesis of endometriosis?
bleeding into tissues then fibrosis
What are the clinical features of endometriosis?
- 25% asymptomatic
- dysmenorrhoea (painful menstruation)
- dyspareunia (pain during sex)
- subfertility
- pain on passing stool
- dysuria
What is the gold standard test for endometriosis?
laparoscopy
How do we treat endometriosis?
- NSAIDs are first line (as endometriosis can be asymptomatic, cause minor problems or be debilitating)
- progesterone only or combined contraceptive pills
- surgical ablation of lesions is definitive treatment
What is endometrial polyps?
localised, sessile (immobile) overgrowth of endometrial tissue that projects into the uterine cavity
Explain the aetiology of endometrial polyps
<10% of women aged 40-50 but incidence rises with age (the risk of malignancy of polyps also rises with age although still rare)
Explain the aetiology and pathogenesis of endometrial polyps
aetiology: unknown
pathogenesis: inappropriate reaction of foci of endometrium to oestrogenic stimulation
What are the clinical features of endometrial polyps?
often asymptomatic
- intermenstrual/post-menopausal bleeding
- menorrhagia (heavy periods)
- dysmenorrhoea (painful periods)
What is the standard investigation for endometrial polyps?
USS
What would most gynacologists recommend if a patient with endometrial polyps presents with symptoms
removal of polyps
What are the 3 layers of the uterus (from inner to outer)
- endometrium
- myometrium
- perimetrium
What are the two layers of the endometrium?
- stratum functionalis - the inner functional layer
2. stratum basalis - the outer layer that regenerates to form the functional layer after each menstrual cycle
What is endometrial hyperplasia?
- results when the endometrium is exposed to high levels of oestrogen for a long period of time
- leads to an excessive growth of endometrial glands relative to stroma
What are the levels of oestrogen and progesterone like in endometrial hyperplasia?
- high oestrogen
- low progesterone
What is the epidemiology of endometrial hyperplasia?
> 40 years
3x higher incidence than endometrial cancer
What pre-disposing factors can cause endometrial hyperplasia
obesity estrogen secreting tumours PCOS Early menarche late menopause nulliparous oestrogen pills tamoxifen PTEN mutation
What is the pathogenesis of endometrial hyperplasia?
unopposed estrogenic stimulation of the endometrium
What are the clinical features of endometrial hyperplasia?
abnormal bleeding (HMB, IMB, PMB and sometimes amenorrhea)
What is the most common cancer of the female reproductive system?
endometrial cancer
Endometrial hyperplasia results in an increased risk of what condition??
endometrial cancer
Why can excess oestrogen occur if you are obese?
adipose tissue allows conversion of androgen to oestrogen (same as in PCOS and endometrial hyperplasia)
Why might women with early menarche, late menopause or nulliparrous be at increased risk of endometrial hyperplasia?
more ovulation cycles –> more oestrogen
What is hypoplastic change of the endometrial functional layer?
if there is increased thickening of the endometrial functional layer
What is the difference between simple and complex hyperplasia?
simple hyperplasia = if the gland: stromal ratio is maintained
complex hyperplasia = if the gland: stromal ratio changes
complex hyperplasia is more likely to be assoicated with nuclear atypia and progess to endometrial cancer
What is the most important factor for cancer progression?
nuclear atypia
How do we treat endometrial hyperplasia?
Eliminating excess oestrogen by:
- weight loss
- stopping unopposed oestrogen therapy
- correcting anovulation
- progesterone medications (counteracts oestrogen)
- hysterectomy –> surgical removal of the uterus eliminates endometrial cancer risk
What are the two types of endometrial cancer?
- 75% - endometrioid adenocarcinoma - natural progression of endometrial hyperplasia onto its malignant transformation
- 25% - serous - independent of endometrial hyperplasia
What is the aetiology of type 1 and 2 endometrial cancer?
- unopposed E2/ hyperplasia progression
2. Mutation
What are the clinical features of endometrial cancer?
- similar to endometrial hyperplasia
- sometimes present with features of advanced metastatic disease e.g abdominal or pelvic pain, bloating, feeling full quickly when eating, changes in bowel or bladder habits, weight loss, pallor, loss of appetite
Which type of endometrial cancer is associated with endometrial atrophy?
type 2 (serous)
Which mutations might lead to type 1 endometrial cancer?
PTEN
KRAS
Which mutations might lead to type 2 endometrial cancer?
P53
What is the E2 status of type 1 and 2 endometrial cancer?
Type 1 - E2 +ve
Type 2 - E2 -ve
Explain the different FIGO stages of endometrial cancer
Stage 1 - confined to uterus
Stage 2 - Cervix is involved
Stage 3 - Anywhere in respiratory tract involved - ovary, vagina and lymph nodes
Stage 4 - mets
What is lynch syndrome?
- a.k.a HNPCC (hereditary non-polyposis colorectal cancer)
- autosomal dominant inherited cancer predisposition syndrome
- causes an individual to have a high lifetime risk of colorectal cancer
- women with lynch syndrome also have a high lifetime risk of endometrial and ovarian cancer
Why does Lynch syndrome occur?
due to the inheritance of an alteration in one of the mismatch repair genes (MLH1, MSH2, MSH6 and PMS2)
What are myometrial tumours?
benign smooth muscle tumours of the myometrium
What is the most common gynaecological condition?
myometrial tumour - black women increased risk
What is the pathogenesis behind myometrial tumours?
benign monoclonal proliferation of smooth muscle cells
What are the clinical features of myometrial tumours?
- present in later reproductive life
- low parity
- vast majority are asymptomatic
- irregular bleeding
- abdominal mass
- bladder problems
- abnormal uterine bleeding
What are the 3 types of myometrial bleeding?
- submucosal
- intramural
- subserosal
What is polycystic ovarian syndrome?
an endocrine disorder characterised by hyperandrogenism, ovulatory dysfunction, menstrual irregularities, +/- polycystic ovaries and insulin resistance affecting women of reproductive age
What is the pathogenesis of polycystic ovarian syndrome?
a dysfunction in the hypothalamic-pituitary-ovarian axis –> too much LH and no LH surge therefore no ovulation
What are the symptoms of increased androstenedione?
- hirsuitism (growth of male-like hair)
- male pattern baldness
- acne (face, chest and back)
What are the symptoms of PCOS?
- infertility
- excessive body hair growth
- weight changes and trouble losing weight
- ovarian cysts
- low sex drive
- irregular or missed periods
- male pattern baldness
- high testosterone levels
- insulin resistance
- fatigue
- acne
- mood changes
What are the hormone changes in PCOS?
- increased LH: FSH ratio
- increased androgen
What are the treatments for PCOS?
- weight loss (decreases insulin resistance)
- metformin (diabetes)
- spironolactone (treats hirsutism)
- oral contraceptive
- clomiphene citrate (induces ovulation
