uterine and ovarian pathology

Question 1

Endometriosis

Answer 1

Inflammation of the endometrium. Peritoneum similar to endometrium so get some ectopic bits.
Aetiology: E.g. ectopic endometrium  metastaisis/regurgitation  bleeding into tissues  fibrosis.
Epidemiology: 6-10% women 30-40yrs.
Symptoms: 25% asymptomatic, others have pelvic pain, dysmenorrhoea, and pain on passing stool, dysuria.
Treatment: medical with progesterone antagonists or surgical with ablation. Linked to ectopic pregnancy.

Question 2

Endometrial polyps: E2 dependent uterine overgrowth

Answer 2

Epidemiology: 10% women 40-50’s. Often asymptomatic, intermenstrual and post menstrual bleeding, menorrhagia, dysmenorrhea.
Investigations: hysteroscopy. 1% are malignant

Question 3

Leiomyoma (uterine fibroids)

Answer 3

Benign myometrial tumours with eogestrogen/progesterone dependent growth.
20% women 30-50 have this. They are non-cancerous growths of the uterus.
Asymtomatic, Menometrorrhagia (prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal = combination of metrorrhagia and menorrhagia), pregnancy issues.
Treatment: NSAIDS, iron to treat deficiency, artery embolization, and ablation. Malignancy risk 0.01%.

Question 4

Endometrial hyperplasia Excessive endometrial proliferation (more E2, less P4)

Answer 4

Types: Simple non-atypical, simple atypical and Complex non-atypical, complex atypical
Risk factors: obesity, exogenous E2, PCOS, E2-producing tumours, tamoxifen (treats breast cancer but increases risk of developing endometrial cancer), Hereditary colorectal cancer linked also (PTEN mutations)
Symptoms of abnormal bleeding. Investigate with hysteroscopy and biopsy.
Treatment: progesterone and IUS.

Question 5

Endometrial cancer: adenocarcinoma

Answer 5

Most common cancer of female genital tract- 9,200 new cases a year in UK and 2,500 deaths.
Presents with pain if late. Investigations with biopsy, hysteroscopy.
Treatment: hysterectomy, progesterone and chemo.
Staging FIGO 1-4.Treat with medical progesterone, surgery and adjuvant therapy (chemo/radio).
Prognosis: stage 1 = 90% 5 year survival. Stage 2-3 = <50%.

Question 6

Epithelial tumours

Answer 6

Epithelial tumours: Most common group of ovarian neoplasms (90%).
3 major carcinoma histologic types:
Serous (tubal), Mucinous (endocervical) and Endometrioid (endometrium)
Each type contains benign/ borderline/ malignant variants. Benign tumours subclassified based on components; cystic (cystadenomas), fibrous (adenofibromas), cystic and fibrous (cystadenofibromas). Malignant epithelial tumours  cystadenocarcinomas

Question 7

Polycystic ovarian syndrome

Answer 7

Endocrine disorder; hyperandrogenism, menstrual abnormalities, polycystic ovaries
Epidemiology: 6-10% women (20-30% have polycystic ovaries.
Symptoms: irregular periods >35 days, hyperandrogenism and 2/3 of polycystic ovaries.
Treatment: weight loss, metformin drugs and surgical ovarian drilling.
Linked to infertility, endometrial hyperplasia /adenocarcinoma.
Overload in E2 and testosterone.
More LH and less FSH.

Question 8

Gonadal failure

Answer 8

Primary failure of gonads HYPEgonadotrophic HYPOgonadism.
Congenital – turners, klinefelters Acquired – infection, surgery chemo, drugs.
Secondary failure of gonads  HYPOgonadotrophic HYPOgonadism.
Sheehan syndrome – pituitary tumours, brain injury

Question 9

Germ cell tumours:

Answer 9

15-20% all ovarian tumours. Chemosensitive.
Germinomatous: Dysgerminomas (differentiation - oogonia, malignant, chemosensitive)
Non-germinomatous:
Teratomas (differentiation towards multiple germ layers). Most mature (benign; 1% malignant transformation)
Yolk sac tumours (differentiation towards extraembryonic yolk: sac, malignant, chemosensitive).
Choriocarcinomas (differentiation - placenta, malignant, often unresponsive). Rx: surgical +/- chemo-/radiotherapy.

Question 10

Sex cord stromal tumours

Answer 10

Rare; arise from ovarian stroma = derived from sex cord of embryonic gonad
Can generate cells from the opposite sex.
Thecoma/ fibrothecoma/ fibroma: Benign, thecomas and fibrothecomas produce E2 (also rarely androgens), fibromas hormonally inactive. Comprised of spindle cells (plump spindle cells with lipid droplets = thecoma appearance). Meig’s syndrome = ovarian tumour, right sided hydrothorax, ascites
Granulosa cell tumours: Low grade malignant, produces E2
Sertoli-Leydig cell tumours: Produces androgens; 10-25% malignant

Question 11

Ovarian cancer

Answer 11

Epidemiology: 2nd commonest gynae cancer; >7,100 women >4,300 deaths/yr UK; 80% >50’s; 80-90% epithelial
Risk factors: FH, ↑age, PMH breast cancer, smoking. E2-only HRT, Lynch II syndrome, obesity, null parity.
Protective factors: OCP, breastfeeding, hysterectomy.
Symptoms: pain, symptoms, bloating, weight loss, urinary frequency, anorexia. Staging = FIGO 1-4.
Prognosis: 5 years 43% survival.

Question 12

Ovarian metastatic tumours:

Answer 12

Müllerian tumours (most common): uterus, fallopian tube, pelvic peritoneum, contralateral ovary
Non-Müllerian tumours:
Lymphatic/ haematogenous spread: GI tract: Large bowel, stomach (Krukenberg tumour), pancreatobiliary
Breast, Melanoma and Less commonly, kidney and lung. Direct extension: bladder, rectal.
Metastatic tumours are confirmed histologically; prognosis is typically poor.

Question 13

Endometriosis

Answer 13

spread of endometrium into the pelvis

Question 14

Endometritis

Answer 14

acute/chronic inflammation (usually due to infection)

Question 15

Endometrial polyps

Answer 15

local endometrial overgrowth

Question 16

Leiomyomata:

Answer 16

benign smooth muscle tumours of the myometrium

Question 17

Endometrial hyperplasia

Answer 17

oestrogenic stimulation of endometrial proliferation; continuous stimulation may lead to atypical hyperplasia and carcinoma

Question 18

Endometrial cancer

Answer 18

commonest gynae cancer with increasing incidence; two types

Question 19

PCOS

Answer 19

common, multiple follicular cysts, hyperandrogenism, menstrual irregularity

Question 20

Gonadal failure

Answer 20

primary (ovarian) and secondary (hypothalamus/pituitary)

Question 21

Ovarian neoplasms

Answer 21

90% epithelial and based on cell type; benign cystadenoma  borderline  malignant cystadenocarcinoma progression; germ cell tumours; sex cord stromal tumours; metastatic tumours