Uterine & Ovarian Pathology Flashcards
What is endometriosis?
a painful disorder in which tissue that lines the inside of the uterus - the endometrium - grows outside of the uterine cavity
ectopic endometrium leads to bleeding into tissues and fibrosis
How many women are affected by endometriosis?
What types of symptoms do they tend to have?
affects 6-10% of women aged between 30 - 40
25% are asymptomatic
other symptoms include:
- dysmenorrhoea
- dyspareunia
- pelvic pain
- subfertility
- pain on passing stool
- dysuria
What is meant by dyspareunia and dysmenorrhoea?
dysmenorrhoea:
- pain during menstruation
dyspareunia:
- difficult or painful sexual intercourse
What investigations are performed in endometriosis?
What are the medical and surgical treatments available?
laparoscopy is performed
medical treatment:
- COCP (combined oral contraceptive pill)
- GnRH agonists / antagonists
- progesterone antagonists
surgical:
- ablation / TAH-BSO
What is endometriosis linked to?
- ectopic pregnancy
- ovarian cancer
- IBD
What is a laproscopy?
it is a surgical diagnostic procedure used to examine the organs inside the abdomen
it is a low-risk, minimally invasive procedure that requires only small incisions
What is endometritis?
What causes it?
inflammation of the endometrium
chronic endometritis has a predominant picture of lymphocytes and plasma cells
it is caused by foreign bodies, chronic retained products and infection
What conditions are associated with endometritis?
- pelvic inflammatory disease (associated with chlamydia)
- retained gestational tissue
- endometrial TB
- IUCD (intrauterine contraceptive device) infection
What symptoms would someone with endometritis present with?
- abdominal / pelvic pain
- pyrexia
- discharge
- dysuria
- abnormal vaginal bleeding
What investigations and treatments are available for endometritis?
investigations:
- biochemistry / microbiology
- USS
treatment:
- analgesia
- antibiotics
- removal of the cause
What are endometrial polyps?
sessile / polypoid E2-dependent uterine overgrowths
they are small, soft growths on the inside of the uterus, or womb
they come from the endometrium
how many people are affected by endometrial polyps?
What investigations are performed?
affects < 10% of women (40 - 50s)
investigations performed are USS and hysteroscopy
What symptoms are present with endometrial polyps?
- often asymptomatic
- intermenstrual / post-menopausal bleeding
- menorrhagia
- dysmenorrhoea
What are the treatments for endometrial polyps?
What is the prognosis?
treatments:
- P4 / GnRH agonists
- curettage
prognosis:
- <1% are malignant
What is curettage?
a surgical process used to remove tissue from inside the uterus
What is leiomyoma (uterine fibroids)?
benign myometrial tumours with E2 / P4 - dependent growth
this is a benign smooth muscle tumour
How many people are affected by leiomyoma?
What are the risk factors?
affects 20% of women aged 30 - 50
risk factors:
- genetics
- nulliparity
- obesity
- polycystic ovary syndrome
- hypertension
What are the symptoms associated with leiomyoma?
- it is often asymptomatic
- menorrhagia - iron deficiency anaemia
- subfertility / pregnancy problems
What is the investigations and prognosis for leiomyoma?
investigations:
- bimanual examination
- USS
prognosis:
- menopausal regression
- malignancy risk of 0.01%
What are the treatments for leiomyoma?
medical:
- intrauterine system (IUS) contraceptive device
- NSAIDs
- oral contraceptive pill (OCP)
- P4
- Fe2+
non-medical:
- artery embolisation
- ablation
- total abdominal hysterectomy (TAH)
What is endometrial hyperplasia?
excessive endometrial proliferation due to increased E2 and decreased P4
the endometrium becomes abnormally thick
What are the risk factors for endometrial hyperplasia?
- obesity
- exogenous E2
- polycystic ovarian syndrome
- E2-producing tumours
- tamoxifen
- HNPCC (PTEN mutations)
What are the different types of endometrial hyperplasia?
simple non-atypical , simple atypical
complex non-atypical , complex atypical
What are the symptoms and investigations for endometrial hyperplasia?
symptoms:
- abnormal bleeding
- intermenstrual bleeding (between periods)
- postcoital bleeding
- post-menopausal bleeding
investigations:
- USS
- hysterectomy +/- biopsy
what are the treatments and prognosis for endometrial hyperplasia?
treatments:
- intrauterine system (IUS)
- P4 (progesterone)
- total abdominal hysterectomy
prognosis:
- endometrial adenocarcinoma
- regression
What are the stages involved in the malignant progression of hyperplasia?
normal
non-atypical hyperplasia:
- resembles normal proliferative endometrium
atypical hyperplasia:
- EIN - endometrial intraepithelial neoplasia
- this is the presence of cytological abnormality
endometrioid adenocarcinoma:
- invasion into the myometrium
What causes the malignant progression of hyperplasia?
it is caused by excess oestrogens from a variety of possible sources
What histological features are present at each stage in the malignant progression of hyperplasia?
non-atypical hyperplasia:
- there is an overgrowth of the whole endometrium revelaing a thick endometrium on ultrasound
complex hyperplasia:
- the proportion of glandular epithelium increases
- the epithelium can be folded into complex architectural patterns
atypical hyperplasia:
- cells show architecural changes of neoplasia with increased nuclear cytoplasmic ratio (bigger nuclei, less cytoplasm)
- irregular shapes
- increased numbers of mitoses
What is endometrial adenocarcinoma?
What are the symptoms it presents with?
it is the most common cancer of the female genital tract
it is a cancer that arises from the endometrium
it is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body
What are the 2 different types of endometrial adenocarcinoma?
type 1 - endometrioid:
- more aggressive than serous or clear cell carcinomas
type 2 - serous:
- this is very rare
How is endometrial adenocarcinoma identified and staged?
investigations:
- USS, biopsy, hysteroscopy
staging:
- FIGO (stages 1 - 4)
What are the treatments and prognosis for endometrial adenocarcinoma?
treatment:
- progesterone (P4)
- total abdominal hysterectomy
- adjuvant therapy - chemo/radiotherapy
prognosis:
- stage 1 - 90% 5 year survival
- stage 2-3 - <50% 5 year survival
What is polycystic ovary syndrome?
an endocrine disorder involving hyperandrogenism, menstrual abnormalities and polycystic ovaries
women with PCOS have infrequent of prolonged menstrual periods or excess androgen (male hormone) levels
the ovaries may develop small collections of fluid (follicles) and fail to regularly release eggs
What is hyperandrogenism?
a medical conditions characterised by high levels of androgens in females
How many women have polycystic ovary syndrome?
What investigations are conducted?
affects 6-10% of women but 20-30% have polycystic ovaries
investigations:
- USS
- fasting biochemical screen - decreased FSH, increased LH, testosterone & DHEAS
- oral glucose tolerance test (OGTT)
How is polycystic ovary syndrome diagnosed?
rotterdam criteria is used to diagnose PCOS
at least 2 of the following are required:
- hyperandrogenism (hirsuitism / biochemical)
- irregular periods for > 35 days
- polycystic ovaries on ultrasound
What are the treatments for polycystic ovary syndrome?
treatments:
- lifestyle - weight loss
- medical - metformin, OCP, clomiphene
- surgical - ovarian drilling
links:
- infertility
- endometrial hyperplasia / adenocarcinoma
What are the 3 origins of ovarian neoplasms?
sex-cord stromal tumours:
- granulosa cell
- thecomas and fibrothecomas
- sertoli-leydig cell tumours
germ cell tumours:
- teratomas
- yolk sac tumours
- embryonal carcinoma dysgerminomas
surface epithelial tumours:
- serous, mucinous, endometrioid, transitional cell, clear cell
What are the most common group of ovarian neoplasms?
What are the three different types?
epithelial tumours
- serous (tubal)
- mucinous (endocervical)
- endometrioid (endometrium)
each type contains benign / borderline / malignant variants
How are benign tumours subclassified?
benign tumours are subclassified based on components
- cystic - cystadenomas
- fibrous - adenofibromas
- cystic and fibrous - cystadenofibromas
What are malignant epithelial tumours called?
cystadenocarcinomas
What is a serous cystadenocarcinoma characterised by?
this tumour is characterised by complex, branching papillae and glands incorporating slit-like spaces
destructive stromal invasion is identified most conspicuouslt within the confluent solid growth pattern exhibited within the ovarian cortex
Where is a serous cystadenocarcinoma usually found?
in the ovary
it is the malignant form of the ovarian serous tumour
What % of ovarian tumours are germ cell tumours?
15-20%
What are the 2 different types of germ cell tumours?
germinomatous:
- dysgerminomas - malignant & chemosensitive
- usually occurs in the ovary
- seminoma in the testis and germinoma in the CNS
non-germinomatous:
- teratomas - differentiation towards multiple germ layers
- most mature are benign - 1% have malignant transformation
What are teratomas?
a rare type of tumor that can contain fully developed tissues and organs, including hair, teeth, muscle, and bone
What are yolk sac tumours and choriocarcinomas?
yolk sac tumours:
- differentiation towards extraembryonic yolk sac
- the cells that line the yolk sac would become the testis or ovaries
- malignant & chemosensitive
choriocarcinomas:
- trophoblastic cancer of the placenta
- malignant
- often unresponsive
What are the treatments for all types of germ cell tumours?
surgical excision +/- chemo/radiotherapy
Where do sex cord stromal tumours arise from?
they are rare
they arise from ovarian stroma, which was derived from the sex cord of the embryonic gonad
What are the 3 different types of sex cord stromal tumours?
What characteristic do they all share?
- thecoma / fibrothecoma / fibroma
- granulosa cell tumours
- sertoli-leydig cell tumours
they can all generate cells from the opposite sex
What is the composition of thecoma/fibrothecoma/fibroma like?
What can they produce?
they are benign
thecomas and fibrothecomas produce E2 (and rarely androgens)
fibromas are hormonally inactive
they are comprised of spindle cells
What syndrome is associated with thecoma/fibrothecoma/fibroma?
Meig’s syndrome
this involves ovarian tumour, right-sided hydrothorax (pleural effusion) and ascites
it resolves after resection of the tumour
What are the properties of granulosa cell tumours?
they are low grade malignant
they produce E2
What are the properties of sertoli-leydig cell tumours?
they produce androgens
10-25% are malignant
What are the risk factors for ovarian cancer?
risk factors:
- family history
- increasing age
- PMH of breast cancer
- smoking
- E2-only hormone replacement therapy
- Lynch II syndrome
- obesity
- nulliparity
What is nulliparity?
never having completed a pregnancy beyond 20 weeks
What are the protective factors for ovarian cancer?
- oral contraceptive pill
- breastfeeding
- hysterectomy
What are the symptoms of ovarian cancer?
How is it staged?
- non-specific symptoms such as pain, bloating and weight loss
- PV bleeding (vaginal)
- urinary frequency
- anorexia
FIGO staging 1-4 is used
What are the treatments for ovarian cancer?
What is the prognosis?
treatments:
- stage <1C epithelial tumours - total abdominal hysterectomy
- omentectomy
- appendectomy
- lymphadenectomy & adjuvant chemo
- chemotherapy only in sensitive germ cell tumours
prognosis:
- overall 5 years - 43% survival
What are the most common type of ovarian metastatic tumours?
Where do they occur?
Müllerian tumours
- uterus
- fallopian tube
- pelvic peritoneum
- contralateral ovary
Where do non-Müllerian tumours come from to become ovarian metastatic tumours?
lymphatic / haematogenous spread:
- GI tract - large bowel, stomach, Krukenberg tumour, pancreatic
- breast (lobular)
- melanoma
- less commonly - kidney and lung
direct extension:
- bladder
- rectal
How are metastatic tumours confirmed?
What is the prognosis like?
ovarian metastatic tumours are confirmed histologically
the prognosis is typically poor
In brief, what is endometriosis and endometritis?
endometriosis:
- spread of endometrium into the pelvis
endometritis:
- acute / chronic inflammation (usually due to infection)
In brief, what are endometrial polyps and leiomyomata?
endometrial polyps:
- local endometrial overgrowth
leiomyomata:
- benign smooth muscle tumours of the myometrium
In brief, what is endometrial hyperplasia and endometrial cancer?
endometrial hyperplasia:
- oestrogenic stimulation of endometrial proliferation
- continuous stimulation may lead to atypical hyperplasia and carcinoma
endometrial cancer:
- commonest gynae cancer with increasing incidence
- there are 2 types
