Uterine Pathology Flashcards
Divisions of the menstrual cycle?
Ovarian cycle
Uterine cycle
Stages of the ovarian cycle?
- Follicular phase
- Ovulation - in an average 28 day cycle, this occurs on day 14
- Luteal phase
Stages of the uterine cycle?
- Menstrual phase
- Proliferative phase
- Secretory phase
For each stage of the uterine cycle, how long do they last, what hormone drives them and what is the effect of each phase on the endometrium?
Describe a histological image of a graafian follicle
Describe a histological image of a section during the proliferative phase
Small, round glands (test-tube shaped) in stroma
Mitotic figures can be seen, due to cell division and proliferation of the stroma & glands
Describe the gross pathological appearance of a section through the ovary
Corpus albicans appears like white, scar tissue
New corpus luteum is yellow
Describe histology during the secretory phase
Curvy, tortuous glands
As the endometrium progresses through the secretory phase, the glands increase in tortuosity and luminal secretions
NOTE - they become more saw-toothed
Why are endometrial biopsies difficult to interpret?
- Constant physiological changes occur before, during and after reproductive life
- Changes due to hormone therapy the patient may have
- Lack of clinical data, i.e: the clinician does not give enough info (for example, when their last period was)
Indications for endometrial sampling?
- Abnormal Uterine Bleeding (AUB) - this includes all causes
- Ix for infertility
- Spontaneous and therapeutic abortion
- Assessment of response to hormone therapy
- Endometrial ablation
- Work up prior to hysterectomy for benign indications; before a hysterectomy, a pipelle biopsy should always be done
- Incidental finding of thickened endometrium on scan
- Endometrial cancer screening in high-risk patients
Types of AUB?
Menorrhagia - prolonged and increased menstrual flow
Metrorrhagia - regular intermenstrual bleeding
Polymenorrhoea - menses occurring at <21 day interval
Polymenorrhagia - increased bleeding and frequent cycle
Menometrorrhagia - prolonged menses and intermenstrual bleeding
Amenorrhoea - absence of menstruation >6 months
Oligoamenorrhoea - menses at intervals of >35 days
What is DUB?
Dysfunctional
Uterine Bleeding - this is AUB with no organic cause
Irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining (no organic cause for the bleeding)
What is PMB?
Post-menopausal bleeding - this is AUB >1 year after the cessation of menstruation
Causes of AUB in adolescence / early reproductive life?
DUB (usually due to anovulatory cycles, i.e: patient remains in proliferative phase and do not enter the secretory phase)
Pregnancy / miscarriage
Endometritis
Bleeding disorders
Causes of AUB during reproductive life / peri-menopause?
Pregnancy / miscarriage
DUB (causes include anovulatory cycle and luteal phase defects)
Endometritis
Endometrial / endocervical polyp
Leiomyoma (AKA fibroids)
Adenomyosis
Exogenous hormone effects
Bleeding disorders
Endometrial
HYPERPLASIA NEOPLASIA (cervical, endometrial)
Causes of AUB post-menopause?
Atrophy (this is common; however, if a patient has atrophy on TVUS but there symptoms persist, consider biopsy, as cancer could still be the cause)
Endometrial polyp (very common cause of bleeding in post-menopausal women)
Exogenous hormones (HRT, tamoxifen)
Endometritis
Bleeding disorders
Endometrial HYPERPLASIA
Endometrial CARCINOMA
SARCOMA
Methods of assessing the endometrium?
TVUS (vaginal ultrasound) - the following endometrial thicknesses are generally considered to be indications for biopsy:
- >4mm in post-menopausal women
- >16mm in pre-menopausal women
Hysteroscopy
Methods of sampling the endometrium?
Endometrial pipelle - no dilatation or anaesthesia required (outpatient procedure) and it is very safe; however, the sample is limited
Dilatation and curettage - most common operation performed on women and is the most thorough method of sampling the endometrium; however, it can miss 5% of endometrial hyperplasia / cancer
Required Hx for a pathological examining an endometrial biopsy?
Age
Date of LMP (last menstrual period) and length of cycle
Pattern of bleeding
Hormones
Recent pregnancy
NOTE - the no. of pregnancies, drugs without hormonal influences do not need to be included
Step-wise considerations on histological assessment of endometrial samples for AUB?
- Is this sample adequate / representative for the given clinical scenario?
- Is there evidence of fresh / old breakdown / haemorrhage?
- Is there an organic benign abnormality? (polyp, endometritis, miscarriage)
- Is there evidence of dysfunctional bleeding?
- Is there hyperplasia (atypical / non-atypical) or malignancy?
Histology during the menstrual phase?
Least informative
Main cause of DUB?
Anovulatory cycles - most common at either end of reproductive life
The corpus luteum does not form and there is continued growth of the functionalis layer (as in PCOS, hypothalamic dysfunction, thyroid disorders, hyperproliactinaemia)
Other causes of DUB?
Luteal phase deficiency - insufficient progesterone or poor response by the endometrium to progesterone
Abnormal follicular development, due to inadequate FSH/LH, so the corpus luteum is poor
Histology of endometrium when there is an anovulatory cycle?
The LMP must be known (for the image below, it was 8 weeks prior)
Huge glands and disordered proliferation, as the glands AND stroma continue to grow; as ovulation has not occurred, the secretory phase does not begin
Endometrium will randomly break down
NOTE - if this continues, it becomes endometrial hyperplasia
