Uterine Pathology Flashcards
What phase of the uterine cycle corresponds to the follicular phase of the ovarian cycle?
Menstrual phase (endometrium is shedding)
What phase of the uterine cycle occurs alongside ovulation in the ovarian cycle?
Proliferative phase - endometrium is growing
What phase of the uterine cycle occurs in the ovarian luteal phase and how long does this normally last?
Secretory phase - always lasts 14 days (does not change regardless of cycle length)
Which of the 3 uterine phases will elongate if a woman’s cycle is longer than the 28 day average?
Proliferative phase
The secretory phase cannot occur without ovulation. Why is this the case?
Progesterone is needed from the corpus luteum to stop the endometrium proliferating and start the secretory phase
=> once it becomes secretory it is ready to accept the blastocyst
Withdrawal of progesterone during the secretory phase causes what to occur?
Shedding of the endometrium
Describe the appearance of the endometrium in post-menopausal women.
- Thin and atrophic lining
- Occasional glands
- Does not grow or shed
What cells surround the oocyte in the Graafian follicle and produce oestrogen?
Granulosa cells
Describe the histological appearance of the endometrium during the proliferative phase
- Glandular epithelium
- Mitotic figures present at the edge of glands (shows glands are actively growing)
- No secretions present (white)
What colour is the corpus luteum on a biopsy and what happens after each one regresses?
- Yellow on biopsy
- After each one regresses it forms a scar
Describe the histological appearance of the endometrium early in the secretory phase.
- glands still relatively round
- 1 or 2 mitotic figures seen (but most glands have ceased growing)
- White secretions released from nuclei around edge of gland
Describe the histological appearance of the endometrium later in the secretory phase.
- Glands appear “wiggly”
- filled with white secretion
What drugs make an endometrial biopsy difficult to interpret?
- endometrium responds to hormonal changes
=> pathology need to know if patient is on hormonal drugs (contraceptive, HRT etc) before interpreting biopsy
What indications are there for an endometrial biopsy?
- Bleeding
- Miscarriage or therapeutic abortion
- Check response to hormone therapy
- Prior to Endometrial ablation
- Prior to hysterectomy
- Check for endometrial cancer in patient groups with increased risk (e.g. Lynch syndrome)
What is Lynch Syndrome and what cancers can it predispose to?
Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
=> predisposes to cancers in the colon, rectum and endometrial cancer
Why may hormonal therapy be used to treat certain patients with endometrial cancer?
If patients are overweight or obese - they are at a higher risk of developing endometrial cancer
These patients are also a high risk for surgery => they can be given hormonal therapy to attempt to control the cancer instead
What do the clinical terms menorrhagia, amenorrhoea and oligomenorrhoea mean?
Menorrhagia = longer and heavier periods
Amenorrhoea = absence of period for > 6 months
Oligomenorrhoea = Periods after a cycle > 35 days
What is meant by AUB and DUB?
AUB - Abnormal Uterine Bleeding
DUB - Dysfunctional Uterine Bleeding (no organic cause)
What is the definition of post-menopausal bleeding?
abnormal uterine bleeding > 1 year after cessation of menstruation
bleeding at time of menopause = peri-menopausal bleeding
What usually causes abnormal uterine bleeding in younger age during a woman’s early reproductive life?
- DUB usually due to anovulatory cycles
- Pregnancy/miscarriage
- Endometritis
- Bleeding disorders
What can cause abnormal uterine bleeding in patients who are in their reproductive age OR are perimenopause?
- Pregnancy/miscarriage
- DUB: anovulatory cycles, luteal defects,
- Endometritis
- Endometrial/endocervical polyp
- Leiomyoma (fibroid)
- Adenomyosis
- Exogenous hormone effects (HRT etc)
- Bleeding disorders
- Neoplasia: cervical, endometrial
What is an endometrial or endocervical polyp?
- outpouching of the endometrium into the cavity
- covered by the normal fibrous stroma of the endometrium BUT does not shed every month
What is a fibroid?
Also known as a Leiomyoma
=> benign tumour of the smooth muscle
What occurs in endometriosis?
- Endometrial glands and stroma grow outwith uterine cavity
- still under hormonal control so they proliferate and bleed every month (this causes a lot of pain)
- Can be found in abdominal cavity (e.g. pelvic side wall)
What is meant by adenomyosis?
Endometrial glands and stroma grow inside the MYOmetrium
i.e. the muscular layer
- again they proliferate and bleed under hormonal control each month => causing patients significant pain
What are the main causes of abnormal uterine bleeding post-menopause?
- Atrophy
- Endometrial polyp
- Exogenous hormones: HRT, tamoxifen
- Endometritis
- Bleeding disorders
- Endometrial carcinoma
- Sarcoma
Why may HRT cause bleeding after the menopause has occured?
The oestrogen causes a small amount of the proliferative phase to occur again in the endometrium
Why does tamoxifen cause AUB after the meno-pause has occurred?
It decreases the oestrogen in breast tissue (to counteract cancer) however has a slightly pro oestrogenic effect in the uterus
=> it also causes a small amount of the proliferation phase to occur
How is endometrial thickness investigated?
Transvaginal ultrasound
An endometrial thickness on TVUS of what value would indicate the need for further investigation?
> 4mm in postmenopausal women
16mm in premenopausal
indication for biopsy
How can the endometrium be assessed on investigation?
Transvaginal US
Hysteroscopy
How can the endometrium be sampled?
Endometrial pipelle
Dilatation and curretage
What are the advantages of using the endometrial pipelle to sample the endometrium?
No dilatation needed
No anaesthesia
Outpatient procedure
Very safe
What are the disadvantages of an endometrial pipelle sample and why would this possibly prompt a dilatation and curettage sample?
- Pipelle sample is limited and may not reach area of pathology if it is high in uterus
- Dilatation and curettage = most thorough sampling method
What should be noted in a patients history before sending a biopsy to pathology for interpretation?
- Age
- Date of Last Menstrual Period and length of cycle
- Pattern of bleeding
- Hormones
- Recent pregnancy
How should a sample be histologically analysed if the patient is experiencing abnormal uterine bleeding?
- Is sample adequate?
- Any evidence of fresh/old haemorrhage?
- Organic benign abnormality? (polyp, endometritis, miscarriage)
- Any evidence for dysfunctional bleeding?
- Hyperplasia (atypical/non atypical) or malignancy?
During which phase of the uterine cycle is a biopsy the least informative?
Menstrual phase
- can confirm no cancer
- difficult to comment on endometrial architecture as it is “falling away” during this phase
What causes anovulatory cycles and at what ages do these tend to occur?
- No ovulation => Corpus luteum does not form
- Continued proliferation phase, no secretory phase
- Commonest at extremes of reproductive life
E.g. Polycystic ovary syndrome, hypothalamic dysfunction, thyroid disorders, hyperprolactinaemia
How is DUB caused by a luteal phase insufficiency?
- Insufficent progesterone production by corpus luteum
OR - Poor response by the endometrium to progesterone
- often occurs in perimenopausal women, as least suitable eggs have been left till last
=> poor eggs cause poor corpus luteum
What can be visualised histologically in the endometrium if a patient is having anovulatory cycles?
- Disordered proliferation of glands
- Abnormal gland shape
- No secretions present
What organic causes of AUB originate in the endometrium?
- Endometritis
- Polyp
- Miscarriage
What causes of AUB originate in the myometrium?
- Adenomyosis
- Leiomyoma
What usually contributes to the lack of endometrial infection?
- Cervical mucous plug protects endometrium from ascending infection
- Cyclical shedding of the endometrium also helps with resistance (as microorganisms are shed with it each month)
What microorganisms normally cause infection of the endometrium, resulting in endometritis?
Neisseria
Chlamydia
TB (not common in UK)
Actinomyces (fungal infection caused by some IUDs)
What can cause the inflammation of endometritis without evidence of infection?
- Intra-uterine contraceptive device (IUD)
- Postpartum/Postabortal
- Post curettage
- Chronic endometritis
- Granulomatous disease (e.g. sarcoid? TB?)
- Associated with leiomyomata or polyps
What cell indicates chronic infectious endometritis on histology until proven otherwise?
- Plasma cell (these should NOT be found in the endometrium)
What organisms related to pelvic inflammatory disease may cause a chronic infectious endometritis?
Neiserria gonorrhoea
Chlamydia
enteric organisms
How do patients with endometrial polyps usually present?
- Usually asymptomatic
- May present with bleeding or discharge
- Some polyps can twist on their axis, damage their blood supply and cause infarction
When do patients usually get endometrial polyps?
- Occur around and after the menopause
Polyps are always benign. TRUE/FALSE?
FALSE - ALMOST always benign
BUT endometrial carcinoma can present as a polyp
Describe how the growth of an endometrial cancer is similar to that of a polyp?
Exophytic growth off of endometrial wall and into cavity
- polyps have a smooth outline whereas cancers grow into “craggy” appearance
What signs on histology would indicate that AUB has been caused by a miscarriage?
- presence of chorionic villi (placental tissue)
- RBCs with nuclei in cytotrophoblast (only present in foetus <12 weeks => these indicate foetal tissue is present)
What is meant by a molar pregnancy?
An abnormal growth of cells caused by a non-viable pregnancy
What is the difference between a partial and complete molar pregnancy?
Complete - Only the fathers DNA is present
=> Placenta can form, but NO foetus can form
Partial - 2x copies of father’s DNA, 1x copy of mother’s DNA
=> Part of a foetus can form along with a “crazy” placenta
How do the chorionic villi appear on histology in a molar pregnancy ?
- Swollen
- trophoblast growing off ALL sides rather than just one
- grow in clusters resembling bunches of grapes
A complete molar pregnancy increases the risk of what rare and aggressive form of cancer?
Choriocarcinoma
How does adenomyosis appear on histology?
Endometrial glands and stroma within the myometrium
How do patients with leimyomas usually present?
Menorrhagia
infertility
mass effect,
pain
Single or multiple, may distort uterine cavity
What does a microscopic view of a leiomyoma show?
interlacing smooth muscle cells
What name would be given to the cancer that develops from the glandular tissue of the endometrium?
Carcinoma
What name would be given to a cancer developing from the muscle in the myometrium?
LeiomyoSARCOMA
