Uterine Pathology

Question 1

what are the three phases of the ovarian cycle?

Answer 1

follicular phase
ovulation
luteal phase

Question 2

what are the three phases of the uterine cycle?

Answer 2

menstrual phase
proliferative phase
secretory phase

Question 3

what is the time, hormones involved and the effect in the following phases?

a) proliferative
b) secretory
c) menstrual
d) fertilised
e) post-menopausal

Answer 3

a) day 1-14, oestrogen, growth
b) day 16-28, progesterone, secretion
c) day 1-3, withdrawal, necrosis
d) secretory onwards, progesterone and HCG, hypersecretion and decidualisation
e) non-cycling, inactive and atrophic

Question 4

what is a graafian follicle?

Answer 4

fluid-filled structure in the mammalian ovary within which an ovum develops prior to ovulation

*contains oocyte and granulosa cells

Question 5

what is the regressed form of the corpus luteum called?

Answer 5

corpus albicans

Question 6

what occurs histologically during the secretory phase?

Answer 6

increasing tortuosity and lumenal secretions

Question 7

what are the indications for endometrial sampling?

Answer 7

abnormal uterine bleeding
investigation for infertility
spontaneous and therapeutic abortion
assessment of response to hormonal therapy
endometrial ablation
work up prior to hysterectomy for benign indications
incidental finding of thickened endometrium on scan
endometrial cancer screening in high risk patients

Question 8

what is dysfunctional uterine bleeding?

Answer 8

abnormal uterine bleeding with no organic cause

Question 9

what is post menopausal bleeding?

Answer 9

abnormal uterine bleeding >1 year after cessation of menstruation

Question 10

what are causes of AUB in adolescence / early reproductive life?

Answer 10

DUB - anovulatory cycles
pregnancy / miscarriage
endometritis
bleeding disorders

Question 11

what are causes of AUB in reproductive life / perimenopause?

Answer 11

pregnancy / miscarriage 
DUB - anovulatory cycles, luteal phase defects
endometritis 
endometrial / endocervical polyp
leiomyoma 
adenomyosis 
exogenous hormone effects 
bleeding disorders

hyperplasia
neoplasia - cervical, endometrial

Question 12

what are the causes of AUB post menopause?

Answer 12

atrophy 
endometrial polyp 
exogenous hormones: HRT, tamoxifen 
endometritis 
bleeding disorders

hyperplasia
endometrial carcinoma
sarcoma

Question 13

what is most common method of assessing the endometrium?

Answer 13

TVUS

*hysteroscopy is also a good method

Question 14

an endometrial thickness of what is generally taken as an indication for biopsy?

Answer 14

> 4mm post menopausal

16mm in premenopausal

Question 15

how is an endometrial pipelle carried out?

Answer 15

3.1mm in diameter, no dilatation needed
no anaesthesia 
outpatient procedure 
very safe
limited sample

Question 16

what is the most thorough sampling method which is the most common operation performed on women?

Answer 16

dilatation and curretage

*although can miss 5% of hyperplasias / cancers

Question 17

what history is required for uterine pathology?

Answer 17

age 
date of LMP and length of cycle
pattern of bleeding 
hormones 
recent pregnancy 

*do not need to know number of pregnancies, drugs without normal influences etc

Question 18

how are the endometrial samples for AUB assessed histologically?

Answer 18

is the sample adequate for given clinical scenario?
is there evidence of fresh/old breakdown?
is there an organic benign abnormality (polyp, endometritis, miscarriage)?
is there evidence for dysfunctional bleeding?
is there hyperplasia or malignancy?

Question 19

what is the least informative phase for endometrial sampling?

Answer 19

menstrual phase

Question 20

what are most cases of DUB due to?

Answer 20

anovulatory cycles

• commonest at either end of reproductive life
• corpus luteum does not form
• continued growth of functionalis layer (PCOS, hypothalamic dysfunction, thyroid disorders, hyperprolactinaemia)

Question 21

how is luteal phase deficiency another common cause of DUB?

Answer 21

insufficient progesterone or poor response by the endometrium to progesterone
abnormal follicular development (inadequate FSH/LH) = poor corpus luteum

Question 22

what causes within the endometrium cause AUB?

Answer 22

endometritis
polyp
miscarriage

Question 23

what causes within the myometrium cause AUB?

Answer 23

adenomyosis

leiomyoma

Question 24

what does endometritis look like histologically?

Answer 24

abnormal pattern of inflammatory cells

*normally, cervical mucuous plug and cyclical shedding protects endometrium from ascending infection

Question 25

what are the likely causes of endometritis?

Answer 25

organisms = neisseria, chlamydia, TB, CMV, actinomyces, HSV

inflammation without organism = IUCD, postpartum, postabortal, post curettage, chronic endometritis NOS, granulomatous, assoc with leiomyomata or polyps

Question 26

what is chronic plasmacytic endometritis and what condition is it associated with?

Answer 26

chronic endometritis which is infectious unless proved otherwise

associated with pelvic inflammatory disease (neiserria gonorrhoea, chlamydia, enteric organisms)

Question 27

what are the symptoms of endometrial polyps?

Answer 27

usually asymptomatic but may present with bleeding or discharge

often occur around and after the menopause

Question 28

endometrial polyps are almost always malignant - true or false?

Answer 28

false - almost always benign

*BUT endometrial carcinoma can present as a polyp

Question 29

what is a molar pregnancy?

Answer 29

abnormal form of pregnancy in which a non-viable fertilised egg implants in the uterus (or tube)

Question 30

how are molar pregnancies characterised?

Answer 30

a form of gestational trophoblastic disease which grows a mass characterised by swollen chorionic villi

Question 31

how can molar pregnancies be categorised?

Answer 31

partial moles or complete moles

• complete = single (90%) or two (10%) sperm combining with egg which has lost its DNA (the sperm then reduplicates forming a complete 46 chromosome set but only paternal DNA present
• partial = egg fertilised by two sperm or by one sperm which reduplicates itself yielding genotype of 69XXY (have maternal and paternal DNA)

Question 32

what has a higher risk of developing into choriocarcinoma (a malignant tumour of trophoblast) - complete hydatidiform or partial moles?

Answer 32

complete

Question 33

what is adenomyosis and what are the symptoms?

Answer 33

endometrial glands and stroma break through to the the myometrium

causes menorrhagia / dysmenorrhea

Question 34

what is a leiomyoma?

Answer 34

benign tumour of smooth muscle, may be found in locations other than the uterus

Question 35

what may be the symptoms of a leiomyoma?

Answer 35

menorrhagia
infertility
mass effect
pain

*single or multiple, may distort uterine cavity

Question 36

what does the growth of a leiomyoma depend on?

Answer 36

oestrogen

Question 37

what does a leiomyoma look like microscopically?

Answer 37

interlacing smooth muscle cells

Question 38

what is the rare malignant transformation of a leiomyoma called?

Answer 38

leiomyosarcoma