Week 2 - D - Uterine Pathology (abnormal uterine bleeding causes) Flashcards
In the mestrual cycle Have the ovarian and uterine cycle What are the phases of both cycles?
Ovarian cycle
- Follicular phase
- Ovulation
- Luteal phase
Uterine cycle
- Menstrual phase
- Proliferatory phase
- Secretory phase
Ovarian cycle – follicular phase (1st half oc cycle – this is when a number of follicles mature (6or7) – usually one becomes the dominant follicle (Graafian follicle)) and this is ovulated, then the luteal phase occurs
What hormone causes ovulation?
Lutienziing hormone causes ovulation
Estrogen levels peak towards the end of the follicular phase.
This causes a surge in levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
This lasts from 24 to 36 hours, and results in the rupture of the ovarian follicles, causing the oocyte to be released from the ovary via the oviduct
What hormone drives the proliferative phase of the uterine cycle and what effect does this have?
Which hormone drives the secretory phase and what effect does this have?
Which hormones drive the menstrual phase of the uterine cycle?
Oetrogen drives the proliferative phase from day 1to14 - causes growth of the endometrium
Progesterone drives the secretory phase - day 16 to 28 - maintains the endometrium and thickens the cervical mucus
There is hormone withdrawal in the menstrual phase leading to endometrial shedding
What hormones are important if fertilisation occurs?
Progesterone and beta-human chorinic gonadotrophin
Ganulosa cells produce oestogen and progesterone when the egg is in the ovary What is the largest follicle (usually the one that is ovulated) known as?
This is the Graffian follicle
The corpus luteum produces progesterone for about 8-9 days and if there is no development of the placenta to produce HCG the corpus luteum degenerates by about day 12 to form the corpus albicans What colour is the coprus luteum and what colour is the corpus albicans?
The coprus luteum has a yellowish colour and the corpus albicans has a whitish appearance
Endometrial biopsy is one of the most common and difficult to interpret histopathological specimens Want to exclude any cancers or any signs of precursor to cancer such as atypical endometrial hyperplasia What is .endometrial hyperplasia?
Endometrial hyperplasia occurs when the endometrium, the lining of the uterus, becomes too thick.
It is not cancer, but in some cases, it can lead to cancer of the uterus.
What age group of women does endometrial hyeprplasia typically occur in and what is a typical symptoms?
Typically occurs in post-meonpausal women and typically causes abnormal uterine bleeding
What are implications for endometrial sampling?
Abnormal uterine bleeding
Assessment for infertility
Spontaenous and therapeutic abortion
Incidental finding of thickened endometrium on scan
What is the main cause of abnromal uterine bleeding (usually isnt because of endometrial hyperplasia)? Which carcinoma affects young or old usually - endomtrial or cervical cancer?
Dysfunctional uterine bleeding - ie no identified pathology accounts for 50% of cases of abnormal uterine bleeding
Endometrial carcinoma - affects the post meonpasual
Cervical carcinoma - affects the young
What is the 1st,2nd and 3rd line in treatment of dysfunctional uterine bleeding? How often is the PAP smear carried out for cervical cancer?
1st line - Levenogestrol (IUS) (Mirena coil)
2nd line - Antifibrinolytic (transexamic acid), NSAID or Combined oral contraceptive pill
3rd line - Oral progesterone - norethisterone
Cervical cancer smear:
Aged 25-49 - every 3 years
Aged 50-64 - everyy 5 years
Aged 65+ - not routinely carried out
Types of abnormal uterine bleeding - describe these definitions
- * Menorrhagia
- * Metrorrhagia
- * Polymenorrhoea
- * Polymenorrhagia
- * Menometrorrhagia
- * Amenorrhea
- * Oligomenorrhoea
- Menorrhagia-increased&prolonged menstrual flow
- Metrorrhagia - regular intermenstrual bleeding
- Polymenorrhoea - increased frequency of menstrual cycles <21 days
- Polymenorrhagia -increased&prolonged menstrual flow and incresed frequency of menstruation
- Menometrorrhagia - prolonged menses and intermenstrual bleeding
- Amenorrhea- absence of menstruation >6months
- Oligomenorrhea - menses at intervals >35 days
WHat is postmenopasual bleeding defined as in relation to abnormal uterine bleeding?
Post menopausal bleeding (PMB) is abnormal uterine bleeding (AUB) >1 year after cessation of menstruation
Is the majority of DUB anovulatory or ovulatory? WHat women are they more common in?
85% are anovulatory and are more common in obese women
15% are ovulatory and are more common in those aged 35-45 - presents with regular menstrual bleeding
(Poorer quality progesterone - This means the glands keep on proliferating until they collapse and then bleeding occurs – these anovulatory cycles are relatively common and shouldn’t pose a worry unless women is wanting to get pregnanct )
There are a lot of causes of abnormal uterine bleeding both pre menopausal and post menopasual
What method is used to assess the thickeness of the endometrium?
Thickness greater than what in post and premenospausal women is generally taken as an indicator for a biopsy?
Transvaginal ultrasound is used to assess the thickeness
Thickness greater than 16mm in premenopausal women indicated a biopsy
Thickness greater than 4mm post menopausal indicates a biopsy
Having a negative biopsy is reassuring but if symptoms persist should be further investogated
What is the most common method used to sample the endometrium? IS aneasthetic needed?
Endomtrial pipelle biopsy
No anaesthesia
Outpatient procedure
Very safe
Can also try dilatation and curettage in which the cervix is dilated and curettage to obtain endometrial sample
What is important history to have in a women with abnormal uterine bleeding?
Age
Date of last menstrual period
Patterns of bleeding
Hormones
Recent pregnancy
When looking at the endometrial sample~Want to examine for evidence of any old or new blood Any typical or atypical endometrial hyerplasia on histology What phase in the menstrual cycle is least infromative for taking an endometrial biopsy?
The menstrual phase as the glands in the stroma are breaking down as the endometrium is shedding and it is therefore not a useful biopsy
irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining (no organic cause for bleeding) What is this?
This is dysfunctional uterine bleeding - most common cause of abnormal uterine bleeding
When anovulatory DUB occurs, it is commonest at either end of reproductive life
What happens with the coprus luteum and stratum functonalis of the endometrium?
There is no growth of the coprus luteum and continued growth of the stratum functionalis of the endometirum
This is because there is unopposed oestrogen production leading to growth of the endometrium
Continued proliferation of stratum functionalis layer of the endometrium which is meant to be shed in menstruation
The gland has just continued to grow and eventually will break down which will cause bleeding WHat happens if it doesn’t breakdown?
If it doesnt breakdown endometrial hyerplasia may occur
Pathology of the organic causes of AUB
- Endometrium
- * Endometritis
- * Polyp
- * Miscarriage
- Myometrium
- * Adenomyosis
- * Leiomyoma
What cells are looked for histologically in endometritis?
Plasma cells are not normal cells of the endometrium and they are looked for in this condition
There are a lot of different causes of endometritis It can occur due to specific organsisms - name one? - usually the barrier to ascending infection has to be broken hwoever But can also be due to the barrier to ascending infection being broken Give examples of when this may be the case?
Chalmyida trachomatis can cause endometritis
Childbirth (post-partum)
Miscarriage
Termination of pregnancy
Intra-uterine contraceptive devise insertion
What types of cells is chronic endometritis distinguished by?
Plasma cells are not normal cells of the endometrium and they are looked for in this condition
What is the treatment of endometritis?
Give antibitocs - eg doxycycline with metronidzaoe)
An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be pedunculated) Pedunculate dpolyps are more common than sessile ones What can polyps rarely be a presentation of?
Can rarely be a presentation of endometrial carcinoma
The way to confirm a prregnanyc on histology is too see chorionic villi or trophoblasts We look at the miscarriage to confirm a condion called hydaditform moles (molar pregnancy) What is the chorionic villi?
Chorionic villi are villi that sprout from the chorion to provide maximum contact area with maternal blood.
They are an essential element in pregnancy from a histomorphologic perspective, and are, by definition, a product of conception.
The chorion is the outer layer of the amniotic sac and encloses the sac and placenta - separates foetus form endometrium What is blood collecting betweent eh chorion and endometrium known as? WHy is this dangerous?
This is a chorionic haematoma
Dangerous as it can can disrupt the blood supply between placenta and endometrium leading to hypoxia of the baby
Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus (or tube) A form of gestational trophoblastic disease which grows as a mass characterised by swollen chorionic villi. Categorized as partial moles or complete moles
WHat is the difference between complete and partial mole?
Complete mole
Complete 46 chromsome set but only paternal DNA - results in complete mole and no feotus
Partial mole - DNA from paternal and maternal but is triploid (XXY) and therefore partial mole and foetus is seen
WHat is the risk factor of choriocarcinoma (malignanat tumour of trophoblatic cells) when a female has a molar pregnancy?
2.5% risk of developing into a choriocarcinoma (Complete mole has a higher carcinoma rate than partial mole)
Where can choriocarcinoma spread to? What is the likelihood that the complete mole becomes invasive and spreads into the uterus?
Complete hydatidiform moles have 2.5% risk of developing into choriocarcinoma, but also a 10% chance of becoming an invasive mole
Choriocarcinoma may have pulomary metastases
Myometrium causes of abnormal uterine bleeding include adenomysosi and leimoyoma What is adenomyosis? What is leimyoma?
Adenomysosi is when endometrial tissue is found within the myometrium (Endometrial glands and stroma within the myometrium )
Can cause menorrhagia or dysmenorrhoea
Leimyoma is fibroids - benign tumours of smooth muscle
What does a biopsy of leimyoma look like on histogy? What are the symptoms of leimymoma?
Looks like smmooth muscle on biopsy - single nucleus, tapered and nonstriated
Can present with menorrica, ferility problems, pain also and large mass
Why may leimoyoma cause infertility problems?
This is becuase the tumour may be large enough to affect implantation of the egg in the uterus (natural IUCD)
What type of cancers do cancers of the endometrium tend to be?
Adenocarcinoma (endometrial hyperplasia and neoplasia will be reviewed in a future lecture)
