Week 2 - D - Uterine Pathology (abnormal uterine bleeding causes)

Question 1

In the mestrual cycle Have the ovarian and uterine cycle What are the phases of both cycles?

Answer 1

Ovarian cycle

• Follicular phase
• Ovulation
• Luteal phase

Uterine cycle

• Menstrual phase
• Proliferatory phase
• Secretory phase

Question 2

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?

Answer 2

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

Question 3

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?

Answer 3

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

Question 4

What hormones are important if fertilisation occurs?

Answer 4

Progesterone and beta-human chorinic gonadotrophin

Question 5

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?

Answer 5

This is the Graffian follicle

Question 6

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?

Answer 6

The coprus luteum has a yellowish colour and the corpus albicans has a whitish appearance

Question 7

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?

Answer 7

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.

Question 8

What age group of women does endometrial hyeprplasia typically occur in and what is a typical symptoms?

Answer 8

Typically occurs in post-meonpausal women and typically causes abnormal uterine bleeding

Question 9

What are implications for endometrial sampling?

Answer 9

Abnormal uterine bleeding

Assessment for infertility

Spontaenous and therapeutic abortion

Incidental finding of thickened endometrium on scan

Question 10

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?

Answer 10

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

Question 11

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?

Answer 11

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

Question 12

Types of abnormal uterine bleeding - describe these definitions

• * Menorrhagia
• * Metrorrhagia
• * Polymenorrhoea
• * Polymenorrhagia
• * Menometrorrhagia
• * Amenorrhea
• * Oligomenorrhoea

Answer 12

• 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

Question 13

WHat is postmenopasual bleeding defined as in relation to abnormal uterine bleeding?

Answer 13

Post menopausal bleeding (PMB) is abnormal uterine bleeding (AUB) >1 year after cessation of menstruation

Question 14

Is the majority of DUB anovulatory or ovulatory? WHat women are they more common in?

Answer 14

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 )

Question 15

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?

Answer 15

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

Question 16

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?

Answer 16

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

Question 17

What is important history to have in a women with abnormal uterine bleeding?

Answer 17

Age

Date of last menstrual period

Patterns of bleeding

Hormones

Recent pregnancy

Question 18

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?

Answer 18

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

Question 19

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?

Answer 19

This is dysfunctional uterine bleeding - most common cause of abnormal uterine bleeding

Question 20

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?

Answer 20

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

Question 21

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?

Answer 21

If it doesnt breakdown endometrial hyerplasia may occur

Question 22

Pathology of the organic causes of AUB

• Endometrium
  
  • * Endometritis
  • * Polyp
  • * Miscarriage
• Myometrium
  
  • * Adenomyosis
  • * Leiomyoma

What cells are looked for histologically in endometritis?

Answer 22

Plasma cells are not normal cells of the endometrium and they are looked for in this condition

Question 23

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?

Answer 23

Chalmyida trachomatis can cause endometritis

Childbirth (post-partum)

Miscarriage

Termination of pregnancy

Intra-uterine contraceptive devise insertion

Question 24

What types of cells is chronic endometritis distinguished by?

Answer 24

Plasma cells are not normal cells of the endometrium and they are looked for in this condition

Question 25

What is the treatment of endometritis?

Answer 25

Give antibitocs - eg doxycycline with metronidzaoe)

Question 26

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?

Answer 26

Can rarely be a presentation of endometrial carcinoma

Question 27

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?

Answer 27

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.

Question 28

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?

Answer 28

This is a chorionic haematoma

Dangerous as it can can disrupt the blood supply between placenta and endometrium leading to hypoxia of the baby

Question 29

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?

Answer 29

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

Question 30

WHat is the risk factor of choriocarcinoma (malignanat tumour of trophoblatic cells) when a female has a molar pregnancy?

Answer 30

2.5% risk of developing into a choriocarcinoma (Complete mole has a higher carcinoma rate than partial mole)

Question 31

Where can choriocarcinoma spread to? What is the likelihood that the complete mole becomes invasive and spreads into the uterus?

Answer 31

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

Question 32

Myometrium causes of abnormal uterine bleeding include adenomysosi and leimoyoma What is adenomyosis? What is leimyoma?

Answer 32

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

Question 33

What does a biopsy of leimyoma look like on histogy? What are the symptoms of leimymoma?

Answer 33

Looks like smmooth muscle on biopsy - single nucleus, tapered and nonstriated

Can present with menorrica, ferility problems, pain also and large mass

Question 34

Why may leimoyoma cause infertility problems?

Answer 34

This is becuase the tumour may be large enough to affect implantation of the egg in the uterus (natural IUCD)

Question 35

What type of cancers do cancers of the endometrium tend to be?

Answer 35

Adenocarcinoma (endometrial hyperplasia and neoplasia will be reviewed in a future lecture)