7 Endometrial path 1

ENDOMETRIAL DATING:

Proliferative phase Secretory phase Menses

-Estrogen high, FSH/LH present -Progesterone & Corpus luteum -Disintegration of glands
-Glands are Tubular/straight -Glands are dilated & tortuous -Hemorrhage
pseudostratified columnar columnar w/basal vacuolation -Inflammatory cells present
w/mitosis -Stroma have edema, spiral
-compact cellular stroma arterioles
DYSMENORRHEA: Painful menstrual cycle:
- Primary: do to Increase Prostaglandins  increase uterine contractions
- Secondary: M.C do to endometriosis
AMENORRHEA:
- Primary: Ovarian problem: not enough estrogen etc…
- Secondary: HT/Pituitary lesion: no FSH/LH or GnRH
- End organ or Anatomical reason: No vagina, Imperforate hymen, cervical stenosis
- Do Not forget to do a Pregnancy test

DYSFUNCTIONAL UTERINE BLEEDING “DUB” (Bleeding w/no organic reason)

- Any alteration in hormonal response may result in many disturbances:
o Atrophy, Abnormal Proliferative/Secretory phases or Hyperplasia
- Types of abnormal bleeding in DUB:
o MENORRHAGIA: Excess bleeding during menses (above 80ml)
o METRORRHAGIA: Uterine bleeding between menses (irregular intervals)
o MENOMETRORRHAGIA: Frequent or excessive flow
o POLYMENORRHEA: Bleeding at intervals w/in 21 days (more than 1 time)
- Most cases are either at Menarche (12-20) and in Perimenopausal periods
- Anovulatory Type: M.C type of DUB (M.C in 12-20 years old)
o Prolonged estrogen stimulation compared to Progesterone (absent secretory phase 
Endometrial Hyperplasia & excessive bleeding)
 Polycystic ovary, Functional ovarian tumor (making estrogen)
 Marked obesity or Malnutrition
o Treatment: OCP’s & progestational agents
- Inadequate Luteal Phase: (M.C type for women > than 40)
o This is an Ovulatory type of DUB (just to little progesterone)
o Causes inadequate maturation of the Corpus luteum
o Decreases serum 17-Hydroxyprogesterones (normal at 7 days is <14)
o Implicated in infertility & recurrent pregnancy loss
- Irregular shedding of the endometrium: (M.C type for women > than 40)
o This is an Ovulatory type of DUB (persistent Luteal phase)
o To much progesterone
 7 Endometrial path 2

BLEEDING AS A RESULT OF WELL DEFINED ABNORMALITY:

ACUTE ENDOMETRITIS:
- Most often do to bacterial infection following delivery or miscarriage
o Strep Agalactiae (Group B) is most common + neutrophils
- Clinically: fever, uterine tenderness, discharge and abdominal pain
CHRONIC ENDOMETRITIS:
- Chlamydia or Gonorrhea, Post partum or Post abortion’s (retained tissues), IUD’s, TB (miliary
spread or M.C do to drainage of TB salpingitis)
o IUD’s  Actinomycosis (makes sulfur granule sinus tracts)
- Clinical findings: abnormal bleeding
- Micro: Plasma cells & Macrophages (Neutrophils only in acute stages)
ENDOMETRIAL POLYPS:
- Composition: find glands & stroma
- Associated with: hyper-estrogenism or Tomoxifen therapy
- Clinical findings: at or near menopause; may cause bleeding
ENDOMETRIOSIS:
- Describes the presence of endometrial glands/stroma outside uterus (abnormal)
- M.C. in Ovaries, then the Uterine ligaments, rectovaginal pouch, peritoneum
- Clinical findings:
o Causes Infertility, dysmenorrhea, Pelvic pain (Dysperunia)
o This tissue responds to ovarian & intrinsic hormones  bleeding
o Painful stooling during menses (tissue in rectovaginal pouch is enlarged)
o Numerous hemorrhagic cysts over uterus & ovaries (differentiate from PID)
 More Scarring (from inflammation) than PID because endometriosis lasts longer
allowing more injury and repair (fibrosis)
- Pathogenesis:
o Regurgitation/Implantation: Retrograde bleeding thro fallopian tubes
o Vascular/lymphatic dissemination: thro pelvic veins & lymph (lung/LN)
- Morphology:
o Nodules – red/blue to Yellow/brown on or below the serosa
o Ovaries “Chocolate cysts” – Large masses (3-5cm) do to blood debris
- Micro: (Need 2 out of 3 for diagnosis)
o Endometrial glands OR Stroma (OR both) in ectopic locations
o Hemosiderin pigment in ectopic locations
ADENOMYOSIS: (related to endometriosis)
- Presence of endometrial tissue in the uterine Myometrium “infiltrates”
o “Blood filled spaces in the myometrium”
- Gross: Uterine enlargement, Irregular thickening of wall, Many small cysts
- Micro: Glands + Stroma in the myometrium (Cancer will NOT have stroma)*
- Clinically: Menorrhagia or Dysmenorrhea do to hemorrhage of foci
o Colicky dysmenorrhea, pelvic pain mostly during premenstrual period
o Enlarged Uterus, NO nodules or masses but has Menorrhagia & Pain*
ENDOMETRIAL HYPERPLASIA “Endometrial Intraepithelial Neoplasia”:
- May progress to endometrial carcinoma
- Caused by:
o Prolonged estrogen stimulation by anovulation or  estrogen production
o Menopause (Prolonged HRT), Early menarche or a Late menopause
o Polycystic ovary
o Functional ovarian tumors (granulosa/thecal tumor)
- Classifications:
o Simple (Cystic) – Low grade:
 Include both, Anovulatory & Endometrial Intraepithelial Neoplasia
 See glands of various sizes, Irregularity
 Largely do to persistent estrogen stimulation  atrophy
 7 Endometrial path 3

o Complex (adenomatous):
 Architectural atypia w/out cellular atypia (no nuclear changes)
 See crowding of glands, irregular branching glands
o Atypical (adenomatous w/atypia) – High grade (Intraepithelial Neoplasia)
 Architectural atypia with cellular atypia (see nuclear changes)
 25% risk of progression to adenocarcinoma
- Clinical Findings:
o Menorrhagia, Metrorrhagia, Menometrorrhagia, Post menopausal bleeding
- Treatment: OCP’s, Progesterone’s, or Hysterectomy if Atypia is present

TUMORS OF THE ENDOMETRIUM:

ENDOMETRIAL CARCINOMA:
- M.C invasive cancer of female genital tract – 7% of all invasive female cancer
o Now more prevalent than cervical cancer (do to early detection)
- Clinical finding: Abnormal postmenopausal bleeding***
- Endometriod adenocarcinoma:
o Relationship with obesity (maybe diabetic), Hypertension, Infertility
o Relationship with PTEN mutations & microsatellite instability
- Papillary serous adenocarcinoma:
o Usually in Older age and are Aggressive
o P53 mutations* in 80% of cases
- Gross: Localized polypoid OR diffuse tumor involving entire surface
- Diagnosis: PAP smear (Variable) or Curettage to histologically view lining
- Grading:
o Grade I: Well differentiated – recognizable glands
o Grade II: Differentiated adenocarcinoma w/partly solid areas (<50%)
o Grade III: Mostly solid/undifferentiated OR Serous/Clear cell (Always)

MYOMETRIUM TUMORS:
LEIOMYOMA’S: “Fibroids”
- 25% of women in reproductive age
- Estrogen responsive (increases during pregnancy)
- Sites: myometrium, uterine ligaments, Lower uterine segment, Cervix
- Classification: Intramural, Submucosal or Sub Serosal
- Clinical features:
o Uterine bleeding, Increased micturation frequency, Pain (infarction)
o Obstructive Delivery, cramping during menses
- Gross: Firm, white, solid, well circumscribed**
- Micro: Well encapsulated, Whorled spindle cells, Low mitotic rates
o Secondary changes  Hyalinization, Myxoid, and Mucinous etc…
LEIOMYOSARCOMA:
- Uncommon malignant neoplasm – Almost never from leiomyoma
- Peak incidence is 40-60
- Gross: Bulky masses invading uterine wall & projecting into uterine lumen
- Micro: Extremely well differentiated (anaplastic)
o Differentiate from leiomyoma by Atypia, Mytosis & necrosis