CP6-2 uterine pathology and pcos

Question 1

What is endometriosis?

Answer 1

Presence of ectopic endometrial tissue

Question 2

What is the epidemiology of endometriosis?

Answer 2

6-10% of women aged 30-40
10% of women in UK will suffer with endometriosis
10% of women worldwide have endometriosis

Question 3

What are four theories for the aetiology of endometriosis?

Answer 3

Regurgitation theory
Metaplasia theory
Stem cell theory
Metastasis theory

Question 4

How does endometriosis pathogenisize?

Answer 4

Endometrial bleeding into tissues can’t be removed so becomes fibrosed

Question 5

How do patients with endometriosis present?

Answer 5

25% asymptomatic
Dysmenorrhea
Dyspareunia (pain before, during or after sex)
Pelvic pain
Subfertility
Pain in passing stool
Dysuria

Question 6

What is the gold standard test for endometriosis?

Answer 6

Laparoscopy

Question 7

What is first line treatment for endometriosis?

Answer 7

NSAIDs
With progesterone only or combined contraceptive pill

Question 8

What is the definitive treatment of endometriosis?

Answer 8

Surgical ablation of lesions

Question 9

What is the prevalence of endometriosis associated infertility?

Answer 9

30-50%

Question 10

What are endometrial polyps?

Answer 10

Sessile/polypoid endometrial overgrowths

Question 11

What is the pathogenesis of endometrial polyps?

Answer 11

Inappropriate reaction of foci of endometrium to oestrogenic stimulation

Question 12

What is the epidemiology of endometrial polyps?

Answer 12

<10% of women aged 40-50

Question 13

How do patients with endometrial polyps present?

Answer 13

Often asymptomatic
Intermenstrual/post menopausal bleeding
Menorrhagia
Dysmenorrhea

Question 14

What percentage of women endometrial polyps will have abnormal uterine bleeding?

Answer 14

25%

Question 15

Are polyps usually benign or malignant?

Answer 15

Benign

Question 16

What are the two layers of the endometrium?

Answer 16

Stratum functionalis
Stratum basalis

Question 17

What percentage of hysterectomies have endometrial polyps (not reason for hysterectomy)?

Answer 17

10-24%

Question 18

What hormone stimulates growth of the endometrium?

Answer 18

Oestrogen

Question 19

What hormone opposes oestrogen to control/stop endometrial growth?

Answer 19

Progesterone

Question 20

What is endometrial hyperplasia?

Answer 20

Hyperplasia of the endometrium as a result of excess oestrogen

Question 21

What can increase risk of excess oestrogen/endometrial hyperplasia?

Answer 21

Obesity due to excess adipose tissue
PCOS
Oestrogen secreting tumours (e.g. granulosa cell tumours)
Early menarche
Late menopause
Not giving birth
Oestrogen only HRT
Tamixofen
Mutation of the PTEN tumour suppressor gene

Question 22

What can increase risk of excess oestrogen/endometrial hyperplasia?

Answer 22

Obesity due to excess adipose tissue
PCOS
Oestrogen secreting tumours (e.g. granulosa cell tumours)
Early menarche
Late menopause
Not giving birth
Oestrogen only HRT
Tamixofen
Mutation of the PTEN tumour suppressor gene

Question 23

What is the epidemiology of endometrial hyperplasia?

Answer 23

Incidence increases by 3x in over 40 year olds

Question 24

What is the pathogenesis of endometrial hyperplasia?

Answer 24

unopposed oestrogenic stimulation of the endometrium

Question 25

How does a patient with endometrial hyperplasia present?

Answer 25

abnormal bleeding

Question 26

What is simple hyperplasia?

Answer 26

When hyperplasia is present with a normal stroma to gland ratio

Question 27

What is complex hyperplasia?

Answer 27

Hyperplasia with increase glands and decreased stroma

Question 28

What is the risk of progression to endometrial cancer with simple and complex hyperplasia?

Answer 28

Simple = 1% Complex = 5%

Question 29

What percentage of simple and complex hyperplasia is associated with atypia?

Answer 29

Simple = 10% Complex = 30%

Question 30

How is endometrial hyperplasia treated?

Answer 30

Weight loss of obese Stopping unopposed oestrogen therapy Correcting anovulation e.g. treat PCOS Give progesterone medications to counteract effect of oestrogen Hysterectomy - remove uterus but often keep ovaries and Fallopian tubes

Question 31

What are the two types of endometrial adenocarcinomas?

Answer 31

Type 1 - endometriosis adenocarcinoma Type 2 - serous adenocarcinoma

Question 32

What is the epidemiology of endometrial cancer?

Answer 32

most common cancer of female genital tract with 9200 new cases/year and 2500 deaths/year in the UK

Question 33

What is the aetiology of endometrial cancer?

Answer 33

unnopposed E2 (aka estradiol) or mutation

Question 34

What is the pathogenesis of endometrial cancer?

Answer 34

hyperplasia progression and IEC origin for type 2 (serous)

Question 35

How do patients with endometrial cancer present?

Answer 35

similar to endometrial hyperplasia +/- symptoms of advanced metastatic disease e.g. weight loss, changes in bowel and bladder habits, loss of appetite, feeling full quickly, etc...)

Question 36

What are the characteristics of type 1 endometrial cancer?

Answer 36

most common of two types (incidence = 75%) effects pre- or perimenopausal women derives from endometrial hyperplasia. associated with PTEN and KRAS mutations estradiol +ve can be grade 1,2 or 3

Question 37

What are the characteristics of type 2 endometrial cancer?

Answer 37

least common of two types (incidence = 25%) effects postmenopausal women derives from endometrial atrophy. associated with P53 mutations estradiol -ve can only be grade 3

Question 38

What are the stages of endometrial cancer?

Answer 38

Stage 1a or b - 1a = endometrial and 1b = myometrial Stage 2 = cervical Stage 3a, b or c - 3a = ovary, 3b = vagina, stage 3c = lymph nodes Stage 4a or b - a = bladder or small bowel and b = liver

Question 39

What is lynch syndrome?

Answer 39

aka hereditary non-polyposis colorectal cancer is an autosomal dominant inherited condition which predisposes an individual to colorectal, endometrial and ovarian cancer in their lifetime. It is a result of a mutation in mismatch repair genes.

Question 40

What mutations are involved in Lynch syndrome?

Answer 40

Alteration in mist match repair genes e.g. MLH1, MSH2,

Question 41

What are myometrial tumours?

Answer 41

Benign smooth muscle tumours of the myometrium

Question 42

What is the epidemiology of myometrial tumours?

Answer 42

commonest gynaecological condition. black women have an increased risk

Question 43

What is the aetiology and pathogenesis of myometrial tumours?

Answer 43

Unknown aetiology but suspect due to E2/P4 stimulation resulting in benign monoclonal proliferation of smooth muscle cells

Question 44

How do patients with myometrial tumours present?

Answer 44

majority asymptomatic can present with: irregular bleeding, abdominal mass, bladder problems or abnormal uterine bleeding

Question 45

What is PCOS?

Answer 45

Polycystic ovarian syndrome - an endocrine disorder characterised by hyperandrogenism, ovulatory dysfunction, menstrual irregularities +/- polycystic ovaries and insulin resistance.

Question 46

What is the epidemiology of PCOS?

Answer 46

6-10% of women of reproductive age

Question 47

What is the aetiology and pathogenesis of PCOS?

Answer 47

Aetiology unknown although ?genetic mutation resulting in dysfunction in the hypothalamic-pituitary-ovarian axis causing too much LH, and no LH surge leading to no ovulation

Question 48

What are the symptoms of PCOS and what are they associated with?

Answer 48

Increased androstenedione causes hirsuitism, male pattern baldness and acne Insulin resistance causes increased weight and acanthosis nigiricans Infertility due to lack of ovulation causing amenorrhea or oligomenorrhea

Question 49

How is PCOS diagnosed?

Answer 49

pelvic ultrasound to look for follicles and cysts hormone tests to see if increased LH:FSH ratio and for increased androgen

Question 50

How is PCOS treated?

Answer 50

Weight loss - reduces inclusion resistance Metformin - increase insulin sensitivity Oral contraceptive - regulate cycle Clomiphene citrate - induces ovulation Ovarian drilling - punctures cystic ovary to induce ovulation Spironolactone - contraception required but treats hirsutism