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4 indications for endometrial biopsy?

Assess abnormal bleeding.
Assess infertility (other tests are done these days).
Evacuation of products of conception (part of ectopic pregnancy workup).
Assess response of endometrium to hormonal Tx (eg. tamoxifen).

1

What, simply, are you looking for in a endometrial biopsy to assess infertility?

Whether or not ovulation has occurred. -and thus if the endometrium is proliferative or secretory.

2

What's the first seen histological evidence of ovulation?

Abundant subnuclear granules.

3

What does proliferative endometrium look like, histologically? (name 2-3 things)

Round glands with stratified nuclei and frequent mitoses.
Dense stroma.

4

What does secretory endometrium look like, histologically? (name 2 things)

Gland nuclei are less stratified with subnuclear granules.
Stroma is full of edema.

5

What do you see in day 23-24 secretory endometrium? (name 4 things)

Marked edema.
Intraluminal secretions.
More blood vessels- "spiral arteries".
Pre-decidual cells.

6

What do you see in late secretory endometrium?

Confluent sheets of predecidua.
Lymphocytes.

7

What do you suspect if you see proliferative endometrium at day 18 of a woman's menstrual cycle?

Anovulatory endometrium.

8

Menorrhagia vs. metrorrhagia vs. menometrorrhagia?

Menorrhagia: heavy bleeding in amount and duration
Metrorrhagia: irregular bouts of bleeding, not necessarily heavy.
Menometrorrhagia: both heavy and irregular.

9

Definition of postmenopausal bleeding?

Bleeding that occurs at least 1 year after menopause.

10

What is dysfunctional uterine bleeding NOT?

It's not caused by a specific, otherwise defined pathological process.
It's not post-menopausal bleeding.

11

What IS dysfunctional uterine bleeding (DUB) caused by / indicative of?

Alteration in cyclical hormonal regulation of endometrium, usually indicative of ovulatory dysfunction.

12

What's a common histological finding in DUB? What is that?

Stromal and glandular breakdown.
No ovulation -> no progesterone -> proliferation continues.
When stroma and glands outgrow blood supply, they break down an slough off.

13

What is a specific histological finding that can be seen in the stromal breakdown of DUB?

Stromal blue balls.

14

What ages get DUB?

Adolescents - perimenopausal women.

15

Who gets endometrial atrophy? What causes it?

Largely post-menopausal women.
It's caused by a lack of estrogen.

16

How do endometrial glands change in endometrial atrophy?

They become cystic (and non-proliferative).

17

What age group gets endometrial polyps, most commonly?

4th and 5th decades.

18

Do endometrial polyps have the potential for malignant transformation?

No - though sometimes cancers are found within them incidentally when they're removed.

19

What is a endometrial polyp?

Focal hyperplasia of the basal endometrium.

20

What's seen in the histology of endometrial polyps? (3-4 things)

Dense stroma with enlarged blood vessels.
Glands irregular, dilated, and focally crowded.
Fragments of regular endometrium are present.

21

Do polyps respond to menstrual cycle hormones like the rest of the endometrium?

No, they do their own thing.

22

Review: What's a leiomyoma?

A benign smooth muscle tumor (in this context, of the uterus, but they can be elsewhere).

23

Who gets leiomyomas of the uterus?

Happens in women over 30, most commonly over 40.
More common in African American women (happens younger, more symptomatic)

24

3 pieces of evidence suggesting a hormonal role in leiomyoma?

Leiomyoma grows during pregnancy.
Abnormal gene expression -> increased sensitivity to estrogen.
Tamoxifen makes leiomyoma worse.

25

What does tamoxifen do?

It's an estrogen-receptor antagonist in breast tissue (why it's used for hormone-sensitive cancers).
But it's an estrogen-receptor AGONIST in endometrium. (which promotes leiomyoma growth, and increases risk for endometrial cancer)

26

3 classifications of leiomyoma by location?

Submucosal - extending into endometrium
Intramural - within myometrium
Subserosal - on the external surface of the uterus

27

What are 3 complications of a large, pedunculated subserosal leiomyoma?

Torsion
Infarction
Parasitization (breaks off from uterus and starts growing on adjacent structure)

28

Which type of leiomyoma is more likely to present as a palpable mass?

Subserosal.

29

Which type of leiomyoma is more likely to present with bleeding?

Submucosal leiomyoma