Flashcards in Gyn. Path. 1 Deck (50):
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).
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.
What's the first seen histological evidence of ovulation?
Abundant subnuclear granules.
What does proliferative endometrium look like, histologically? (name 2-3 things)
Round glands with stratified nuclei and frequent mitoses.
What does secretory endometrium look like, histologically? (name 2 things)
Gland nuclei are less stratified with subnuclear granules.
Stroma is full of edema.
What do you see in day 23-24 secretory endometrium? (name 4 things)
More blood vessels- "spiral arteries".
What do you see in late secretory endometrium?
Confluent sheets of predecidua.
What do you suspect if you see proliferative endometrium at day 18 of a woman's menstrual cycle?
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.
Definition of postmenopausal bleeding?
Bleeding that occurs at least 1 year after menopause.
What is dysfunctional uterine bleeding NOT?
It's not caused by a specific, otherwise defined pathological process.
It's not post-menopausal bleeding.
What IS dysfunctional uterine bleeding (DUB) caused by / indicative of?
Alteration in cyclical hormonal regulation of endometrium, usually indicative of ovulatory dysfunction.
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.
What is a specific histological finding that can be seen in the stromal breakdown of DUB?
Stromal blue balls.
What ages get DUB?
Adolescents - perimenopausal women.
Who gets endometrial atrophy? What causes it?
Largely post-menopausal women.
It's caused by a lack of estrogen.
How do endometrial glands change in endometrial atrophy?
They become cystic (and non-proliferative).
What age group gets endometrial polyps, most commonly?
4th and 5th decades.
Do endometrial polyps have the potential for malignant transformation?
No - though sometimes cancers are found within them incidentally when they're removed.
What is a endometrial polyp?
Focal hyperplasia of the basal endometrium.
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.
Do polyps respond to menstrual cycle hormones like the rest of the endometrium?
No, they do their own thing.
Review: What's a leiomyoma?
A benign smooth muscle tumor (in this context, of the uterus, but they can be elsewhere).
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)
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.
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)
3 classifications of leiomyoma by location?
Submucosal - extending into endometrium
Intramural - within myometrium
Subserosal - on the external surface of the uterus
What are 3 complications of a large, pedunculated subserosal leiomyoma?
Parasitization (breaks off from uterus and starts growing on adjacent structure)
Which type of leiomyoma is more likely to present as a palpable mass?
Which type of leiomyoma is more likely to present with bleeding?
How do endometrial polyps and submucosal leiomyoma look different on hysteroscopy?
Endometrial polyp: Opaque mucosa
Submucosal leiomyoma: Transparent serosa mucosa with very visible dilated blood vessels.
What's the cut surface of a fibroid look like?
White - tan
No necrosis or hemorrhage
Leiomyoma histological appearance, especially the nuclei?
Lots of smooth muscle
Nuclei are hypochromatic, but shaped the same with rare mitoses
Is leiomyoma a precursor lesion to leiomyosarcoma?
Nope. Leiomyoma doesn't (or perhaps does only very very rarely, like a benign mole on your skin) progress to cancer.
Who gets leiomyosarcoma?
Women over age 40, more common in African Americans.
How does leiomyosarcoma look, grossly?
More homogenous, not well-circumscribed, loss of whorls.
Hemorrhage and necrosis.
Softer, less rubbery mass.
Doesn't bulge from the whatever surface it's on (it's more infiltrative)
Histologic features of leiomyosarcoma?
Pretty much what you'd expect:
Increased cellularity with lots of atypia.
Invasion of nearby tissue and blood vessels.
Areas of coagulative necrosis.
"Bizarre giant cells"...
Endometrial tissue where it shouldn't be, outside the uterus, growing and bleeding and causing problems.
Who gets endometriosis?
Women of reproductive age... more frequently seen in women with infertility.
Risk factors for endometriosis?
Exposure to estrogen menses flowing out fallopian tubes)
Things that reduce risk for endometriosis?
Exposure to progesterone via...
Oral (or other progestin-containing) contraceptives
3 hypotheses regarding the pathophysiology of endometriosis? Which is most supported?
Transplantation - stuff in the uterus gets out, sets up shop elsewhere.
Metaplasia - peritoneum changes into endometriotic tissue.
Induction - undifferentiated mesenchyme becomes endometriotic tissue.
Transplantation is most supported.
What are the 2 most common sites of endometriosis?
What are 3 arguments supporting the transplantation hypothesis for endometriosis?
Menses backflow out fallopian tubes into pelvic peritoneum is very common.
Backflow would explain ovarian and pelvic endometriosis being the most common forms.
Endometriosis in distant sites can be explained by vascular/lymphatic spread or surgery.
Gross appearance of endometriosis?
Red and/or "black and blue" nodules on tissues.
What gross (grossly named) structure does endometriosis of the ovary often form?
Chocolate cyst. Yum.
Classic symptoms of endometriosis? (name 4)
Dysmenorrhea (secondary... whatever that means)
Dyspareunia (painful intercourse)
Unusual symptoms will vary with location.
What happens when endometriosis invades the colon?
It irritates the colon and causes thickening of the muscularis...
Basically endometriosis of the myometrium... a more local spread.
Same classic symptoms as endometriosis. More common.