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Describe the case of a 45yo woman (case 7)?

Her presenting complaint is:
-urinary frequency.
OE: large uterus.
Imaging: circumscribed myomerial mass.


What are the possible causes of the 45yo woman?

Could possibly be a benign tumour of the smooth muscle, could be malignant. Or it could be metastases (other tumours from outside).


What is the macroscopic appearance of a benign leiomyoma?

Circumscribed solid cream nodules within the myometrium.


Why do leiomyoma's cause menorrhagia and dysmenorrhoea?

They increase the surface area of the endometrial cavity, so there is excess bleeding. As the uterus contracts around the nodules it can cause pain.


What are leiomyoma's?

They are benign smooth muscle tumours. These are common and they are hormone receptive; regress following menopause.


What are leiomyosarcoma?

They are malignan tumours of smooth muscle.


What is the macroscopic appearance of leiomyosarcoma's?

There is a necroic core, haemorrhagic, bigger and heterogenous cut surface.


What is the microscopic appearance of a leiomyoma?

Colelction of smooth muscle cells that are arranged in new growth formation. There are cigar shaped nuclei with pink elongated cytoplasm.


Describe the case of the 40yo woman (case 8)?

Presenting complaint:
-Cyclical abdominal pain and blood in her urine.
OE: Nil.
Laparotomy was performed - where they saw cherry red nodules on the peritoneum that look slightly cystic.


What are the possible causes of the 40yo woman?

Fibroids, endometriosis, leiomyoma or a primary endometrial pathology.


What is the macroscopic appearance of endometriotic cysts?

They appear as chocolate cysts (brown material).


What is the microscopic appearance of endometriosis?

There are endometrial type glands and stroma surrounding glands. Sometimes there are changes in surrounding tissue that is due to fibrosis or an increase in macrophages.


Where does endometriosis occur?

Most commonly in the ovaries, also uterine ligaments and rest of gynae tract.


Why is endometriosis a problem?

Endometriosis responds to hormones during the menstrual cycle and it bleeds into adjacent tissue during menstruation. This causes:
-Tissue inflammation.
-Infertility/ectopic pregnancy.
It can also give rise to malignancy.


Describe the case of the 37yo woman (case 9)?

Presenting complaint:
-very heavy and irregular periods for 5 months.
Past history:
-Morbidly obese (BMI = 52).


What are the possible causes of the 37yo woman?

Polycystic ovarian syndrome.


What are the possible causes of the 37yo woman?

Polycystic ovarian syndrome, could have leiomyomas or incidental endometriosis.


Why does PCOS cause heavy menstrual bleeding?

In PCOS patients their primary follicles always mature however they never ovulate. This means that the patient's hormonal cycle are always mainly oestrogen production (so always increasing the endometrial lining of blood). This causes the endometrium to proliferate so much so that it will leak out of the vagina as the uterus cannot hold that much blood. It will seem like a period, however, it isn't and thus periods will appear as irregular.

N.B. Excess proliferation can lead to cancer as well.


How do we investigate abnormal bleeding?

1. You can do an ultrasound. The ultrasound will show a thickened endometrium.
2. Pipelle biopsy - introduce a tube into the uterus. Not done under direct vision. Tricky procedure if patients are obese.
3. Curettage (D & C) - the cervix is dilated up and an instrument is introduced into the cervix to scrape some tissue out.


What is the macroscopic appearance of PCOS endometrium?

Thick, irregular, shaggy, cream and it is starting to invade into underlying endometrium (where the endometrium ends and myometrium starts is blurred).


What is the microscopic appearance of endometrial carcinoma?

The glands proliferate and become increasingly crowded and complex - irregular and thicker.


What are the various causes of excessive oestrogen?

Various conditions can lead to excessive oestrogen exposure over a lifetime:
-Exogenous oestrogen (hormone replacement therapy = HRT or Tamoxifen for breast cnacer).
-Hormone secreting tumours.
-Early menarche, alte menopause.
-Nulliparity (pregnancy is a progestogenic state).


What happens if there is too much oestrogen?

There is over stimulation of the endometrium - the endometrium becomes too thick and can outstrip the blood supply. The endometrium breaks down and sheds as "irregular bleeding". It also may udnergo mutation and develop into neoplasia (hyperplasia or cancer).


What is the epidemiology of endometrial carcinoma?

Strong environmental risk factors relate to westernisation of lifestyle and obesity. Most risk factors appear related to oestrogenic stimulation of endometrium. Effects of overweight and obesity on cancer risk are largely mediated by increased oestrogen levels (mainly through peripheral conversion of androstenedione to estrone by adipocytes).


Describe the case of the 22yo woman (case 10)?

Presents with her first smear (can either get the smear though the conventional way of by a cytobrush). In this patient there were changes of a low grade lesion.


What is cytology?

You get your diagnosis by examing the structure of individual or groups of cells. Usually no architecture is present. Cytology specimens obtained via:
1. Cervical smear/brushing.
2. fine needle aspiration.
The tissue is put onto a glass slide and is screened by a cytology technologist and if abnormal it is reviewed by a pathologist.


What is the microscopic appearance (cytology slide) of dysplasia?

The size of the nucleus in relation to the cytoplasm has changed, the nuclei is bigger and more hypochromatic and variation from nucleus to nucleus (irregularity).

There are two grades:
1. Low grade (CIN 1).
2. High grade (CIN 2-3).


What causes low grade dysplasia of the cervix (CIN 1)?

STI's - HPV. this causes a mucosal break in the surface so the virus becomes integrated into the cell. the virus will then become interated into the cell's DNA - replication of the viral genome will alter the cell cycle. Unchecked proliferation and then mutations.


What happens once the PAP smear has occurred?

The report will go back to the cervical screening register in NZ. There will be a smear in 12 months to reassess.


Describe the case of the 24yo woman (case 11)?

Previous smear 3 years ago was normal and the smear now, she presents with a high grade dysplasia (CIN 2/3).