Lecture 26 Flashcards
(46 cards)
Describe the case of a 45yo woman (case 7)?
Her presenting complaint is: -urinary frequency. -menorrhagia. -dysmenorrhoea. 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:
-Infertility.
-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: -Pain. -Cysts. -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). -Diabetic. -Hypertensive. -Nulliparous.
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?
- You can do an ultrasound. The ultrasound will show a thickened endometrium.
- Pipelle biopsy - introduce a tube into the uterus. Not done under direct vision. Tricky procedure if patients are obese.
- 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:
- Obesity.
- Exogenous oestrogen (hormone replacement therapy = HRT or Tamoxifen for breast cnacer).
- PCOS.
- 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).
