Pathology of the Female Reproductive Tract Part 2​

Question 1

Menses refers to blood and other matter being discharged from the uterus at menstruation. What is the normal durational range for menses?

Answer 1

• 24-35 days

- not normal if you fluctuate from 25 in one cycle then 35 in another cycle

Question 2

What is the cycle and what is the normal cycle length (regularity) of menses?

Answer 2

• number of days from 1st day of bleeding in one menstrual cycle
• <7-8 days

Question 3

What is the normal duration of bleeding?

Answer 3

• <7-8 days

Question 4

What is the definition of normal and abnormal bleeding as part of a menstrual cycle?

Answer 4

• normal = blood flow that doesn’t affect normal life

- abnormal = blood flow that impacts on normal life, clots of flooding

Question 5

What marks the beginning of a new menstrual cycle?

Answer 5

• 1st day of bleeding

- ovulation occurs 14 days prior to the next beginning of a cycle

Question 6

What is inter-menstrual bleeding?

Answer 6

• inter = between

- bleeding inappropriately between cycles

Question 7

What is post coital bleeding?

Answer 7

• coitus is latin for coming together (sex)

- spotting or bleeding that occurs after intercourse

Question 8

What is menopause?

Answer 8

• woman no longer has periods

- duration of >1 year

Question 9

What is acute and chronic abnormal uterine bleeding (AUB)?

Answer 9

• abnormal with no pattern bleeding not associated with anything
• acute = <6 months
• chronic = >6 months

Question 10

What is the International Federation of Gynaecology and Obstetrics (FIGO)?

Answer 10

• international classification of abnormal uterine bleeding

Question 11

The International Federation of Gynaecology and Obstetrics (FIGO) is the international classification of abnormal uterine bleeding (AUB). What does the PALM acronym as part of the FIGO classification of PALM-COEIN refer to?

Answer 11

• refers to structural changes causing AUB
• P = polyps
• A = adenomyosis (adeno = gland, myo = muscle and osis means condition)
• L = leiomyoma (leio = smooth, myo = muscle = fibroids)
• M = malignancy and hyperplasia

Question 12

The International Federation of Gynaecology and Obstetrics (FIGO) is the international classification of abnormal uterine bleeding (AUB). What does the COEIN acronym as part of the FIGO classification of PALM-COEIN refer to?

Answer 12

• refers to non-structural causes of AUB
• C = coagulopathy
• O = ovulatory dysfunction
• E = endometrial
• I = iatrogenic
• N = not yet classified

Question 13

The International Federation of Gynaecology and Obstetrics (FIGO) is the international classification of abnormal uterine bleeding (AUB). The PALM acronym as part of the FIGO classification of PALM-COEIN refers to structural changes causing AUB:

• P = polyps
• A = adenomyosis (adeno = gland, myo = muscle and osis means condition)
• L = leiomyoma (leio = smooth, myo = muscle = fibroids)
• M = malignancy and hyperplasia

How can these changes be assessed?

Answer 13

• imaging and histology

Question 14

What are the 5 clinical features of a red flag that suggest gynaecological caner?

Answer 14

• Post coital Bleeding (after sex)
• Postmenopausal Bleeding (following menopause)
• Intermenruel bleeding (between periods) that is recurrent
• pelvic mass
• cervix lesion
• abnormal bleeding when on hormone therapy
• failure of treatment after 3 months

Question 15

Assessment of the uterus and endometrium is conducted in women at high risk of benign or malignant genital tract pathology. This essentially comprises of three components, what are the 3 components?

Answer 15

1 - pelvic ultrasound
2 - hysteroscopy
3 - endometrial biopsy

Question 16

What is the difference between colposcopy and hysteroscopy?

Answer 16

• colposcopy = imaging device to study cervix

- hysteroscopy = imaging device to study uterine walls

Question 17

Postmenopausal bleeding is bleeding, generally in older adults following the cessation of their periods. What % of the bleeding is due to a thickened endometrium and endometrial cancer?

Answer 17

• 96% of endometrial cancer is due to endometrial thickening

- 10-12% then become cancerous but all need investigating

Question 18

Postmenopausal bleeding is bleeding, generally in older adults following the cessation of their periods. 96% of the bleeding is due to a thickened endometrium because of endometrial cancer. What thickness would then trigger the need to perform a hysteroscopy?

Answer 18

• > 4mm

Question 19

What are the main causes of postmenopausal bleeding?

Answer 19

• polyps = 30%
• submucosal fibroids = 20%
• endometrial atrophy = 30%
• hyperplasia = 8–15%
• endometrial carcinoma = 8–10%
• ovarian, tubal, cervical malignancy = 2%

Question 20

If a woman has begin taking hormone replacement therapy and and she continues to have postmenopausal bleeding, what needs to be done?

Answer 20

• referred for further investigation

Question 21

What is Tamoxifen?

Answer 21

• medication for breast cancer

- increases risk of developing endometrial hyperplasia or cancer

Question 22

What are fibroids?

Answer 22

• leiomyomas (leio = smooth, myo = muscle)
• smooth muscle tumours (myometrium layer of endometrium)
• <1% become malignant

Question 23

Fibroids are leiomyomas (leio = smooth, myo = muscle), smooth muscle tumours where <1% become malignant. Which population are these most common in?

Answer 23

• African-Caribbean women

Question 24

Fibroids are leiomyomas (leio = smooth, myo = muscle), smooth muscle tumours where <1% become malignant. How do we known if the fibroid has potentially become malignant (sarcoma - cancer in connective tissue)?

Answer 24

• if patient has pain
• if patient has abnormal bleeding
• if fibroid grows exponentially

Question 25

What is a lesion?

Answer 25

- damage or abnormal change in the tissue of an organism | - usually caused by disease or trauma

Question 26

What is a pre-invasive lesion of the endometrium?

Answer 26

- histopathological and molecular alterations of the endometrium - related to high-risk of uterine carcinoma development

Question 27

What is endometrial hyperplasia?

Answer 27

- hyperplasia means to increase cell number | - thickening of the endometrium

Question 28

Endometrial hyperplasia is thickening of the endometrium. What hormone drives endometrial hyperplasia?

Answer 28

- estrogen | - unopposed continues secretion

Question 29

Endometrial hyperplasia is thickening of the endometrium, driven primarily by estrogen. There are 2 types of endometrium hyperplasia, what are they?

Answer 29

1 - simple hyperplasia = proliferative lesion with minimal glandular complexity and crowding with abundant stroma between glands (can progress to complex) 2 - complex hyperplasia = proliferative lesion with severe glandular complexity and crowding as well as minimal stroma between glands

Question 30

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. Would the combined pill cause endometrial hyperplasia?

Answer 30

- no | - estrogen is not unopposed as there is progesterone as well

Question 31

Endometrial hyperplasia is thickening of the endometrium, driven primarily by unopposed secretion of estrogen. If a patient has non-atypical simple of complex endometrial hyperplasia, what treatment could you provide?

Answer 31

- high dose progesterone

Question 32

Why is obesity associated with endometrial hyperplasia?

Answer 32

- adipocytes convert the precursor of estrogen, esteron into estrogen

Question 33

What are some of the main risk factors for developing endometrial hyperplasia and endometrial cancer?

Answer 33

- age - obesity/diabetes - polycystic ovary syndrome (unopposed estrogen and obesity) - hypertension - family history

Question 34

What is the gold standard for diagnosing endometrial hyperplasia and endometrial cancer? 1 - hysteroscopy and endometrial biopsy 2 - ultrasound 3 - MRI 4 - colposcopy

Answer 34

- hysteroscopy and endometrial biopsy | - confirmed with histology

Question 35

The gold standard for diagnosing endometrial hyperplasia and endometrial cancer is hysteroscopy and endometrial biopsy. What method should be used to assess the level the cancer has invaded if cancer is confirmed? 1 - X-ray 2 - ultrasound 3 - MRI 4 - colposcopy

Answer 35

3 - MRI

Question 36

There are 2 types of endometrial cancer, what are they?

Answer 36

- type 1 = endometrioid adenocarcinomas linked to estrogen | - type 2 = not linked to excess oestrogen

Question 37

The gold standard for diagnosing endometrial hyperplasia and endometrial cancer is hysteroscopy and endometrial biopsy. If cancer has been confirmed then lymphadenopathy should be performed. What 2 areas in the body should be scanned if the patient has type 1 cancer (estrogen related)? 1 - head and chest 2 - chest and pelvis 3 - abdomen and pelvis 4 - abdomen and head

Answer 37

3 - abdomen and pelvis

Question 38

The gold standard for diagnosing endometrial hyperplasia and endometrial cancer is hysteroscopy and endometrial biopsy. If cancer has been confirmed then lymphadenopathy should be performed. The pelvis and abdomen are the 1st 2 areas to scan, but what other area in the body should also be scanned if the patient has type 2 cancer (non estrogen related)? 1 - head 2 - chest 3 - abdomen 4 - pelvis

Answer 38

2 - chest

Question 39

There are 2 types of endometrial cancer: - type 1 = endometrioid adenocarcinomas linked to estrogen - type 2 = not linked to excess oestrogen Which is more dangerous?

Answer 39

- type 2 cancers

Question 40

In stage 1 of endometrium cancer where does the cancer remain?

Answer 40

- myometrium invasion | - generally good survival if detected here (95%)

Question 41

A 51-year-old woman presents with a 2 month history of postmenopausal bleeding. Her periods stopped last year and she has been using continuous combined hormone replacement therapy for 9 months. A transvaginal ultrasound scan revealed a normal-size anteverted uterus with normal ovaries and an endometrial thickness of 3 mm. Clinical examination was unremarkable. What is the most appropriate management? 1 - cervical smear 2 - endometrial biopsy 3 - change to cyclical hormone replacement therapy and further investigation 4 - inpatient hysteroscopy 5 - cease hormone replacement therapy and investigate further if symptoms persist beyond 6 weeks

Answer 41

5 - cease hormone replacement therapy and investigate further if symptoms persist beyond 6 weeks

Question 42

A 50-year-old patient with a BMI of 20 and one episode of postmenopausal bleeding presents to the clinic. She is otherwise asymptomatic. Abdominal and pelvic examination is unremarkable and the endometrial thickness is 6 mm. An outpatient hysteroscopy and biopsy is arranged and the cavity is noted to be 8 cm in length and an adequate sample is taken. The endometrium was noted to be atrophic at hysteroscopy and the cavity normal. At 2 weeks later, the histology report reads "some inactive endometrium but sample insufficient for diagnostic purposes". On reading the histology report, what would be the most appropriate action? 1 - Arrange MRI of pelvis 2 - Arrange an urgent hysteroscopy and curettage under general anaesthesia 3 - Discharge the patient from the clinic and ask the GP to re-refer them should they have a further episode of bleeding 5 - Recommend the GP start hormone replacement therapy 6 - Review the patient in clinic in 6 months and repeat endometrial sampling

Answer 42

3 - Discharge the patient from the clinic and ask the GP to re-refer them should they have a further episode of bleeding - if bleeding persisted then GP would need to refer back