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The endometrium & its pathology I&II Flashcards

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1
Q

What are the layers of endometrium?

A
  • compactum
  • spongiosum
    -basalis
    -junctional zone
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2
Q

what is the role of inflammatory cells?

A

inflammatory cells helps with implantation and menstruation

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3
Q

junctional layer

A

between basalis and myometrium
one cell thick
bimordial pattern of behaviour - partly basal and partly myometrial

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4
Q

What layers do you lose during ovulation?

A
  • compactum
  • spongiosum
    -basalis - anchors everything, you lose everything above it.
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5
Q

What causes bleeding?

A

drop in oesterogen and progesterone leads to bleeding in menustration

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6
Q

Menstruation

A
  • initiated by withdrawl if E and P
    -local mediators PG’s and platelet aggregating factor (PAF)
    -spiral artery vasoconstriction
  • ischaemia and tissue damage
  • spiral artery relaxation
    -shedding of functional endometrium
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7
Q

What brings blood to endometrium?

A

Spiral artery
during menstruation they constrict and this prevents blood getting into the endometrium so layers start to shed

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8
Q

What are different factors involved to control bleeding?

A

PGs = E and I relaxes SM and F2a and Tx constricts
interleukins = IL -8 , 13, 16 bring in other inflammatory cells
-tissue necrosis factors TNF + platelet aggregating factors stops bleeding
-matrix metallo - proteinases - help re - build tissue
-coagulation/ fibrinolysis
-junctional zone - intrinsic error that can cause bleeding

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9
Q

For normal menstruation you need a balance and regulation between ….

A
  • inflammatory cascade
  • coagulation cascade
  • fibrinolysis cascade
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10
Q

menorrhagia

A

too much bleeding

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11
Q

polymenorrhoea

A

bleeding too often more than one cycle every month

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12
Q

amenorrhoea

A

not regular monthly periods

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13
Q

Intermenustrual bleeding (IMB)

A

bleeding in between periods

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14
Q

Post -cotial bleeding (PCB)

A

bleeding straight after intercourse

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15
Q

What are types of abnormal uterine bleeding(AUB)?

A
  1. acute
  2. intermittent
  3. chronic
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16
Q

What are different factors of AUB?

A
  • frequency
    -regularity
  • duration
    -volume
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17
Q

what are examples of structural problems of the endometrium that cause abnormal uterine bleeding?

A
  • polyp
    -adenomyosis
    -leiomyoma
    -malignancy
    (PALM)
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18
Q

what are examples of non- structural problems of the endometrium that cause abnormal uterine bleeding?

A
  • coaggulation
  • ovulatory dysfunction
    -endometrial
  • latrogenic
    -not otherwise classified
    (COIN)
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19
Q

What are some pathological causes of abnormal vaginal bleeding?

A
  • fibroids - submucous
  • adenomyosis
  • endometrial pathology - benign adenomas or polyps , hyperplasia , carcinoma
  • cervical pathology - polyps, carcinoma
  • cervical infection - chlamydia
  • pregnancy!!!
    => if its none of above, it is dysfunctional uterine bleeding (DUB)
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20
Q

What are some intrauterine structural abnormalities and why are they important?

A

-submucous fibroids (leiomyomas) are associated with a threefold increased risk of abnormal bleeding - invariably menorrhagia
- endometrial polyps (adenomas) are more frequent in women with menustrual disorders
- casual/ causal - diagnostic bias?

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21
Q

Abnormal bleeding -aims

A
  • exclude pregnancy
  • exclude cervical pathology
    exclude focal benign intracavity pathology (polyps, submucous fibroids)
  • consider other endometrial pathology (>45)
  • use the least invasive method to achieve this
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22
Q

Endometrial abnormalities

A
  • dysfunctional uterine bleeding
  • endometrial polyps
    -endometrial hyperplasia
  • endometrial hyperplasia with atypia (mild to severe)
  • endomterial adenocarcinoma
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23
Q

What can it be if a woman presenting with menorrhagia and doesnt have obivous pathological or structural cause?

Study These Flashcards
A

-molecular level problem , cellular dysfunction
- it is a diagnosis of exclusion (DUB)

24
Q

Where does DUB occur?

Study These Flashcards
A

PGs = E and I relaxes SM and F2a and Tx constricts
interleukins = IL -8 , 13, 16 bring in other inflammatory cells
-tissue necrosis factors TNF + platelet aggregating factors stops bleeding
-matrix metallo - proteinases - help re - build tissue
-coagulation/ fibrinolysis
-junctional zone - intrinsic error that can cause bleeding

25
What are polyps?
- benign (adenomas are malignant) - focal/ individual problem -rest of endometrium is normal
26
Clinical examination - points in history:
Last menustrual period - was it normal? regular or irregular periods - cycle control (ovulation vs anovulation) - heavy -clots, flooding? -with bleeding between (IMB)? -PCB -pain medication , smoker, smear, operations contraception - hormonal vs non hormanl
27
Why do you experience pain in periods?
- ischemia - prostaglandins involved
28
overweight - why is too much oestrogen a problem?
testosterone -> oestrogen in fat tissue leads to breast development in males peripheral conversion (from ovaries) testosterone converted to oestrogen
29
clinical examination
- BMI -abdomen : distension, scar, pain, masses - bimanual : uterine size, adnexal masses, pain - cervix : polyps, suspect lesions
30
abnormal bleeding investigation
- pregnancy test where appropriate -Hb if heavy bleeding - swabs - endocervical (chylamydia) - cervical smear - only if due - transvaginal ultrasound +/- endometrial sampling +/- hysteroscopy - in patient or OPD
31
When do you perform hysteroscopy?
- putting camera in the uterus - put in saline to open up the walls of uterus - if TVS abnormal - Non - response to medical therapy - multiple risk factors for endometrial
32
positives of transvaginal sonography (TVS)
- can asses the relationship of fibroids to the cavity - has a high detection rate for polyps -assess function - anovulatory cycles - can reliably assess structures outside the uterus ( tubal and ovarian pathology) - well accepted by patients - relatively cheap with few complications
33
negatives of TVS
- periovulatory endometrium is hard to hide pathology in or imediately post menstrual to asses ET -cut off values for ET are arbitary in premenopausal women - @ 6mm post menstrual or 12 mm anytime in cycle - ultrasound is ideal for focal pathology but not good for predicting endometrial pathology - a biopsy is still needed in many cases
34
what is the difference between polyps and fibroids?
polyps - epithelial , lighter in colour fibroids - muscular, darker in colour
35
What are risk factors for significant endometrial abnormality?
- obesity (peripheral oestrogen production) - nullipartity - not having children -hormonal contraception -early menarche/ late menopause - length of E2 exposure - weak factor -Hypertension /Diabetes -anovulation , eg. PCOS - Genetics - FH breast/ endometrial/ colonic cancer - Lynch syndrome (HNPCC) , 5% genetic , 95% sporadic
36
endometrial hyperplasia
too much tissue growth - overgrowth and bleed alot more - initially simple but slowly becomes atypical with unopposed E2 then becomes a carcinoma
36
endometrial hyperplasia
too much tissue growth
37
unopposed oestrogen in obesity?
- aromatase enzyme in adipose tissue which converts testosterone -> oestrogen so BMI is vital factor , the more adipose tissue the more conversion - so aromatase blocking medicine helps
38
Why is unopposed oestrogen bad?
endometrial cancer risk is increased by exposure to endogenous and exogenous oestrogen - obesity -- peripheral conversion of androgen to oestrogen (aromatase) - BMI is the most vital factor - The more adipose tissue the more conversion -chronic anovlation eg. PCOS -follicular ovarian oestrogen production continues -progesterone only produced after ovulation -unopposed oestrogen - over years leads to hyperplasia and sometimes cancer
39
what factors do you need to consider when giving treatments for DUB?
- does she need or want treatment? - does she need contraception/desire pregnancy? -how much is the problem affecting her quality of life?
40
What are non-hormonal options for treating DUB?
=> non-hormonal needed for pregnant women bc hormones affects fetus, 1. tranexamic acid - anti fibronyltic 40-50% reduction in blood loss -corrects excessive fibrin breakdown in endometrium (affects plamsinogen action) 2. mefanamic acid 30% reduction in blood loss - NSAID : corrects PG imbalance to allow normal vasoconstriction and PG imbalance to allow normal vasoconstriction and platelet aggregation - Good for pain also!
41
What are hormonal options for treating DUB?
- Mirena IUS - 90% reduction blood loss - 30% amenorrheic - local high dose progestagen - thin endometrium - Kyleena new 4 year option -COCP - 20 -30% reduction in blood loss - Removes cyclincal events - thin endometrium -Progestagens less beneficial for volume loss - use to control cycle length in anovulatory DUB
42
What are some treatment options for DUB?
- surgery - for failed medical treatment -Endometrial resection/ ablation - Hysterectomy : vaginal/ abdominal - Remove ovaries?
43
Menorrhagia management
See image
44
Treatments for polyps and fibroids
polyps: surgery TCRP Fibroids: - medical Mirena IUS or Kyleena -surgery TCRF/ Myomectomy - Hysterectomy : total/ subtotal abdominal, vaginal
44
Treatments for polyps and fibroids
polyps: surgery TCRP Fibroids: - medical Mirena IUS or Kyleena -surgery TCRF/ Myomectomy - Hysterectomy : total/ subtotal abdominal, vaginal
44
What is the method of examining real cases?
- How old is patient ( 45) -is the cycle regular? -is there erratic bleeding? - Do you need to investigate the endometrium? - if so, how? -Treatment?
45
Real cases
- 41 year old - heavy periods for 9 months - bleeds for 9 days evry 28 reg (K= 9/28) - Affecting ability to go work -NO IMB or PCB - Smear 2 years ago - normal - contraception - condoms - no other relevant medical or family history is she likely to have significant endometrial abnormality? Any other likely diagnoses?
46
Case 1- TVS normal, no polyps or fibroids , no contraception interfering with cycle
Diagnosis : DUB
47
case 1 : treatment
volume control - tranexamic acid - mefanamic acid - mirena IUS
48
Case 2: <45 y/o, TVS normal, no polys or fibroid, heavy period, 65 days cycle
Diagnosis : DUB , abnormal cycle so anovulatory bc of 65 days cycle
49
case 2: treatment
- volume and cycle control volume: -tranexamic acid - mefanamic acid -mirena IUS cycle control : -combined oral contraceptive pill
50
Case 3: 45 year old, IMB for last 6 months, K = 5/29 regular, contraception condoms , smear 1 year ago - normal , no other medical history notes
- TVS - polyps : that could be causing the IMB for last 6 months - hysteroscopy - to remove the polyp
51
Case 4: 51 y/o, heavy bleeding most days last 3 months, cycles used to be irregular (every 2-6 months), Gynae history of PCOS, Nulliparous, contraception - condoms, medical - obesity /NIDDM/ High BP
TVS - thickened endometrium - no discrete polyp seen Endometrial biopsy
52
Endometrial abnormalities
- most menorrhagia is DUB and treatments reflect the dysfunction - exclude focal pathology - needs focal removal - beware erractic bleeding - pathology much more likely - TVS and biopsy +/- hysteroscopy diagnosis in nearly all

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