What symptom is common to more or less every uterine condition?
Abnormal or dysfunctional uterine bleeding.
Review: What are the 3 layers of the uterus?
How are these layers further subdivided?
Serosa / Myometrium / Endometrium
Myometrium has 3 layers of smooth muscle.
Endometrium has a functional and basal zone.
Review: What causes the changes in endometrial structure during the menstrual cycle, and how does the structure change?
Proliferative phase driven by estrogen; both epithelial and stromal compartments grow (~3-4mm endometrial thickness).
Secretory phase driven by progesterone; glands become coiled and sacculated while stroma becomes epithelioid. Secretes glycogen.
Menstrual phase driven by loss of progesterone; spiral arteries spasm causing ischemia and shedding.
Endometritis can be classified as acute or chronic. Acute endometritis is generally bacterial.
What are the causes of chronic endometritis, and how is it diagnosed?
Chronic endometritis can be caused by retained products of conception (POC), PID, IUDs, and tuberculosis.
The histological hallmark is plasma cells in the endometrial stroma.
What disease is describe by presence of glands AND stroma outside of the uterus?
How does it appear grossly and on histology?
Often cystic; classic appearance on ovary is the "chocolate cyst". Histology reveals heavy staining of hemosiderin.
What complications can result from endometriosis?
How may it be treated?
Since the tissue is hormonally responsive, it cycles and bleeds which can cause reactive changes (fibrosis, adhesions). Pain, infertility, and increased risk of cancer at the ectopic site.
Medically (NSAIDs and aromatase inhibitors) or surgically.
T/F: Adenomyosis is a form of endometriosis.
True! It is endometrial tissue that is ectopically located. More or less.
How does adenomyosis present?
With enlarged, nodular myometrium.
Abnormal uterine bleeding, cystic bleeding, pain, infertility...
What can cause endometrial hyperplasia?
Describe its morphology and classification.
Estrogen exposure; for example, obesity, anovulation (unopposed), estrogen-producing tumors.
Increased gland:stroma ratio. Classified by architecture; atypia portends risk of endometrial carcinoma.
Describe the hyperplasia-carcinoma pathway of the endometrium.
Hyperplasia of the endometrium predisposes to Type I "endometroid" carcinoma. A series of tumor factors are expressed sequentially: PTEN, hMLH1, KRAS, MI, b-catenin and PIK3CA.
What morphological features are common to both Type I and II endometrial carcinoma?
Cellular atypia, mitoses
Describe the usual setting in which Type II endometrial carcinoma occurs.
How does it compare clinically to Type I?
Occurs in atrophic (not hyperplastic) background. p53 mutation is key.
Worse prognosis, more aggressive.
Between Type I and Type II endometrial carcinoma, which:
1. Occurs in older women?
2. Is more common?
3. Is also known as "serous"?
4. Is preceded by endometrial intraepithelial carcinoma (EIC)?
5. Features papillary growth?
1. Type II
2. Type I
3. Type II
4. Type II
5. Type II
Name five malignant neoplasms of the endometrium.
Endometroid carcinoma (Type I)
Serous carcinoma (Type II)
Clear cell carcinoma
Leiomyomas are the most common benign tumor in females.
Who usually gets them?
What symptoms do they present with?
How do they appear on gross exam and histology?
Estrogen-dependent; common in premenopausal women with a preponderance for African-americans.
Usually asymptomatic, may bleed.
Multiple, well-demarcated tumors of monoclonal smooth muscle cells.
How do leiomyosarcomas arise?
De novo from myometrial mesenchymal cells (IE not from leiomyomas!)
Singular lesion with hemorrhage, necrosis, mitoses and atypia.
What sites does leiomyosarcoma tend to metastasize to?
Pelvis, lungs, bones.
Between leiomyoma and leiomyosarcoma, which:
1. Appears "white and whirly"?
2. Is estrogen-dependent?
3. Frequently recurs?
4. Shrinks after menopause?
What other tumors may be seen in the myometrium (that is, besides fibroids and leiomyosarcoma)?
Endometrial stroma sarcoma
Malignant Mixed Mullerian Tumor (MMMT)
1. What condition features 6p21 rearrangements?
2. Is associated with PTEN mutation?
3. Occurs in higher prevalence in black women?
4. Is marked by hemosiderin?
5. Occurs more in the obese and/or anovulatory?
1. Endometrial polyps
2. Type I (endometrioid) carcinoma
3. Leiomyomas (fibroids)
5. Endometrial hyperplasia, and thus Type I carcinoma.