FGT 3: Endometrium 1

endometrial polyp. how can it cause bleeding?

Hyperplastic protrusion of endometrium; can prolapse, tear off --> abnormal uterine bleeding

endometrial hyperplasia

Increased proliferation of endometrial glands relative to the stroma

Mid-secretory phase histo

Luminal secretions and stromal edema

Tumor suppressor gene mutated in endometrial hyperplasia (and endometrial carcinoma)

PTEN

chronic endometretis causes? (4)

Pelvic inflammatory disease, IUDs (foreign body), retained products of conception (e.g. placenta), TB

Late secretory phase histo

Prominent spiral arteries (supply the endometrium) and predecidual stromal change

What phase begins after ovulation? UNDERSTANDING

Secretory phase

Early secretory phase histo

Subnuclear vacuoles

What is a common cause of hemorrhage in the myometrium?

adenomyosis

adenomyosis

adenomyosis Extension of endometrial glands and stroma into the myometrium

What is the most common cause of dysfunctional uterine bleeding? Seen in what patients?

anovulatory cycle menarche and menopause

Which layer of the endometrium is always preserved during the menstrual phase?

basal layer (doesn't get sloughed off)

endometriosis. due to?

benign, hormonally sensitive endometrial tissue *outside of the uterus* (undergoes normal menstrual cycle) due to regurgitation of sloughed off endometrium through Fallopian tubes, into peritoneum --> implant at other site

acute endometritis arises in what setting?

caused by *bacterial infections* arising after delivery/miscarriage (from *retained products of conception, e.g. placenta* - nidus of infection)

tx for pt with endometrial hyperplasia (with cytologic atypia) that would like to become pregnant in the future?

continuous progestin and close follow-up --hysterectomy once done having kids

Days of the menstrual phase of the endometrium

days 0-4

Days of secretory phase of endometrium

days 15-28

Days of the proliferative phase of endometrium

days 4-14

endometriosis presentation. complication?

dysmenorrhea (pain during menstruation), pelvic pain can cause *infertility* (b/c can happen on Fallopian tube--> tubal scarring --> infertility --> egg has trouble moving to uterus to implant)

What is a "*chocolate cyst*"?

endometriosis of the ovary -- due to accumulation of old blood in the cyst (b/c implants in the ovary, grows/sheds, grows/sheds, etc.)

Presentation of acute endometritis (3)

fever, pelvic pain, abnormal uterine bleeding

Gestational endometrium has ______ changes on histology. This is called the ____-_____ reaction.

hypersecretory; Arias-Stella

Histo of menstrual phase

in the endometrium: neutrophilic infiltrate, necrosis and hemorrhage --b/c acute inflammation following necrosis (to clean up necrotic debris)!!!

How does an inadequate luteal phase cause dysfunctional uterine bleeding?

inadequate corpus luteum --> inadequate production of progesterone to maintain the secretory endometrium

endometriosis can give rise to?

malignant transformation to endometrioid/clear cell ovarian carcinomas note: requires malignant transformation b/c the initial tissue is benign

Cystic atrophy is associated with what cause of dysfunctional uterine bleeding? What is cystic atrophy?

menopausal/postmenopausal changes glands are cystically dilated, endometrium is atrophied

3 phases of menstrual cycle? UNDERSTANDING

menstrual phase, proliferative phase, secretory phase

Term for bleeding between periods Term for excessive bleeding during period

metrorrhagia (bleeding between periods) menorrhagia (excessive bleeding during period)

What process initiates the secretory phase of the endometrium?

ovulation (usually at day 14)

importance of endometrial hyperplasia?

precursor for endometrial carcinoma -- especially endometrial hyperplasia with *cytologic atypia*

What is the main determinant as to whether a woman with endometrial hyperplasia will develop endometrial carcinoma?

presence (or absence) of cytologic atypia

Type of endometrium seen in a biopsy of an anovulatory cycle patient

proliferative endometrium; glands present with stromal breakdown -- due to unopposed estrogen

when does endometriosis present?

reproductive age -- due to hormonal-sensitivity

Endometrial polyps are associated with what drug?

tamoxifen (anti-estrogen for breast cancer) -- this is b/c it has pro-estrogen effects in the endometrium --> endometrial hyperplasia

What histological feature helps to Dx endometrial polyps? Why are these present?

thick walled vessels -- need thick vessels so that the polyp is not sloughed off during menstruation

Histo of proliferative phase

tubular, elongated glands, glandular and stromal mitoses; no luminal secretions

endometrial hyperplasia presentation

uterine bleeding in *post menopause*

Tx for endometrial hyperplasia with cytologic atypia? without?

with cytologic atypia: hysterectomy without cytologic atypia: cyclic progestin

Histological findings in endometriosis (3) - common sense

- benign endometrial glands - benign endometrial stroma - hemorrhage

2 most common locations of cutaneous involvement of endometriosis. What are the implants (of tissue) called?

- periumbilical region - C section scar -- implants are called *gun powder nodules* note: endometriosis can arise in virtually any part of body

asymptomatic pt w/ chronic endometritis should be tested for what organisms?

--b/c these cause Pelvin inflammatory disease

What are the 2 types of abnormal uterine bleeding? Due to?

1. organic -- due to lesion (e.g. carcinoma) 2. dysfunctional -- usually due to hormonal imbalance

chronic endometritis buzzword

*Plasmacytes* (plasma cells) in the endometrium --normally, no plasma cells in endometrium

Endometrial hyperplasia is caused by (3)

*unopposed estrogen stimulation* (obesity, polycystic ovarian disease, estrogen replacement therapy)

What is the cause of an anovulatory cycle?

*unopposed estrogen*; endometrium keeps proliferating until outgrows blood supply --> proliferative glands break down, slough off --> bleeding

What begins the proliferative phase? What's happening in the proliferative phase? UNDERSTANDING

GnRH from hypothilamus stimulates ant. pituitary --> FSH, LH release --> development of primary follicle --> primary follicle produces estrogen --> estrogen stimulates endometrial proliferation

What happens to the corpus luteum? What results? UNDERSTANDING

Corpus luteum degenerates to corpus albcians --> decreased estrogen, progesterone --> endometrium cannot support implantation --> endometrium sloughs off (menstrual phase)

What causes the LH surge? What does the LH surge do? What results? UNDERSTANDING

Estrogen stimulates GnRH from hypothilamus, stimulates FSH, LH from ant. pituitary --> inc. LH, FSH --> LH causes developing follicle to rupture (ovulation), releasing oocyte and forming corpus luteum

What does the corpus luteum produce? UNDERSTANDING

Estrogen and progesterone; progesterone maintains endometrium to support implantation