Disorders of the Endometrium and Myometrium

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Pandey, ROSSU, SEM4

What are the normal menstrual cycle phases?

1. Proliferative/follicular
2. Ovulation
3. Secretory/Luteal
4. Menstruation

What occurs in the Proliferative phase to the endometrium?

1. Small glands ad dense stroma
2. Mitosis within glands and stroma

What occurs in the Early Secretory phase to the endometrium?

1. Vacuolation of glandular epithelium
2. Ovulation leading to subnuclear vacuoles

What occurs in the Mid-Secretory phase to the endometrium?

1. Luminal secretion
2. Stromal edema

What occurs in the Late Secretory phase to the endometrium?

1. Spiral Arteries
2. Decidual stromal cells
3. Saw Tooth Glandular Pattern

Outline the Endometrium transformation in pregnancy:

1. Hypersecretory endometrium showing dilated glands
2. Decidual transfrmation of stromal cells
3. Infolding and vacuolation of the glandular epitheliam called the Arias-Stella Phenomenon

Identify the dilated glands in the endometrium in pregnancy:

Identify the Decidua in Endometrium in Pregnancy:

Identify Arias Stella in Endometrium in Pregnancy:

Identify Anovulatory Endometrium

Identify Endometrial Polyp

Identify Chronic Enometritis:

Identify Submucosal Leiomyoma:

What is the most common cause of Dysfunctional Uterine Bleeding?

Anovulatory Cycle

Discuss Anovulatory Uterine Bleeding:

Unknown etiology mostly, but can be due to a variety of syndromes:
Menarche or peri-menaupause
Endocrine disorders
Estrogen secreting ovarian tumors
Polycystic Ovary Syndrome
Marked Obesity
Severe Malnutrition
Chronic Systemic Disease

Outline the pathogenesis of Anovulatory Uterine Bleeding:

1. Failure of ovulation
2. Persistent and unopposed exposure to estrogen
3. Persistent proliferation of the endometrium
4. Ischemic necrosis and bleeding

What are the clinical features of Chronic Endometritis?

1. Abnormal bleeding
2. Pain
3. Discharge
4. Infertility

Which diseases can cause a secondary chronic endometritis?

1. Chronic PID in patients
2. Retained gestational tissue
3. Women with Intrauterine contraceptive devices
4. TB

Identify Chronic Endometritis:

What is the difference between Adenomyosis and Endometriosis?

Adenomyosis is endometrial tissue within the myometrium. It can be asymptomatic or bring blood, pain, or dyspereunia. There is an enlarged uterus. This is seen with endometrial glands in the myometrium.

Endometriosis is endometrial tissue in an abnormal location. There is cyclicl dysmenorrhea, dyschesia, dyspereunia, and bowel symptoms. There is "chocolate cyst of ovary". This is located in specific areas and the cysts are filled with brown fluid, endometrial glands, endometrial stroma, and hemosiderin.

Identify Adenomyosis:

Identify Endometriosis

What is the metastatic theory of the pathogenesis of endometriosis?

Endometriosis occurs due to the regurgitation of endometrial tissue. Or the Vascular / Lymphatic disemination.

What is the metaplastic theory of the pathogenesis of endometriosis?

That it is due to differentiation in the coelomic cavity.

Identify Chocolate Cyst

Identify Endometrial glands and hemosiderin:

Identify Adenomyosis Gross:

Identify Endometrial Glands within the Myometrium seen in Adenomyosis

Discuss Endometrial Polyps:

1. Due to a possible Tamoxifen administration
2. Dilated/Atrophic glands
3. Ulceration leads to uterine bleeding

Identify Endometrial Polyp Histo

Discuss Endometrial Hyperplasia:

1. Proliferation of endometrial glands
2. There is unopposed estrogen stimulation
3. Menorrhagia, Metrorrhagia
4. THIS INCREASES THE RISK OF ENDOMETROID ENDOMETRIAL CARCINOMA

Outline the pathology of Endometrial Hyperplasia:

1. Simple Hyperplasia with minimal gland croding and small cysts
2. Complex Hyperplasia with crowded back to back glands.
3. Atypical Complex Hyperplasia with nuclear pleomorphis and mitoses

Identify Simple Hyperplasia

Identify Complex Hyperplasia

What are the risk factors of Endometrioid Endometrial Carcinoma?

1. 55-65 yr
2. Unopposed estrogen and immunosuppression
3. Obesity, early menarche, late menopause, polycystic ovary syndrome, nulliparity, tamoxifen, DM, HTN

Identify Endometrioid Endometrial Carcinoma Histo:

What are the grades of Endometrioid Endometrial Carcinoma?

Grade 1- Well Differentiated has only glands
Grade 2- Moderately differentiated 50/50
Grade 3- Poorly differentiated >50% of solid areas

Discuss Non-Endometrioid Endometrial Carcinoma:

Seen in older women 65-75 years. Mostly due to an Estrogen Deficiency. This has a poor prognosis.
They are all poorly diferentiated.

Outline the natural history of non-endometrioid endomtrial carcinoma:

1. Atrophic Endometrium
2. Endometrial Intraepithelial Carcinoma
3. Serous Carcinoma

Identify Atrophic Endometrium:

Identify Endometrial Intraepithelial Carcinoma:

Identify Serous Carcinoma in Non-Endometrioid Endometrial Carcinoma:

What are the types of Non-Endometriod Endometrial Carcinoma?

1. Serous Carcinoma from endometrial surface epithelium
2. Clear Cell Carcinoma resembling gestational endometrium
3. Malignant Mixed Mullerian Tumor showing both glandular and stromal compartments are malignant

Discuss Type 1 Endometrial Carcinoma:

55-65 years old. This is due to unopposed estrogen, obesity, HTN, or DM. It is Endometrioid and is preceded by Hyperplasia.
Its unique markers are PTEN, MSI, B-catenin.
It spreads via lymphatics.

Discuss Type 2 Endometrial Carcinoma:

65-75 years old. This is seen with atrophy and thin plaque. Morphoogically it is serous, clear cell, and mixed mullerian tumor. The precursor is endometrial intraepithelial carcinoma

Discuss Leiomyoma:

Most common gynecological tumor. Location is submucosa, intramural, and subserosal.
Estrogen promotes their growth but does not initiate it.
There is no malignant transformation

What are the complications of a Leiomyoma?

Bleeding, spontaneous abortions, infertility

What is seen histologically in a Leiomyoma?

1. Bundles and Whorls of smooth mucle cells.
2. NO cellular or nuclear atypia
3. Low mitotic activity. But there is a mitotically active subtype

Discuss Leiomyosarcoma:

This is a "classical sarcoma" in that it is rapidly growing, hematogenously metastasizes, and is bulky and flashy.
There IS cellular and nuclear atypia!
It metastasizes to brain, lung and bones.

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