Obgyn - Path Of Endometrium And Myometrium

Front 1

Description of Endometrium... what is the hormone responsible?

- Proliferative Phase
- Secretory Phase
- Menstrual Phase
- Pregnancy
- Post-Menopausal

Back 1

Proliferative Phase (prior to ovulation) - Day 1-14
- Estrogen
- Glands straight, tubular
- Stroma dense, mitotically active
- Increased tortuosity of spiral arteries

Secretory Phase (after ovulation) - Day 14-18
- Progesterone
- Glands complex
- Increased tortuosity of spiral arteries
- More elaborate venous drainage
- Stroma edematous, eventually pseudodecidual (day 23-27)

Menstrual Phase (if no fert)
- Estrogen and Progesterone fall
- Glands degenerate
- Stroma infiltrated by neutrophils

Pregnancy
- HCG
- Endometrium thick and hypersecretory = Aria-Stella Rxn
- Hobnail Cells

Post-Menopausal
- Estrogen withdrawal
- Endometrium inactive
- Glandular epithelium atrophies

Front 2

Aria-Stella Reaction
- what is?
- clinical issue?

Back 2

Condition of pregnant uterus stimulated by HCG --
- endometrium becomes thick and hypersecretory
- hobnail cells
- BENIGN
- seen in cells from curettage after spontaneous abortion

***Can mimic carcinoma (endometrial/ovarian)

Front 3

Hobnail Cells

Back 3

- Seen in histo of pregnant uterus during Aria-Stella Rxn
- Cells protrude into lumen and have abundant granular cytoplasm

Front 4

Oral Contraceptives
- effect on endometrium?
- rates of carcinoma? why?

Back 4

- interferes with normal cycling, so endometrial biopsies may have asynchronous morphologic features

- reduced rates of ovarian and endometrial carcinoma due to inhibition of ovulation and growth-inhibiting properties of progesterone-containing preparations

Front 5

Dysfunctional Uterine Bleeding (DUB)
- causes?

Back 5

- may develop secondary to uterine pathology
- may be due to hormonal imbalance in the hypothal-pit-ovarian axis --> anovulation
.... In absence of ovulation, estrogen effects persis - endometrium remains in proliferateive phase
.... No progesterone support, so vascular changes dont occur properly, endometrium inappropriately breaks down and bleeding occurs
*Can occur even in the presence of ovulation of the CL doesnt produce enough progesterone (secretory phase is shortened with premature bleeding)

Front 6

Endometritus
- what is?
- causes: acute v. chronic
- histo: acute v. chronic
- presentation?
- can lead to?

Back 6

= abdnormal inflammatory infiltrate within endometrium

- ACUTE - due to ascending cervical infection
- histo: infiltrate of neutrophils

- CHRONIC - due to IUD, PID, retained product of conception after delivery/abortion
- infiltrate of plasma cells and lymphocytes

Presentation: abnormal bleeding and/or pelvic pain

If endocervical canal becomes occluded, PYOMETRA - purulent material --> long standing, can cause squamous endometrial carcinoma

Front 7

Adenomyosis
- what is?
- gross presentation?
- histo?
- clinical presentation?

Back 7

= presence of endometrial glands and stroma that are abnormally placed within myometrium, but still responsive to normal hormonal effects

- Gross: uterus is enlarged and myometrium contrains reddish, cystic foci = hemorrhagic cysts

- Histo: foci composed of endometrial glands (proliferative phase) and stroma

- Clinical Pres: pelvic pain, abnormal bleeding, dysmenorrhea, dyspareunia
--> symptoms often regress following menopause

*Do not confuse with invasive adenocarcinoma

Front 8

Endometriosis
- what is?
- how many women?
- what age most commonly?
- sx?
- how many are infertile?
- how many develop cancer? what cancer?

Back 8

= presence of endometrial glands and stroma located outside of uterus - ovary, fallopian tube, adnexa, peritoneum, etc.
- 5-10% women
- most commonly develops in late 20s or 30s
- sx: dysmenorrhea, pelvic pain, dyspareunia
- 1/3 are infertile
- 1-2% develop malignant transformation to adenocarcinoma

Front 9

What are the theories behind endometriosis? What is the most accepted?

Back 9

Most accepted: fragments of endometrium reflux through fallopian tube during menstruation --> implant in extrauterine sites; also spread via lymph and blood to more distant sites

Metaplastic Theory: peritoneal lining cells undergo endometrial metaplasia

Induction Theory: unknown substances secreted by endometrium induce endometrial differentiation at ectopic sites

Front 10

Endometriosis
- gross appearance
- histo

Back 10

Gross: foci are reddish, hemorrhagic lesions, which become "chocolate cysts" - brown-black color due to cyclic bleeding and accumulation of degenerated tissue

Histo: endometrial glands and stroma present with variable amounts of fibrosis and old hemorrhage (hemosiderin-laden macrophages)

Front 11

Endometrial Polyps
- what are?
- population?
- where form?
- histo?
- can lead to...?

Back 11

= benign proliferative lesions that develop as a result of focal hypersensitivity of endometrial glands to effects of Estrogen (or unresponsiveness of Progesterone)
- Perimenopausal women
- Most solitary
- Most in fundus, but may fill entire endometrial cavity
- Histo: composed of benign glands which may show cystic or hyperplasic changes; fibrous endometrial stroma containing dilated blood vessels
--> may become ulcerated or infarcted --> bleeding

- adenocarcinoma develops in 0.5%

Front 12

Endometria Hyperplasia
- cause?
- ave time for progression to invasive carcinoma?
- Classification? Rates of progression to cancer of each?
- New diagnosis - what is the common problem?
- Clinical presentation?
- Tx?

Back 12

Cause: excess or unopposed estrogen effect, e.g.:
- PCOS
- Granulosa Cell Tumors
- Obesity
- Exogenous Estrogen Tx

= pre-neoplastic

- Ave time for progression to invasive carcinoma:
- hyperplasia w/o atypia = 10 yrs
- atypical hyperplasia = 4 yrs

Classification:
- Simple - mild glandular complexity w/o atypia (1% progress to cancer)
- Complex - marked glandular complexity without atypia (3%)
- Atypical - marked glandular complexity with atypia (25%)

- New diagnosis: EIN = Endothelial Intraepithelial Neoplasia - most include loss of function of PTEN tumor suppressor gene

Clinical Pres: abnormal uterine bleeding

Tx: reduction of estrogen stimulation; hysterectomy

Front 13

Adenocarcoma of Endometrium
- __-most common cancer in American women?
- pop/mean age
- main cause?
- increased risk with...?
- decreased risk with...?

Back 13

= 4th most common cancer in American women
- post-menopausal; mean age >60
- main cause: increased or unopposed estrogen
- increased risk with breast/ovarian cancer
- decreased risk from cigarette smoking (inhibits hepatic conversion of estrone to active estriol)

Front 14

What are the different histological subtypes of adenocarcinoma of the endometrium?
- Describe them
- How are they graded?

Back 14

1) Endometrioid = 60%

2) Secretory - well-differentiated; tumor cells show subnuclear vacuolization

3) Serous - non-estrogen dependen; poor prognosis; spreads throughout peritoneum

4) Clear cell - non-estrogen dependent; poor prognosis; contain abundant glycogen and have hobnail appearance

Graded on percentage that forms glandular structures and degree of nuclear atypia

Front 15

Adenocarcinoma of the Endometrium
- clinical presentation?
- metastasis?
- treatment?
- prognosis/ survival rates?

Back 15

- Clinical Pres: often abnormal uterine bleeding (post-menopausal)

**Not reliably detected by routine cytologic exam

- Metastasize directly to paraaortic lymph nodes or through bloodstream (advanced cases)

- Tx: hysterectomy, post-op radiation tx for high risk

- Prognosis: related to tumor grade/stage, histo subtype, age, expression of hormone receptors in tumor cells (hormone receptors = favorable)
--- 80% at two years
--- 65% at ten years

Front 16

What is ESS?

Back 16

Endometrial Stromal Sarcoma

Front 17

ESS
- gross appearance?
- histo?
- progression of disease?

Back 17

- Gross: polypoid appearance; OR more diffusely infiltrated within the myometrium... may invade uterine vessels

- Histo: cells resemble proliferative phase endometrial stroma; rich surrounding vascular network

- recurrence not uncommon
- potential for distant metastisis, esp when not well-differentiated

Front 18

Adenosarcoma
- what is?

Back 18

- Low-grade malignancy
- Contains benign endometrial-type glandular elements and malignant endometrial stromal elements (sarcome)

Front 19

Carcinosarcoma
- aka?
- what is? consist of?

Back 19

- aka: Malignant Mixed Mesodermal Tumor
- Highly aggressive tumor
- Contains both malignant epithelial and stromal elements

**stomal elements may not just be endometrial stroma: may be smooth muscle, skeletal muscle, bone, cartilage or fat

Front 20

Uterine Leiomyoma
- What is?
- %
- Progression
- Gross appearance?
- Size
- Histo?
- Clinical Presentation?
- Tx?

Back 20

= Benign tumor arising from myometrial smooth muscle
**Most common neoplasm of female genital tract

- develop in ~70% women

- usually regress after menopause (lack of Estrogen; E promotes their growth)

- Gross: firm, well-circumscribed (not encapsulated) white-gray whorled appearance
- Range in size from <1 mm - >30 cm

Histo: uniform spindle cells arranged in interlacing bundles; low mitotic rate; lack nuclear atypia; lack extensive necrosis

- Clin Pres: bleeding, abdominal discomfort, compression of adjacent structures, .... may prolapse through cervix
**Might rapidly enlarge during pregnancy - Progesterone

- Tx: myomectomy (isolated resection of the tumor), hysterectomy, ablation by arterial thrombosis

Front 21

What is the most common neoplasm of the female genital tract?

Back 21

Uterine Leiomyoma

Front 22

Leiomyosaroma
- what is?
- common?
- size?
- age?
- prognosis/survival?

Back 22

= Malignany neoplasm arising from myometrial smooth muscle
- much less common than benign leiomyomas
- Larger in size
- Occur at later age
- Gross: invades adjacent myometrium; contains large areas of necrosis
- Histo: higher mitotic rate; nuclear atypia, areas of necrosis

- Prognosis:
- less than 5 cm - almost never recur
- BUT most found late, so overall 5-year survival = 20%