endometrium dr. raid jastania. dysfunctional uterine bleeding menorrhagia, intermenstrual bleeding...
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Endometrium
Dr. Raid Jastania
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Dysfunctional Uterine Bleeding• Menorrhagia, intermenstrual bleeding
• Causes:– DUB– Organic (structural) causes
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Dysfunctional Uterine Bleeding• Menorrhagia, intermenstrual bleeding
• Causes:– DUB– Organic (structural) causes
• Cervix: CIN, carcinoma
• Endometrium: polyp, hyperplasia, carcinoma, endometriosis
• Pregnancy related: endometritis, retained products, tumors
• Myometrium: Adenomyosis, Leiomyoma, Leiomyosarcoma
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Dysfunctional Uterine Bleeding• DUB:
– 1. Anovulatory cycle– 2. Inadequate Luteal phase– 3. Contraceptive-induced bleeding
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Dysfunctional Uterine Bleeding• DUB:
– 1. Anovulatory cycle• Very young, or elderly
• Hormonal: hypothalamic-pituitary, thyroid, adrenal, ovary
• Malnutrition, obesity, severe emotional stress
• Findings: Proliferative phase endometrium, disordered, no secretory phase
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Dysfunctional Uterine Bleeding• DUB:
– 2. Inadequate Luteal phase:• Lack of progesterone
• Findings: delay in secretory phase
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Dysfunctional Uterine Bleeding• DUB:
– 3. Contracepitve-induced bleeding• With the old oral contraceptives
• Discordant appearance of gland and stroma
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Endometritis• Acute infection, follow delivery or abortion• Retained products of conception• Chronic
– Chronic gonorrhea– T.B– Retained products of conception– IUD– Spontaneous chronic infection
• Findings: – acute infection: neutrophils, necrosis– Chronic infection: Lymphocytes, plasma cells
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Endometriosis
• Endometrial foci outside the uterus• Results in dysmenorrhea, infertility• Common in pelvis, ovary, tube, ligaments,
or any other sites• Theory
– Regurgitation theory– Metaplastic theory– Vascular and lymphatic dissemination theory
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Endometriosis
• Findings:– Red-blue-brown nodules, solid/cystic
“chocolate cyst”– Foci of endometrium
• Endometrial glands• Endometrial stroma• Bleeding, hemosidrin
– Complications: adhesions, infertility, pain, dysuria, dyspareunia
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Adenomyosis
• Endometrial foci within the myometrium• Usually of the basal layer endometrium• Usually non-functioning• Findings:
– Thick uterine wall with small cystic areas– Endometrial tissue in the myometrium
• Symptoms: pain, menorrhagia, dysmenorrhea
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Endometrial Hyperplasia• Excess estrogen:
– Anovulatory cycle– Estrogen intake– Tumors (or conditions) secreting estrogen: polycystic
ovary, granulosa cell tumor, thecoma
• Classification:– Simple hyperplasia (with or without atypia)– Complex hyperplasia (with or without atypia)
• Complex hyperplasia with atypia: 20-25% progress to endometrial carcinoma
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Tumors of the endometrium
• Endometrial polyps
• Endometrial carcinoma
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Tumors of the endometrium
• Endometrial polyps– ?neoplastic– Benign– Findings:
• Polypoid sessile 0.5-3 cm• Normal endometrium, cystic change
– Symptoms: menorrhagia– Rarely associated with hyperplasia or
carcinoma
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Tumors of the endometrium
• Endometrial carcinoma– US: the most common cancer of the female
genital tract– 55-65 years– Risk factors
• Obesity• DM, hypertension• Infertility• Previous hyperplasia
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Tumors of the endometrium
• Symptoms: Menorrhagia, mass, pain
• Types:• Endometrioid adenocarcinoma
• Serous carcinoma
• Clear cell carcinoma
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Tumors of the endometrium
• Endometrial carcinoma– Types:
• Estrogen dependent– Endometrioid adenocarcinoma– 55-65 year– Follow hyperplasia– Mutation of PTEN gene
• Estrogen independent– Serous carcinoma and Clear cell carcinoma– Elderly 70 years– P53 mutation– High grade by definition, poor prognosis
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Tumors of the endometrium
• Endometrial carcinoma– Survival: 5-year survival
• Stage I (limited to uterine cavity): 90%
• Stage II (extend to cervix): 50%
• Stage III (outside the uterus): 20%
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Tumors of the Myometrium
• Leiomyoma
• Leiomyosarcoma
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Tumors of the Myometrium
• Leiomyoma– Most common benign tumor in female– 30-50% of women at reproductive age– Black>White– ?Estrogen related– Shrink postmenopausal– Clinically: asymptomatic, mass lesion,
menorrhagia
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Tumors of the Myometrium
• Leiomyoma– Findings:
• Sharply circumscribed , firm, white gray, whorled cut surface
• Intramural, submucosal, subsersal
• Smooth muscle bundles
• Secondary changes: cystic change, hemorrhage, degeneration
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Tumors of the Myometrium
• Leiomyosarcoma:– Malignant– De novo (rarely arise in leiomyoma)– Large mass, infiltrating the wall, or polypoid,
sometime similar to leiomyoma– Smooth muscle bundles: Mitosis, atypia,
necrosis– Overall 5-year survival: 40%
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• A massively obese (5'3", 275 pounds), 55-year-old, sexually active woman, nulligravida (no pregnancies), presented to her gynecologist because of vaginal spotting for 1 year. Her medical history included non-insulin-dependent diabetes mellitus and medically controlled hypertension, both diagnosed at age 43. Her gynecologic history included: menarche, age 11; coitarche, age 20; lifetime sexual partners, 2; 6 menses/year until age 51 when she became menopausal and her menstrual periods stopped.
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• An endometrial biopsy yielded abundant tissue.
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• Following the biopsy, the patient was lost to follow-up for 8 years. She is now brought to the ER after fainting at home. Her hemoglobin is 5 g/dL. Endometrial biopsy is repeated, followed by a simple hysterectomy with bilateral salpingo-oophorectomy.
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