Difference between revisions of "Endometrium"

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The '''endometrium''' is typically biopsied because of abnormal bleeding.
The '''endometrium''' is typically biopsied because of abnormal bleeding.


===Indications===
==Indications for endometrial biopsy==
Biopsies done for bleeding:  
Biopsies done for bleeding:  
*Too much bleeding (if premenopausal) - ''AUB'' = abnormal uterine bleeding.
*Too much bleeding (if premenopausal) - ''AUB'' = abnormal uterine bleeding.
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**DUB is diagnosed if other causes of bleeding are excluded.
**DUB is diagnosed if other causes of bleeding are excluded.


===Normal microscopic findings===
=Normal microscopic findings=
==General==
*Endocervical glands are commonly seen, as is endocervical mucous.
*Endocervical glands are commonly seen, as is endocervical mucous.
**This is 'cause the gynecologist scrapes some off on the way in or out.
**This is 'cause the gynecologist scrapes some off on the way in or out.
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*Nuclei columnar.
*Nuclei columnar.


==A simple approach==
=A simple approach=
===Low power===
==Low power==
#Decide whether you're look at endometrium.
#Decide whether you're look at endometrium.
#Gland-to-stroma ratio normal?
#Gland-to-stroma ratio normal?
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#*Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia).
#*Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia).


===High power===
==High power==
#Mitoses present in the glands?
#Mitoses present in the glands?
#*Present in the proliferative phase, hyperplasias, malignancies.
#*Present in the proliferative phase, hyperplasias, malignancies.
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#*Some are normal during menses.
#*Some are normal during menses.


==Endometrial polyp==
=Dating endometrium=
===Epidemiology===
==Proliferative phase==
*Very common.
 
===Microscopy===
Features:<ref>URL: [http://www.pathologyoutlines.com/uterus.html#endopolyp http://www.pathologyoutlines.com/uterus.html#endopolyp].</ref>
*Large blood vessels (muscular) - '''key feature'''.
*Fibrotic stroma - '''key feature'''.
*Polypoid shape - epithelium on three sides.
**May not be seen... as polyp is fragmented on removal.
 
Notes:
*Endometrial glands may be out of phase with surrounding endometrium.
**Often proliferative.
*+/-Cystic dilation of glands.
*Cellular stroma.
 
==Dating endometrium==
===Proliferative phase===
*Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion.
*Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion.
**Key features: pseudostratification, mitoses.
**Key features: pseudostratification, mitoses.
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**Gynecologists prefer the ovarian descriptor, i.e. ''follicular phase''; pathologists go by what they see, i.e. ''proliferative'' endometrium.
**Gynecologists prefer the ovarian descriptor, i.e. ''follicular phase''; pathologists go by what they see, i.e. ''proliferative'' endometrium.


===Secretory phase===
==Secretory phase==
*Early secretory phase - post-ovulatory day 1-5:
*Early secretory phase - post-ovulatory day 1-5:
**Glands: secretory vacuoles.
**Glands: secretory vacuoles.
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*Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.<ref>GAG. 6 Oct 2009.</ref>
*Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.<ref>GAG. 6 Oct 2009.</ref>


==Abnormalities of endometrium==
=Specific entities/abnormalities=
===Disordered proliferative phase===
==Endometrial polyp==
===Epidemiology===
*Very common.
*May be a cause of menorrhagia (heavy & long menses).
 
===Microscopic===
Features:<ref>URL: [http://www.pathologyoutlines.com/uterus.html#endopolyp http://www.pathologyoutlines.com/uterus.html#endopolyp].</ref>
*Large blood vessels (muscular) - '''key feature'''.
*Fibrotic stroma - '''key feature'''.
*Polypoid shape - epithelium on three sides.
**May not be seen... as polyp is fragmented on removal.
 
Notes:
*Endometrial glands may be out of phase with surrounding endometrium.
**Often proliferative.
*+/-Cystic dilation of glands.
*Cellular stroma.
 
==Disordered proliferative phase==
===General===
*Association: anovulation.
*Association: anovulation.


Features:<ref>{{Ref PBoD|1080 and 1082}}</ref>
===Microscopic===
Features:<ref name=Ref_PBoD1080>{{Ref PBoD|1080 and 1082}}</ref>
*Proliferative type endometrium with:
*Proliferative type endometrium with:
**Cystic dilation of glands without secretions.
**Cystic dilation of glands without secretions.
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Image: [http://upload.wikimedia.org/wikipedia/commons/a/ab/Endometrial_stromal_condensation_high_mag.jpg Endometrial stromal condensation - high mag. (WC)].
Image: [http://upload.wikimedia.org/wikipedia/commons/a/ab/Endometrial_stromal_condensation_high_mag.jpg Endometrial stromal condensation - high mag. (WC)].


===Endometrium of a woman taking [[OCP]]===
==Oral contraceptive effect==
===General===
*Very common.
*Most pills a mix of progesterone and estrogen.
**The progesterone is what generates the characteristic appearance -- that is similar to pregnancy.
 
===Microscopic===
Features:<ref name=Ref_PBoD1082>{{Ref PBoD|1082}}</ref>
Features:<ref name=Ref_PBoD1082>{{Ref PBoD|1082}}</ref>
*Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
*Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
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Image: [http://commons.wikimedia.org/wiki/File:Endometrium_ocp_use3.jpg Endometrium of woman on an OCP (WC)].
Image: [http://commons.wikimedia.org/wiki/File:Endometrium_ocp_use3.jpg Endometrium of woman on an OCP (WC)].


===Postmenopausal women===
==Postmenopausal women==
===General===
*Menopause happens at around 50 years old.
 
===Microscopic===
Features:
*Atrophy glands.
*Thin endometrium.
 
Notes:
*If a woman is truly postmenopausal, mitoses in the glandular epithelium is pretty much always pathologic.
*If a woman is truly postmenopausal, mitoses in the glandular epithelium is pretty much always pathologic.
**Exception is inflammation... e.g. the person has had several biopsy attempts and was seeded with pathogens.
**Exception is inflammation... e.g. the person has had several biopsy attempts and was seeded with pathogens.
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{{main|Endometrial hyperplasia}}
{{main|Endometrial hyperplasia}}
Can be thought of as a precursor lesion for endometrial carcinoma.
Can be thought of as a precursor lesion for endometrial carcinoma.
It comes in two main flavours:
#Simple.
#Complex.
Each flavour may or may not have nuclear atypia.


==Endometrial carcinoma==
==Endometrial carcinoma==
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Endometrial cancer is the common gynecologic malignancy (in the USA).<ref name=pmid19332248>{{cite journal |author=Lu KH |title=Management of early-stage endometrial cancer |journal=Semin. Oncol. |volume=36 |issue=2 |pages=137–44 |year=2009 |month=April |pmid=19332248 |doi=10.1053/j.seminoncol.2008.12.005 |url=}}</ref>
Endometrial cancer is the common gynecologic malignancy (in the USA).<ref name=pmid19332248>{{cite journal |author=Lu KH |title=Management of early-stage endometrial cancer |journal=Semin. Oncol. |volume=36 |issue=2 |pages=137–44 |year=2009 |month=April |pmid=19332248 |doi=10.1053/j.seminoncol.2008.12.005 |url=}}</ref>


==See also==
=See also=
*[[Uterine tumours]].
*[[Uterine tumours]].
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]

Revision as of 02:28, 10 August 2011

The endometrium is typically biopsied because of abnormal bleeding.

Indications for endometrial biopsy

Biopsies done for bleeding:

  • Too much bleeding (if premenopausal) - AUB = abnormal uterine bleeding.
  • Post-menopausal bleeding.
  • Dysfunctional uterine bleeding AKA DUB - may get D&C if they fail medical management.[1]
    • DUB is diagnosed if other causes of bleeding are excluded.

Normal microscopic findings

General

  • Endocervical glands are commonly seen, as is endocervical mucous.
    • This is 'cause the gynecologist scrapes some off on the way in or out.

Endocervical glands vs. Endometrial glands

Endocervical

  • Less hyperchromatic.
  • Nuclei round & small.
  • Cell borders usually well-defined.

Endometrial

  • More hyperchromatic.
  • Nuclei columnar.

A simple approach

Low power

  1. Decide whether you're look at endometrium.
  2. Gland-to-stroma ratio normal?
  3. Glands round?
    • Round is normal.
    • Irregular - may be seen in menses, endometrial hyperplasia, disordered proliferative endometrium.
  4. Glands pseudostratified?
    • Pseudostratified glands are normal in the proliferative phase, hyperplasias, malignancy.
  5. Balls of cells?
    • Blue - likely menstrual (stromal condensation).
    • Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia).

High power

  1. Mitoses present in the glands?
    • Present in the proliferative phase, hyperplasias, malignancies.
  2. Mitoses present in the stroma?
    • Present in the proliferative phase, hyperplasias, malignancies.
  3. Mucous present in the glands?
    • Present in the secretory phase.
  4. Inflammatory cells present?
    • Some are normal during menses.

Dating endometrium

Proliferative phase

  • Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion.
    • Key features: pseudostratification, mitoses.
  • Stroma: cellular stroma (spindle cells), mitoses.

Note:

  • Proliferative phase = folicular phase.
    • Gynecologists prefer the ovarian descriptor, i.e. follicular phase; pathologists go by what they see, i.e. proliferative endometrium.

Secretory phase

  • Early secretory phase - post-ovulatory day 1-5:
    • Glands: secretory vacuoles.
      • First basal to the epithelial nuclei (infranuclear vacuoles).
      • Then apical to the epithelial nuclei (supranuclear vacuoles).
  • Mid secretory phase - post-ovulatory day 6-8:
    • Glands: Mucus in glands.
    • Stroma: Edema (empty space around the glands).
  • Late secretory phase (beginning) - post-ovulatory day 9-12:
    • Stroma:
      • Spiral arterioles.
      • Predecidual changes -- mnemonic NEW:
        1. Nucleus central.
        2. Eosinophilic cytoplasm key feature (may be subtle to the novice).
        3. Well-defined cell borders.
  • Premenstrual

General refs.: [3][4]

Notes:

  • Secretory phase = luteal phase.
    • Gynecologists prefer the ovarian descriptor, i.e. luteal phase; pathologists go by what they see, i.e. Secretions in the (endometrial) glands.
  • When the patient is >40 years, some advocate the use of the term proliferative type endometrium (instead of the term proliferative endometrium).[5]
  • Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.[6]

Specific entities/abnormalities

Endometrial polyp

Epidemiology

  • Very common.
  • May be a cause of menorrhagia (heavy & long menses).

Microscopic

Features:[7]

  • Large blood vessels (muscular) - key feature.
  • Fibrotic stroma - key feature.
  • Polypoid shape - epithelium on three sides.
    • May not be seen... as polyp is fragmented on removal.

Notes:

  • Endometrial glands may be out of phase with surrounding endometrium.
    • Often proliferative.
  • +/-Cystic dilation of glands.
  • Cellular stroma.

Disordered proliferative phase

General

  • Association: anovulation.

Microscopic

Features:[8]

  • Proliferative type endometrium with:
    • Cystic dilation of glands without secretions.
  • +/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).

Notes:

  • Proliferative phase endometrium:
    • Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion, abundant mitoses.
    • Stroma: cellular, stroma (spindle cells), mitoses.

Image: Endometrial stromal condensation - high mag. (WC).

Oral contraceptive effect

General

  • Very common.
  • Most pills a mix of progesterone and estrogen.
    • The progesterone is what generates the characteristic appearance -- that is similar to pregnancy.

Microscopic

Features:[9]

  • Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
  • Stroma decidualized -- mnemonic NEW:
    • Nucleus central.
    • Eosinophilic cytoplasm.
    • Well-defined cell borders.

Image: Endometrium of woman on an OCP (WC).

Postmenopausal women

General

  • Menopause happens at around 50 years old.

Microscopic

Features:

  • Atrophy glands.
  • Thin endometrium.

Notes:

  • If a woman is truly postmenopausal, mitoses in the glandular epithelium is pretty much always pathologic.
    • Exception is inflammation... e.g. the person has had several biopsy attempts and was seeded with pathogens.

Endometrial hyperplasia

Main article: Endometrial hyperplasia

Can be thought of as a precursor lesion for endometrial carcinoma.

It comes in two main flavours:

  1. Simple.
  2. Complex.

Each flavour may or may not have nuclear atypia.

Endometrial carcinoma

Main article: Endometrial carcinoma

Endometrial cancer is the common gynecologic malignancy (in the USA).[10]

See also

References

  1. ↑ URL: http://emedicine.medscape.com/article/257007-treatment. Accessed on: 15 July 2010.
  2. ↑ TC. 22 June 2009.
  3. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1081. ISBN 0-7216-0187-1.
  4. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 237. ISBN 978-0470519035.
  5. ↑ GAG. Jan 2009
  6. ↑ GAG. 6 Oct 2009.
  7. ↑ URL: http://www.pathologyoutlines.com/uterus.html#endopolyp.
  8. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1080 and 1082. ISBN 0-7216-0187-1.
  9. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1082. ISBN 0-7216-0187-1.
  10. ↑ Lu KH (April 2009). "Management of early-stage endometrial cancer". Semin. Oncol. 36 (2): 137–44. doi:10.1053/j.seminoncol.2008.12.005. PMID 19332248.
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