Endometrium

1. Endometrium Dr. Raid Jastania

4. Dysfunctional Uterine Bleeding • Menorrhagia, intermenstrual bleeding • Causes: • DUB • Organic (structural) causes

5. 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

6. Dysfunctional Uterine Bleeding • DUB: • 1. Anovulatory cycle • 2. Inadequate Luteal phase • 3. Contraceptive-induced bleeding

7. 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

8. Dysfunctional Uterine Bleeding • DUB: • 2. Inadequate Luteal phase: • Lack of progesterone • Findings: delay in secretory phase

9. Dysfunctional Uterine Bleeding • DUB: • 3. Contracepitve-induced bleeding • With the old oral contraceptives • Discordant appearance of gland and stroma

10. 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

12. 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

13. 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

17. 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

19. 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

22. Tumors of the endometrium • Endometrial polyps • Endometrial carcinoma

23. 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

26. 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

27. Tumors of the endometrium • Symptoms: Menorrhagia, mass, pain • Types: • Endometrioid adenocarcinoma • Serous carcinoma • Clear cell carcinoma

28. 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

35. 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%

36. Tumors of the Myometrium • Leiomyoma • Leiomyosarcoma

37. 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

38. 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

43. 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%

45. 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.

46. An endometrial biopsy yielded abundant tissue.

48. 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.