Endometrium Dr. Raid Jastania

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

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

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

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

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

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

Endometritis Acute infection, follow delivery or abortion Retained products of conception Chronic Chronic gonorrhea T.B IUD Spontaneous chronic infection Findings: acute infection: neutrophils, necrosis Chronic infection: Lymphocytes, plasma cells

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

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

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

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

Tumors of the endometrium Endometrial polyps Endometrial carcinoma

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

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

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

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

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%

Tumors of the Myometrium Leiomyoma Leiomyosarcoma

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

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

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%

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.

An endometrial biopsy yielded abundant tissue.

Following the biopsy, the patient was lost to follow-up for 8 years 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.