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
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 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
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.