Latest revision as of 14:37, 2 March 2017

The endometrium is typically biopsied because of abnormal bleeding. Endometrial hyperplasia and endometrial carcinoma are dealt with in separate articles. An overview of gynecologic pathology is in the gynecologic pathology article.

Indications for endometrial biopsy

Abnormal bleeding:

Abnormal uterine bleeding (AUB).
- Dysfunctional uterine bleeding, abbreviated DUB, is diagnosed if other causes of bleeding are excluded.
- DUB may get a D&C if they fail medical management.^[1]
- Post-menopausal bleeding.

Other indications:^[2]

Products of conception - dealt with in a separate article.
Dating of endometrium - infertility work-up.

Endometrial thickness on ultrasound

A thin endometrium on ultrasound has a very low risk of malignancy.^[3]

Normal microscopic findings

Endometrium - consists of:

Epithelium (endometrial glands).
Stroma (endometrial stroma).

In endometrial biopsies:

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

Glandular telescoping

AKA gland-within-a-gland.

AKA gland intussusception.

AKA telescoping.

Considered an artifact of tissue processing, i.e. normal.^[4]

Image:

Telescoping (bmjjournals.com).^[4]

Endometrial gland compression artifact

AKA compression artifact.

Gland moulding.
Tearing of tissue around the compressed glands - key feature.
Usually at the edge of a tissue fragment.

DDx:

Focal complex endometrial hyperplasia.

Image

Gland compression (bmjjournals.com).^[4]

Micro

An increased gland density is seen focally, at the edge of one tissue fragment, in association with tearing of the stroma (compression artifact).

Endocervical epithelium versus endometrial epithelium

Table

Feature	Endometrial	Endocervical	Tubal metaplasia
Cytoplasmic staining	usu. hyperchromatic +/-vacuoles	clear or light eosinophilic	hyperchromatic
Nucleus-to-cytoplasm ratio	moderate to high (1:2)	low (often 1:3)	high (1:1)
Surface features			villi
Associated stroma	cellular, hyperchromatic	inflamed, less cellular	variable

List

Endocervical:

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

Endometrial:

More hyperchromatic.
Nuclei columnar.

Images

Endocervical and endometrial epithelium - low mag. (WC)
Endocervical and endometrial epithelium - high mag. (WC)

Metaplasias of the endometrium

The big table of metaplasias - adapted from Nicolae et al.:^[5]

Metaplasia	Subtypes	Microscopic	Notes	Risk of malignancy
Morules	-			nearly always
Ciliary	-	ciliated cells	usu. lumped together with tubal, unopposed estrogen, endometriosis	frequent - endometrial hyperplasia (complex and simple), adenocarcinoma
Tubal	complex, simple	ciliated cells, secretory cell, intercallary cells	usu. lumped together with ciliary, unopposed estrogen, seen in endometriosis	frequent (complex only) - endometrial hyperplasia (complex and simple), adenocarcinoma
Mucinous	complex, simple			frequent (complex only)
Squamous	-			rare
Papillary syncytial change (surface)	-			rare
Eosinophilic, oxyphilic, oncocytic				not known
Clear cell (secretory)	-			not reported
Stromal metaplasia	osseous, cartilaginous, adipose, smooth muscle, myoid, sex-cord like			not reported

Tamoxifen effects

Inadequate endometrial biopsy

Endometrial biopsies often have scant tissue.
- This is normal in post-menopausal women.
Ideally, the biopsy should have some endometrial stroma.
- Without stroma it is not possible to assess the gland-to-stroma ratio.

Sign out

No stroma

ENDOMETRIUM, BIOPSY:
- VERY SCANT STRIPPED NON-PROLIFERATIVE COLUMNAR EPITHELIUM, PROBABLY FROM THE LOWER UTERINE SEGMENT.
- NO DEFINITE ENDOMETRIAL STROMA, SEE COMMENT.
- STRIPPED ENDOCERVICAL EPITHELIUM AND ENODOCERVICAL MUCOSA WITHIN NORMAL LIMITS.
- MUCOUS.

COMMENT:
A re-biopsy should be considered within the clinical context.

ENDOMETRIUM, BIOPSY:
- VERY SCANT STRIPPED EPITHELIUM PROBABLY FROM THE LOWER UTERINE SEGMENT.
- NO DEFINITE ENDOMETRIAL STROMA.
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- SMALL FRAGMENTS OF DETACHED BENIGN SQUAMOUS EPITHELIUM.

COMMENT:
A re-biopsy should be considered within the clinical context.

ENDOMETRIUM, BIOPSY: 
- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM AND DETACHED NON-PROLIFERATIVE ENDOMETRIAL GLANDS. 
- ASSESSMENT LIMITED AS VERY SCANT ENDOMETRIAL STROMA IS PRESENT.

ENDOMETRIUM, BIOPSY:
- ENDOMETRIUM: STRIPS OF EPITHELIUM, NON-PROLIFERATIVE. 
- ENDOCERVIX: SCANT BENIGN EPITHELIUM.
- EXOCERVIX: SCANT BENIGN EPITHELIUM.
- OTHER: TUBAL METAPLASIA.

ENDOMETRIUM, BIOPSY:
- STRIPS OF NON-PROLIFERATIVE ENDOMETRIUM. 
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
- SCANT BENIGN SQUAMOUS EPITHELIUM.
- TUBAL METAPLASIA.

ENDOMETRIUM, BIOPSY:
- STRIPS OF BENIGN ENDOMETRIAL EPITHELIUM/TUBAL METAPLASIA, NON-PROLIFERATIVE. 
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
- RARE SQUAMOUS METAPLASTIC CELLS.

Proliferative without definite stroma

ENDOMETRIUM, BIOPSY: 
- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM, ENDOCERVICAL EPITHELIUM AND FOCALLY PROLIFERATIVE ENDOMETRIAL GLANDS.  
- ASSESSMENT LIMITED AS NO DEFINITE ENDOMETRIAL STROMA IS PRESENT.

Possible endometrium - insufficient

ENDOMETRIUM, ASPIRATION:
- ONE MINUTE STRIP OF POSSIBLE NONPROLIFERATIVE ENDOMETRIAL EPITHELIUM, INSUFFICIENT
  FOR ADEQUATE DIAGNOSTIC ASSESSMENT.
- VERY SCANT BENIGN STRIPPED ENDOCERVICAL EPITHELIUM.
- VERY SCANT METAPLASTIC SQUAMOUS EPITHELIUM.

COMMENT:
Re-biopsy is advised.

ENDOMETRIUM, BIOPSY:
- BENIGN STRIPPED ENDOCERVICAL EPITHELIUM AND BENIGN INFLAMED ENDOCERVICAL MUCOSA.
- NO DEFINITE ENDOMETRIUM WITH STROMA, INADEQUATE SPECIMEN.

No endometrium

ENDOMETRIUM, BIOPSY:
- SPECIMEN INADEQUATE; NO ENDOMETRIUM IDENTIFIED.
- ONE VERY TINY FRAGMENT OF ENDOCERVICAL MUCOSA WITHOUT APPARENT PATHOLOGY.

ENDOMETRIUM, BIOPSY:
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- MICROGLANDULAR HYPERPLASIA AND FOCAL SQUAMOUS METAPLASIA.
- NO DEFINITE ENDOMETRIUM IDENTIFIED, SUGGEST RE-BIOPSY.

No tissue

ENDOMETRIUM, BIOPSY:
- NO TISSUE IDENTIFIED ON MICROSCOPY.

Overview

A simple approach

Low power

Decide whether you are looking at endometrium.
Is the gland-to-stroma ratio normal?
- 1:3 is normal.
- If the gland-to-stroma ratio is increased... think complex endometrial hyperplasia.
- If the glands are fused to one another or cribriform... think endometrial carcinoma.
Glands round?
- Round is normal.
- Irregular - may be seen in secretory phase endometrium, menses, disordered proliferative endometrium (focal), simple endometrial hyperplasia (diffuse).
Glands pseudostratified?
- Pseudostratified glands are normal in the proliferative phase endometrium, hyperplasias, malignancy.
Balls of cells?
- Blue - likely menstrual (stromal condensation).
- Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia, endometrioid endometrial carcinoma, may be benign).

High power

Mitoses present in the glands?
- Present in the proliferative phase, hyperplasias, malignancies.
Mitoses present in the stroma?
- Present in the proliferative phase, hyperplasias, malignancies.
Mucous present in the glands?
- Present in the secretory phase.
Inflammatory cells present?
- Some are normal during menses.

Tabular summary

Diagnosis	Key feature (low power)	Additional features	DDx	Other	Image
Proliferative phase endometrium	round spaced pseudostratified glands	mitoses in glands and stroma	disordered proliferative phase, simple endometrial hyperplasia, complex endometrial hyperplasia, early secretory phase endometrium	normal	Proliferative endometrium. (WC)
Secretory phase endometrium	irregular glands with secretions or simple glands with vacuoles	decidual changes (nucleus central, eosinophilic cytoplasm, well-defined cell borders)	endometrial hyperplasia with secretory changes, late proliferative phase endometrium	normal	Secretory phase endometrium. (WC)
Menstrual endometrium	stromal condensation	nonproliferative glands, stromal/epithelial neutrophils, glandular cell apoptosis	disordered proliferative phase	normal	Image
Benign endometrial polyp	fibrous stroma, muscular blood vessels	polypoid shape (epithelium on 3 sides), +/-gland dilation	disordered proliferative endometrium (DPE), simple endometrial hyperplasia (SEH)	DPE and SEH do not occur in polyps	Benign endometrial polyp. (WC)
Endometrium with changes due to exogenous hormones	decidualized stroma (nucleus central, eosinophilic cytoplasm, well-defined cell borders)	inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses)	secretory phase endometrium, endometrial hyperplasia with secretory changes	variant of normal	Endometrium with changes due to exogenous hormones. (WC)
Atrophic endometrium	nonproliferative glands	no nuclear atypia, often without appreciable stroma	serous endometrial carcinoma	normal postmenopausal finding	Inactive endometrium. (WC)
Disordered proliferative endometrium	proliferative focally dilated & irregular glands (usu. with tubal metaplasia)	no nuclear atypia, +/-evidence of shedding (stromal condensation)	simple endometrial hyperplasia, proliferative phase endometrium	can be thought of a waffle diagnosis	Disordered proliferative endometrium. (WC)

Normal endometrium

Proliferative phase endometrium

Main article: Proliferative phase endometrium

Secretory phase endometrium

Main article: Secretory phase endometrium

Menstrual endometrium

General

Technically part of the proliferative phase or follicular phase.

Microscopic

Features:

Proliferative endometrium (mitoses).^[6]
Apoptotic cells common.^[7]
Tightly packed cellular balls of stromal cells with nuclear moulding.
- Known as "blue balls".
- Tightly packed cellular stromal cells known as "stromal condensation".
Inflammation, especially abundant neutrophils.

DDx:

Small cell carcinoma - proliferative activity in the moulded (stromal condensation-like) cells.
Anovulatory endometrium - less neutrophils.

Images

Endometrial stromal condensation - high mag. (WC/Nephron)

www:

Sign out

Endometrium, Biopsy:
- Consistent with menstrual endometrium.
-- Weakly proliferative endometrial glands with apoptosis, fragmented.
-- Abundant balls of condensed non-proliferative endometrial stroma and blood.

Block letters

ENDOMETRIUM, BIOPSY:
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM:
-- STRIPPED WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- ABUNDANT NEUTROPHILS AND BLOOD.

ENDOMETRIUM, BIOPSY:
- CONSISTENT WITH MENSTRUAL PHASE ENDOMETRIUM:
-- WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- BLOOD.

ENDOMETRIUM, BIOPSY:
- VERY WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.

Consistent with menstrual endometrium

ENDOMETRIUM, ASPIRATION:
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH PSEUDOSTRATIFIED
  GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
  AND BLOOD).
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.

ENDOMETRIUM, ASPIRATION:
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH SIMPLE
  GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
  (FOCAL) AND BLOOD).
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.

Late menses

ENDOMETRIUM, ASPIRATION:
- ENDOMETRIAL GLANDS WITH APOPTOTIC CELLS, INFILTRATING NEUTROPHILS,
  AND GLANDULAR PROLIFERATIVE ACTIVITY.
- BALLS OF CONDENSED ENDOMETRIAL STROMA.
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- NEGATIVE FOR HYPERPLASIA.

COMMENT:
The findings are most in keeping with late menstrual endometrium.

Specific entities/abnormalities

Adipose tissue on endometrial biopsy

AKA fat on endometrial biopsy.

General

Benign.
Raises the possibility of perforation - should prompt a phone call to the clinician.

Microscopic

Features:

Adipose tissue, benign - key finding.
Definite endometrium.

DDx:

Extraneous tissue.
- Tissue floater.
- Pick-up.

Images

EMB with fat - intermed. mag.
EMB with fat - intermed. mag.
EMB with fat - high mag.

Sign out

ENDOMETRIUM, BIOPSY:
- BENIGN ADIPOSE TISSUE, SEE COMMENT.
- PROLIFERATIVE PHASE ENDOMETRIUM.

COMMENT:
The presence of adipose tissue raises the possibility of perforation.

The findings were briefly discussed with Dr. Brown on November 6, 2009.

Arias-Stella reaction

Main article: Arias-Stella reaction

Benign atypical endometrial changes associated with chorionic tissue -- may be seen in a completely normal pregnancy and misdiagnosed as a malignancy.^[8]

Endometritis

Main article: Endometritis

Benign endometrial polyp

Main article: Benign endometrial polyp

Anovulatory endometrium

Main article: Anovulatory endometrium

Disordered proliferative endometrium

Abbreviated DPE.
AKA endometrium with disordered proliferative phase.
AKA disordered proliferative phase.

Main article: Disordered proliferative endometrium

Endometrium with changes due to exogenous hormones

Main article: Endometrium with changes due to exogenous hormones

Atrophic endometrium

AKA atrophy of the endometrium.
AKA endometrial atrophy.

Main article: Inactive endometrium

Ablated endometrium

Main article: Ablated endometrium

Endometrium with squamous morules

Main article: Endometrium with squamous morules

Endometrium with psammoma bodies

Main article: Endometrium with psammoma bodies

Endometrial hyperplasia

Main article: Endometrial hyperplasia

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

Main article: Endometrial carcinoma

Endometrial cancer is the most common gynecologic malignancy (in the USA).^[9]

References

↑ URL: http://emedicine.medscape.com/article/257007-treatment. Accessed on: 15 July 2010.
↑ Mazur, Michael T.; Kurman, Robert J. (2005). Diagnosis of Endometrial Biopsies and Curettings: A Practical Approach (2nd ed.). Springer. pp. 1. ISBN 978-0387986159.
↑ Gambacciani, M.; Monteleone, P.; Ciaponi, M.; Sacco, A.; Genazzani, AR. (Aug 2004). "Clinical usefulness of endometrial screening by ultrasound in asymptomatic postmenopausal women.". Maturitas 48 (4): 421-4. doi:10.1016/j.maturitas.2003.10.006. PMID 15283934.
↑ ^4.0 ^4.1 ^4.2 McCluggage, WG. (Aug 2006). "My approach to the interpretation of endometrial biopsies and curettings.". J Clin Pathol 59 (8): 801-12. doi:10.1136/jcp.2005.029702. PMID 16873562.
↑ Nicolae, A.; Preda, O.; Nogales, FF. (Feb 2011). "Endometrial metaplasias and reactive changes: a spectrum of altered differentiation.". J Clin Pathol 64 (2): 97-106. doi:10.1136/jcp.2010.085555. PMID 21126963.
↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 237. ISBN 978-0470519035.
↑ Spencer, SJ.; Cataldo, NA.; Jaffe, RB. (May 1996). "Apoptosis in the human female reproductive tract.". Obstet Gynecol Surv 51 (5): 314-23. PMID 8744416.
↑ Arias-Stella, J. (Jan 2002). "The Arias-Stella reaction: facts and fancies four decades after.". Adv Anat Pathol 9 (1): 12-23. PMID 11756756.
↑ 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.

[1] URL: http://emedicine.medscape.com/article/257007-treatment. Accessed on: 15 July 2010.

[2] Mazur, Michael T.; Kurman, Robert J. (2005). Diagnosis of Endometrial Biopsies and Curettings: A Practical Approach (2nd ed.). Springer. pp. 1. ISBN 978-0387986159.

[pmid15283934-3] Gambacciani, M.; Monteleone, P.; Ciaponi, M.; Sacco, A.; Genazzani, AR. (Aug 2004). "Clinical usefulness of endometrial screening by ultrasound in asymptomatic postmenopausal women.". Maturitas 48 (4): 421-4. doi:10.1016/j.maturitas.2003.10.006. PMID 15283934.

[pmid16873562-4] 4.0 ^4.1 ^4.2 McCluggage, WG. (Aug 2006). "My approach to the interpretation of endometrial biopsies and curettings.". J Clin Pathol 59 (8): 801-12. doi:10.1136/jcp.2005.029702. PMID 16873562.

[pmid21126963-5] Nicolae, A.; Preda, O.; Nogales, FF. (Feb 2011). "Endometrial metaplasias and reactive changes: a spectrum of altered differentiation.". J Clin Pathol 64 (2): 97-106. doi:10.1136/jcp.2010.085555. PMID 21126963.

[Ref_DCHH237-6] Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 237. ISBN 978-0470519035.

[pmid8744416-7] Spencer, SJ.; Cataldo, NA.; Jaffe, RB. (May 1996). "Apoptosis in the human female reproductive tract.". Obstet Gynecol Surv 51 (5): 314-23. PMID 8744416.

[pmid11756756-8] Arias-Stella, J. (Jan 2002). "The Arias-Stella reaction: facts and fancies four decades after.". Adv Anat Pathol 9 (1): 12-23. PMID 11756756.

[pmid19332248-9] 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.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

@@ Line 2: / Line 2: @@
 ==Indications for endometrial biopsy==
-Biopsies done for bleeding:
+Abnormal bleeding:
-*Too much bleeding (if premenopausal) - ''AUB'' = abnormal uterine bleeding.
+*[[Abnormal uterine bleeding]] (AUB).
-*Post-menopausal bleeding.
+**[[Dysfunctional uterine bleeding]], abbreviated ''DUB'', is diagnosed if other causes of bleeding are excluded.
-*Dysfunctional uterine bleeding [[AKA]] ''DUB'' - may get D&C if they fail medical management.<ref>URL: [http://emedicine.medscape.com/article/257007-treatment http://emedicine.medscape.com/article/257007-treatment]. Accessed on: 15 July 2010.</ref>
+**''DUB'' may get a D&C if they fail medical management.<ref>URL: [http://emedicine.medscape.com/article/257007-treatment http://emedicine.medscape.com/article/257007-treatment]. Accessed on: 15 July 2010.</ref>
-**DUB is diagnosed if other causes of bleeding are excluded.
+**Post-menopausal bleeding.
+Other indications:<ref>{{Ref EMB|1}}</ref>
+*[[Products of conception]] - dealt with in a separate article.
+*Dating of endometrium - infertility work-up.
+===Endometrial thickness on ultrasound===
+*A thin endometrium on ultrasound has a very low risk of malignancy.<ref name=pmid15283934>{{Cite journal  | last1 = Gambacciani | first1 = M. | last2 = Monteleone | first2 = P. | last3 = Ciaponi | first3 = M. | last4 = Sacco | first4 = A. | last5 = Genazzani | first5 = AR. | title = Clinical usefulness of endometrial screening by ultrasound in asymptomatic postmenopausal women. | journal = Maturitas | volume = 48 | issue = 4 | pages = 421-4 | month = Aug | year = 2004 | doi = 10.1016/j.maturitas.2003.10.006 | PMID = 15283934 }}</ref>
 =Normal microscopic findings=
@@ Line 26: / Line 33: @@
 *[http://jcp.bmjjournals.com/content/59/8/801/F3.large.jpg Telescoping (bmjjournals.com)].<ref name=pmid16873562/>
-==Endocervical glands vs. Endometrial glands==
+==Endometrial gland compression artifact==
-===Endocervical===
+:[[AKA]] ''compression artifact''.
+*Gland moulding.
+*Tearing of tissue around the compressed glands - '''key feature'''.
+*Usually at the edge of a tissue fragment.
+DDx:
+*Focal [[complex endometrial hyperplasia]].
+===Image===
+*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/figure/fig4/ Gland compression (bmjjournals.com)].<ref name=pmid16873562/>
+===Micro===
+An increased gland density is seen focally, at the edge of one tissue fragment, in association with tearing of the stroma (compression artifact).
+===See also===
+*[[Endometrial gland coiling]].
+==Endocervical epithelium versus endometrial epithelium==
+===Table===
+{| class="wikitable sortable"
+! Feature
+! Endometrial
+! Endocervical
+! Tubal metaplasia
+|-
+| Cytoplasmic staining
+| usu. hyperchromatic +/-vacuoles
+| clear or light eosinophilic
+| hyperchromatic
+|-
+| [[Nucleus-to-cytoplasm ratio]]
+| moderate to high (1:2)
+| low (often 1:3)
+| high (1:1)
+|-
+| Surface features
+|
+|
+| villi
+|-
+| Associated stroma
+| cellular, hyperchromatic
+| inflamed, less cellular
+| variable
+|}
+===List===
+Endocervical:
 *Less hyperchromatic.
 *Nuclei round & small.
 *Cell borders usually well-defined.
-===Endometrial===
+Endometrial:
 *More hyperchromatic.
 *Nuclei columnar.
+===Images===
+<gallery>
+Image:Endometrial and endocervical epithelium - low mag.jpg | Endocervical and endometrial epithelium - low mag. (WC)
+Image:Endometrial and endocervical epithelium - high mag.jpg | Endocervical and endometrial epithelium - high mag. (WC)
+</gallery>
+==Metaplasias of the endometrium==
+The big table of metaplasias - adapted from Nicolae ''et al.'':<ref name=pmid21126963>{{Cite journal  | last1 = Nicolae | first1 = A. | last2 = Preda | first2 = O. | last3 = Nogales | first3 = FF. | title = Endometrial metaplasias and reactive changes: a spectrum of altered differentiation. | journal = J Clin Pathol | volume = 64 | issue = 2 | pages = 97-106 | month = Feb | year = 2011 | doi = 10.1136/jcp.2010.085555 | PMID = 21126963 }}</ref>
+{| class="wikitable sortable"
+! Metaplasia
+! Subtypes
+! Microscopic
+! Notes
+! Risk of malignancy
+! Image
+|-
+| [[Endometrium with squamous morules|Morules]]
+| -
+|
+|
+| nearly always
+| [[Image:Squamous morule 2 - endometrium -- very high mag.jpg|150px|SM. (WC)]]
+|-
+| Ciliary
+| -
+| ciliated cells
+| usu. lumped together with ''tubal'', unopposed estrogen, [[endometriosis]]
+| frequent - [[endometrial hyperplasia]] (complex and simple), adenocarcinoma
+|
+|-
+| Tubal
+| complex, simple
+| ciliated cells, secretory cell, intercallary cells
+| usu. lumped together with ''ciliary'', unopposed estrogen, seen in [[endometriosis]]
+| frequent (complex only) - [[endometrial hyperplasia]] (complex and simple), adenocarcinoma
+|
+|-
+| Mucinous
+| complex, simple
+|
+|
+| frequent (complex only)
+|
+|-
+| Squamous
+| -
+|
+|
+| rare
+|
+|-
+| Papillary syncytial change (surface)
+| -
+|
+|
+| rare
+|
+|-
+| Eosinophilic, oxyphilic, oncocytic
+|
+|
+|
+| not known
+|
+|-
+| Clear cell (secretory)
+| -
+|
+|
+| not reported
+|
+|-
+| Stromal metaplasia
+| osseous, cartilaginous, adipose, smooth muscle, myoid, sex-cord like
+|
+|
+| not reported
+|
+|}
 =Tamoxifen effects=
@@ Line 44: / Line 179: @@
 *Endometrial biopsies often have scant tissue.
 **This is normal in post-menopausal women.
-*To be adequate the biopsy ''must'' have some endometrial stroma, as it is otherwise ''not'' possible to assess the gland-to-stroma ratio.
+*Ideally, the biopsy should have some endometrial stroma.
+**Without stroma it is ''not'' possible to assess the gland-to-stroma ratio.
 ==Sign out==
+===No stroma===
 <pre>
 ENDOMETRIUM, BIOPSY:
-- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM, ENDOCERVICAL EPITHELIUM AND FOCALLY PROLIFERATIVE ENDOMETRIAL GLANDS.
+- VERY SCANT STRIPPED NON-PROLIFERATIVE COLUMNAR EPITHELIUM, PROBABLY FROM THE LOWER UTERINE SEGMENT.
-- ASSESSMENT LIMITED AS NO DEFINITE ENDOMETRIAL STROMA IS PRESENT.
+- NO DEFINITE ENDOMETRIAL STROMA, SEE COMMENT.
+- STRIPPED ENDOCERVICAL EPITHELIUM AND ENODOCERVICAL MUCOSA WITHIN NORMAL LIMITS.
+- MUCOUS.
+COMMENT:
+A re-biopsy should be considered within the clinical context.
+</pre>
+<pre>
+ENDOMETRIUM, BIOPSY:
+- VERY SCANT STRIPPED EPITHELIUM PROBABLY FROM THE LOWER UTERINE SEGMENT.
+- NO DEFINITE ENDOMETRIAL STROMA.
+- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
+- SMALL FRAGMENTS OF DETACHED BENIGN SQUAMOUS EPITHELIUM.
+COMMENT:
+A re-biopsy should be considered within the clinical context.
 </pre>
@@ Line 75: / Line 228: @@
 </pre>
-=A simple approach=
+<pre>
-==Low power==
+ENDOMETRIUM, BIOPSY:
-#Decide whether you're look at endometrium.
+- STRIPS OF BENIGN ENDOMETRIAL EPITHELIUM/TUBAL METAPLASIA, NON-PROLIFERATIVE.
-#Gland-to-stroma ratio normal?
+- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
+- RARE SQUAMOUS METAPLASTIC CELLS.
+</pre>
+===Proliferative without definite stroma===
+<pre>
+ENDOMETRIUM, BIOPSY:
+- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM, ENDOCERVICAL EPITHELIUM AND FOCALLY PROLIFERATIVE ENDOMETRIAL GLANDS.
+- ASSESSMENT LIMITED AS NO DEFINITE ENDOMETRIAL STROMA IS PRESENT.
+</pre>
+===Possible endometrium - insufficient===
+<pre>
+ENDOMETRIUM, ASPIRATION:
+- ONE MINUTE STRIP OF POSSIBLE NONPROLIFERATIVE ENDOMETRIAL EPITHELIUM, INSUFFICIENT
+  FOR ADEQUATE DIAGNOSTIC ASSESSMENT.
+- VERY SCANT BENIGN STRIPPED ENDOCERVICAL EPITHELIUM.
+- VERY SCANT METAPLASTIC SQUAMOUS EPITHELIUM.
+COMMENT:
+Re-biopsy is advised.
+</pre>
+<pre>
+ENDOMETRIUM, BIOPSY:
+- BENIGN STRIPPED ENDOCERVICAL EPITHELIUM AND BENIGN INFLAMED ENDOCERVICAL MUCOSA.
+- NO DEFINITE ENDOMETRIUM WITH STROMA, INADEQUATE SPECIMEN.
+</pre>
+===No endometrium===
+<pre>
+ENDOMETRIUM, BIOPSY:
+- SPECIMEN INADEQUATE; NO ENDOMETRIUM IDENTIFIED.
+- ONE VERY TINY FRAGMENT OF ENDOCERVICAL MUCOSA WITHOUT APPARENT PATHOLOGY.
+</pre>
+<pre>
+ENDOMETRIUM, BIOPSY:
+- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
+- MICROGLANDULAR HYPERPLASIA AND FOCAL SQUAMOUS METAPLASIA.
+- NO DEFINITE ENDOMETRIUM IDENTIFIED, SUGGEST RE-BIOPSY.
+</pre>
+===No tissue===
+<pre>
+ENDOMETRIUM, BIOPSY:
+- NO TISSUE IDENTIFIED ON MICROSCOPY.
+</pre>
+=Overview=
+==A simple approach==
+===Low power===
+#Decide whether you are looking at endometrium.
+#Is the gland-to-stroma ratio normal?
 #*1:3 is normal.
-#*If gland-to-stroma ratio is increased... think ''[[endometrial hyperplasia]]''.
+#*If the gland-to-stroma ratio is increased... think ''[[complex endometrial hyperplasia]]''.
-#*If glands are fused to one another or [[cribriform]]... think ''[[endometrial carcinoma]]''.
+#*If the glands are fused to one another or [[cribriform]]... think ''[[endometrial carcinoma]]''.
 #Glands round?
 #*Round is normal.
-#*Irregular - may be seen in menses, endometrial hyperplasia, disordered proliferative endometrium.
+#*Irregular - may be seen in [[secretory phase endometrium]], menses, [[disordered proliferative endometrium]] (focal), [[simple endometrial hyperplasia]] (diffuse).
 #Glands pseudostratified?
-#*Pseudostratified glands are normal in the proliferative phase, hyperplasias, malignancy.
+#*Pseudostratified glands are normal in the [[proliferative phase endometrium]], hyperplasias, malignancy.
 #Balls of cells?
 #*Blue - likely menstrual (stromal condensation).
-#*Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia).
+#*Pink - consider [[uterine leiomyoma|leiomyoma]], squamous morules (associated with [[endometrial hyperplasia]], [[endometrioid endometrial carcinoma]], may be benign).
-==High power==
+===High power===
 #Mitoses present in the glands?
 #*Present in the proliferative phase, hyperplasias, malignancies.
@@ Line 100: / Line 306: @@
 #Inflammatory cells present?
 #*Some are normal during menses.
+==Tabular summary==
+{| class="wikitable sortable"
+! Diagnosis
+! Key feature (low power)
+! Additional features
+! DDx
+! Other
+! Image
+|-
+| [[Proliferative phase endometrium]]
+| round spaced pseudostratified glands
+| mitoses in glands and stroma
+| [[disordered proliferative phase]], [[simple endometrial hyperplasia]], [[complex endometrial hyperplasia]], early [[secretory phase endometrium]]
+| normal
+| [[Image:Proliferative endometrium - very high mag.jpg|thumb|150px|center|Proliferative endometrium. (WC)]]
+|-
+| [[Secretory phase endometrium]]
+| irregular glands with secretions ''or'' simple glands with vacuoles
+| decidual changes (nucleus central, eosinophilic cytoplasm, well-defined cell borders)
+| [[endometrial hyperplasia with secretory changes]], late [[proliferative phase endometrium]]
+| normal
+| [[Image:Secretory phase endometrium -- high mag.jpg|thumb|120px|center|Secretory phase endometrium. (WC)]]
+|-
+| [[Menstrual endometrium]]
+| stromal condensation
+| nonproliferative glands, stromal/epithelial neutrophils, glandular cell apoptosis
+| [[disordered proliferative phase]]
+| normal
+| Image
+|-
+| [[Benign endometrial polyp]]
+| fibrous stroma, muscular blood vessels
+| polypoid shape (epithelium on 3 sides), +/-gland dilation
+| [[disordered proliferative endometrium]] (DPE), [[simple endometrial hyperplasia]] (SEH)
+| DPE and SEH do ''not'' occur in polyps
+| [[Image:Benign endometrial polyp -- low mag.jpg|thumb|150px|center|Benign endometrial polyp. (WC)]]
+|-
+| [[Endometrium with changes due to exogenous hormones]]
+| decidualized stroma (nucleus central, eosinophilic cytoplasm, well-defined cell borders)
+| inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses)
+| [[secretory phase endometrium]], [[endometrial hyperplasia with secretory changes]]
+| variant of normal
+| [[Image:Endometrium with hormone effect -- high mag.jpg|thumb|150px|center|Endometrium with changes due to exogenous hormones. (WC)]]
+|-
+| [[Atrophic endometrium]]
+| nonproliferative glands
+| no nuclear atypia, often without appreciable stroma
+| [[serous endometrial carcinoma]]
+| normal postmenopausal finding
+| [[Image:Nonproliferative endometrial epithelium - alt -- high mag.jpg|thumb|150px|center|Inactive endometrium. (WC)]]
+|-
+| [[Disordered proliferative endometrium]]
+| proliferative focally dilated & irregular glands (usu. with tubal metaplasia)
+| no nuclear atypia, +/-evidence of shedding (stromal condensation)
+| [[simple endometrial hyperplasia]], [[proliferative phase endometrium]]
+| can be thought of a [[waffle diagnosis]]
+| [[Image:Disordered proliferative endometrium -- low mag.jpg|thumb|150px|center|Disordered proliferative endometrium. (WC)]]
+|- <!--
+|  Diagnosis
+| Key feature
+| Additional features
+| DDx
+| Other
+| Image -->
+|}
 =Normal endometrium=
 ==Proliferative phase endometrium==
-*Abbreviated ''PPE''.
+{{Main|Proliferative phase endometrium}}
+==Secretory phase endometrium==
+{{Main|Secretory phase endometrium}}
+==Menstrual endometrium==
 ===General===
-*Day 1-13 in the protypical menstrual cycle of 28 days.
+*Technically part of the ''proliferative phase'' or ''follicular phase''.
-**May be ''day 5-13'' - if the menstruation is not included.
-**"Exodus" pattern is a term used to describe exfoliation of endometrial cells during the proliferative phase.
-***On [[pap test]]s this is associated with the classic double contoured balls of endometrial epithelium and stroma.
-Note:
-*Proliferative phase = follicular phase.
-**Gynecologists prefer the ovarian descriptor, i.e. ''follicular phase''; pathologists go by what they see, i.e. ''proliferative'' endometrium.
-*When the patient is >40 years, some advocate the use of the term ''proliferative type endometrium'' (instead of the term ''proliferative endometrium'').<ref>GAG. January 2009.</ref>
 ===Microscopic===
-Features:<ref name=pmid16873562/>
+Features:
-*Glands:
+*Proliferative endometrium (mitoses).<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
-**Straight, tubular, composed of tall pseudostratified columnar cells - '''key feature'''.
+*Apoptotic cells common.<ref name=pmid8744416>{{Cite journal  | last1 = Spencer | first1 = SJ. | last2 = Cataldo | first2 = NA. | last3 = Jaffe | first3 = RB. | title = Apoptosis in the human female reproductive tract. | journal = Obstet Gynecol Surv | volume = 51 | issue = 5 | pages = 314-23 | month = May | year = 1996 | doi =  | PMID = 8744416 }}</ref>
-**Mitotic figures - '''key feature'''. †
+*Tightly packed cellular balls of stromal cells with nuclear moulding.
-*Stroma:
+**Known as "blue balls".
-**Cellular stroma (spindle cells).
+**Tightly packed cellular stromal cells known as "stromal condensation".
-**Mitoses.
+*Inflammation, especially abundant [[neutrophil]]s.
-***Usually harder to find than in the glands.
-Notes:
-* † McCluggage says one shouldn't call ''PPE'' without mitoses, as some pseudostratification can be seen in [[atrophic endometrium]].<ref name=pmid16873562>{{Cite journal  | last1 = McCluggage | first1 = WG. | title = My approach to the interpretation of endometrial biopsies and curettings. | journal = J Clin Pathol | volume = 59 | issue = 8 | pages = 801-12 | month = Aug | year = 2006 | doi = 10.1136/jcp.2005.029702 | PMID = 16873562 | PMC = 1860448 }}</ref>
-** There is no guidance on how hard one should look. VL suggests searching ~ 10 mm^2 with the 20x objective. This represents approximately ~ 10 fields of view with a microscope that has a 22 mm eye piece.
-* Significant negatives:
-** No vacuolation.
-** No mucus secretion.
 DDx:
-*[[Endometrial polyp]].
+*[[Small cell carcinoma]] - proliferative activity in the moulded (stromal condensation-like) cells.
-*[[Endometrial hyperplasia]].
+*[[Anovulatory endometrium]] - less neutrophils.
-Images:
+====Images====
-*[http://library.med.utah.edu/WebPath/FEMHTML/FEM017.html Proliferative phase endometrium (utah.edu)].
+<gallery>
-*[http://www.cytochemistry.net/microanatomy/medical_lectures/028%20-%2019_16f.jpg Proliferative phase endometrium (cytochemistry.net)].<ref>URL: [http://www.cytochemistry.net/microanatomy/medical_lectures/oviduct_and_uterus.htm http://www.cytochemistry.net/microanatomy/medical_lectures/oviduct_and_uterus.htm]. Accessed on: 23 October 2012.</ref>
+Image:Endometrial_stromal_condensation_high_mag.jpg | Endometrial stromal condensation - high mag. (WC/Nephron)
+</gallery>
+www:
+*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=5&cat2=26&cat3=0&cat4=3&stype=n Menstrual endometrium - several images (gfmer.ch)].
+*[http://www.hsc.stonybrook.edu/gyn-atlas/UT3415B.htm Menstrual phase endometrium (stonybrook.edu)].
 ===Sign out===
 <pre>
-ENDOMETRIUM, BIOPSY:
+Endometrium, Biopsy:
-- PROLIFERATIVE PHASE ENDOMETRIUM.
+- Consistent with menstrual endometrium.
+-- Weakly proliferative endometrial glands with apoptosis, fragmented.
+-- Abundant balls of condensed non-proliferative endometrial stroma and blood.
 </pre>
-====Not quite normal====
+====Block letters====
 <pre>
 ENDOMETRIUM, BIOPSY:
-- EARLY SECRETORY PHASE ENDOMETRIUM.
+- CONSISTENT WITH MENSTRUAL ENDOMETRIUM:
-- FOCUS OF CROWDED PROLIFERATIVE GLANDS, SEE COMMENT.
+-- STRIPPED WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS.
+-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-COMMENT:
+-- ABUNDANT NEUTROPHILS AND BLOOD.
-There is a small focus of crowded and irregular proliferative glands
-without cytologic atypia.  The possibility of a polyp is considered but the vessels and
-polyp-type stroma are lacking.  Suggest clincal follow up with a consideration of a repeat
-biopsy in 3 to 6 months to rule out a hyperplastic lesion.
 </pre>
-==Secretory phase endometrium==
-*Abbreviated ''SPE''.
-===General===
-*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.
-===Microscopic===
-Features:
-*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).
-Features:
-*Mid secretory phase - post-ovulatory day 6-8:
-**Glands: Mucus in glands.
-**Stroma: Edema (empty space around the glands).
-Features:
-*Late secretory phase (beginning) - post-ovulatory day 9-12:
-**Stroma:
-***Spiral arterioles.
-***Predecidual changes -- mnemonic ''NEW'':
-***#Nucleus central.
-***#Eosinophilic cytoplasm '''key feature''' (may be subtle to the novice).
-***#Well-defined cell borders.
-*Premenstrual:
-**Stroma: [[neutrophil]]s, scattered lymphocytes, stromal balls ("blue balls"); "stromal condensation" (Image: [http://commons.wikimedia.org/wiki/File:Endometrial_stromal_condensation_high_mag.jpg Endometrial stromal condensation (WC)]).
-**Glands: [[apoptosis]] at the base of the gland.<ref>TC. 22 June 2009.</ref>
-General refs.: <ref name=Ref_PBoD1081>{{Ref PBoD|1081}}</ref><ref>{{Ref DCHH|237}}</ref>
-Notes:
-*Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.<ref>GAG. 6 Oct 2009.</ref>
-===Sign out===
 <pre>
 ENDOMETRIUM, BIOPSY:
-- SECRETORY PHASE ENDOMETRIUM.
+- CONSISTENT WITH MENSTRUAL PHASE ENDOMETRIUM:
+-- WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
+-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
+-- BLOOD.
 </pre>
 <pre>
 ENDOMETRIUM, BIOPSY:
-- SECRETORY PHASE ENDOMETRIUM.
+- VERY WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
-- BENIGN SUPERFICIAL EXOCERVICAL EPITHELIUM.
+- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
-- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
+- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
 </pre>
-=Specific entities/abnormalities=
+====Consistent with menstrual endometrium====
-==Arias-Stella reaction==
-{{Main|Arias-Stella reaction}}
-*Benign atypical endometrial changes associated with chorionic tissue -- may be seen in a completely normal pregnancy and misdiagnosed as a malignancy.<ref name=pmid11756756>{{Cite journal  | last1 = Arias-Stella | first1 = J. | title = The Arias-Stella reaction: facts and fancies four decades after. | journal = Adv Anat Pathol | volume = 9 | issue = 1 | pages = 12-23 | month = Jan | year = 2002 | doi =  | PMID = 11756756 }}</ref>
-==Endometritis==
-===General===
-*Usually post-delivery or post-instrumentation, e.g. previous biopsy.
-*May be spontaneous, e.g. tuberculous endometritis.
-===Microscopic===
-====Acute endometritis====
-Features:
-*Neutrophils clusters (>5 PMNs) in the:
-**Endometrial stroma.
-**Within uterine glands.
-Notes:
-*Neutrophils are normal in the context of menses.
-Image:
-*[http://www.hsc.stonybrook.edu/gyn-atlas/UT53.10.1.htm Acute endometritis (stonybrook.edu)].
-====Chronic endometritis====
-Features:<ref name=pmid18476109>{{Cite journal  | last1 = Tawfik | first1 = O. | last2 = Venuti | first2 = S. | last3 = Brown | first3 = S. | last4 = Collins | first4 = J. | title = Immunohistochemical characterization of leukocytic subpopulations in chronic endometritis. | journal = Infect Dis Obstet Gynecol | volume = 4 | issue = 5 | pages = 287-93 | month =  | year = 1996 | doi = 10.1155/S1064744996000555 | PMID = 18476109 | PMC = 2364507 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364507/}}</ref>
-*Plasma cells with in the endometrial stroma - '''key feature'''.
-**Usually superficial/close to the luminal aspect.
-*Lymphocytic infiltrate - usu. marked.
-**May form lymphoid aggregates - '''low power''' finding.
-Other findings:<ref name=pmid18476109/>
-*+/-Necrosis.
-*Edema - common.
-*Hemorrhage.
-Notes:
-*One [[plasma cell]] is not enough to call it.
-DDx:
-*[[Endometrial stromal condensation]].
-Images:
-*[[WC]]:
-**[http://commons.wikimedia.org/wiki/File:Endometritis_-_2_-_high_mag.jpg Endometritis - high mag. (WC)].
-**[http://commons.wikimedia.org/wiki/File:Endometritis_-_2_-_cropped_-_very_high_mag.jpg Endometritis - very high mag. (WC)].
-*www:
-**[http://www.webpathology.com/image.asp?n=2&Case=565 Chronic endometritis (webpathology.com)].
-**[http://www.webpathology.com/image.asp?n=3&Case=565 Chronic endometritis (webpathology.com)].
-**[http://www.webpathology.com/image.asp?n=6&Case=565 Tuberculous endometritis (webpathology.com)].
-==Benign endometrial polyp==
-*Abbreviated ''BEP''.
-*[[AKA]] ''endometrial polyp''.
-===General===
-*Very common.
-*May be a cause of menorrhagia (heavy & long menses).
-===Gross===
-*Polypoid mass in the endometrial cavity.
-Gross DDx:
-*[[Secretory phase endometrium]].<ref name=pmid16873562/>
-*Pedunculated [[uterine leiomyoma|leiomyoma]].
-===Microscopic===
-Features - diagnostic criteria:<ref name=pmid16873562>{{Cite journal  | last1 = McCluggage | first1 = WG. | title = My approach to the interpretation of endometrial biopsies and curettings. | journal = J Clin Pathol | volume = 59 | issue = 8 | pages = 801-12 | month = Aug | year = 2006 | doi = 10.1136/jcp.2005.029702 | PMID = 16873562 | PMC = 1860448 }}</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.
-Glandular changes common:<ref name=pmid16873562/>
-*Endometrial glands may be out of phase with surrounding endometrium.
-**Often proliferative.
-*+/-Cystic dilation of glands/unusual shapes
-**[[Simple endometrial hyperplasia]] should ''not'' be diagnosed in a polyp!
-*+/-Focal gland crowding.
-Notes:
-#Apparently benign polyps should be examined closely at the surface for in situ & invasive malignancies.
-#Stroma often cellular.
-DDx:
-*[[Adenofibroma]].
-*[[Cervical polyp]] - have endocervical mucosa.
-*Lower uterine segment - have endocervical epithelium and lack the thick-walled blood vessels.<ref name=pmid16873562/>
-*[[Endometrial carcinoma]] - esp. [[serous carcinoma of the endometrium]].
-===Sign out===
-====Non-proliferative====
 <pre>
-ENDOMETRIUM, CURETTAGE:
+ENDOMETRIUM, ASPIRATION:
-- BENIGN ENDOMETRIAL POLYP.
+- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH PSEUDOSTRATIFIED
+  GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
+  AND BLOOD).
+- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
 </pre>
+<pre>
+ENDOMETRIUM, ASPIRATION:
+- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH SIMPLE
+  GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
+  (FOCAL) AND BLOOD).
+- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
-====Proliferative====
-<pre>
-ENDOMETRIUM, CURETTAGE:
-- BENIGN ENDOMETRIAL POLYP WITH PROLIFERATIVE ACTIVITY.
 </pre>
-Note:
+====Late menses====
-*It is useful to comment on whether non-polypoid endometrium is proliferative (if present), esp. in menopausal women.<ref name=pmid16873562/>
+<pre>
+ENDOMETRIUM, ASPIRATION:
+- ENDOMETRIAL GLANDS WITH APOPTOTIC CELLS, INFILTRATING NEUTROPHILS,
+  AND GLANDULAR PROLIFERATIVE ACTIVITY.
+- BALLS OF CONDENSED ENDOMETRIAL STROMA.
+- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
+- NEGATIVE FOR HYPERPLASIA.
-==Disordered proliferative endometrium==
+COMMENT:
-*Abbreviated ''DPE''.
+The findings are most in keeping with late menstrual endometrium.
-*[[AKA]] ''endometrium with disordered proliferative phase''.
+</pre>
-*[[AKA]] ''disordered proliferative phase''.
+=Specific entities/abnormalities=
+==Adipose tissue on endometrial biopsy==
+*[[AKA]] ''fat on endometrial biopsy''.
 ===General===
-*Association: anovulation.
+*Benign.
-*Benign - can be grouped with ''normal''.<ref name=pmid18580308>{{Cite journal  | last1 = Sherman | first1 = ME. | last2 = Ronnett | first2 = BM. | last3 = Ioffe | first3 = OB. | last4 = Richesson | first4 = DA. | last5 = Rush | first5 = BB. | last6 = Glass | first6 = AG. | last7 = Chatterjee | first7 = N. | last8 = Duggan | first8 = MA. | last9 = Lacey | first9 = JV. | title = Reproducibility of biopsy diagnoses of endometrial hyperplasia: evidence supporting a simplified classification. | journal = Int J Gynecol Pathol | volume = 27 | issue = 3 | pages = 318-25 | month = Jul | year = 2008 | doi = 10.1097/PGP.0b013e3181659167 | PMID = 18580308 }}</ref>
+*Raises the possibility of perforation - should prompt a phone call to the clinician.
 ===Microscopic===
-Features:<ref name=Ref_PBoD1080>{{Ref PBoD|1080 and 1082}}</ref>
+Features:
-*Proliferative type endometrium with:
+*Adipose tissue, benign - '''key finding'''.
-**Cystic dilation of glands without secretions.
+*Definite endometrium.
-*+/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).
 DDx:
-*[[Simple endometrial hyperplasia]] without atypia - architectural atypia diffuse.
+*Extraneous tissue.
+**[[Tissue floater]].
-Notes:
+**Pick-up.
-*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.
-*Eosinophilic syncytial metaplasia - common.
-**Features: abundant eosinophilic cytoplasm, mild nuclear atypia +/-loss of nuclear stratification, no mitoses).
-Image:
+====Images====
-*[http://commons.wikimedia.org/wiki/File:Endometrial_stromal_condensation_high_mag.jpg Endometrial stromal condensation - high mag. (WC)].
+<gallery>
+Image: Endometrium and adipose tissue - alt -- intermed mag.jpg | EMB with fat - intermed. mag.
+Image: Endometrium and adipose tissue -- intermed mag.jpg | EMB with fat - intermed. mag.
+Image: Endometrium and adipose tissue -- high mag.jpg | EMB with fat - high mag.
+</gallery>
 ===Sign out===
 <pre>
 ENDOMETRIUM, BIOPSY:
-- DISORDERED PROLIFERATIVE ENDOMETRIUM.
+- BENIGN ADIPOSE TISSUE, SEE COMMENT.
+- PROLIFERATIVE PHASE ENDOMETRIUM.
+COMMENT:
+The presence of adipose tissue raises the possibility of perforation.
+The findings were briefly discussed with Dr. Brown on November 6, 2009.
 </pre>
-====Micro====
+==Arias-Stella reaction==
-The sections show endometrium with glands that have pseudostratified columnar cells.  The glands are lined by endometrial epithelium.  Tubal-type epithelium is seen focally.  Mitotic figures are identified within the glands. The gland-to-stroma ratio is slightly increased. Dilated glands are seen only focally; most glands are round and regular.  Apoptotic cells are seen in the glands focally.
+{{Main|Arias-Stella reaction}}
+*Benign atypical endometrial changes associated with chorionic tissue -- may be seen in a completely normal pregnancy and misdiagnosed as a malignancy.<ref name=pmid11756756>{{Cite journal  | last1 = Arias-Stella | first1 = J. | title = The Arias-Stella reaction: facts and fancies four decades after. | journal = Adv Anat Pathol | volume = 9 | issue = 1 | pages = 12-23 | month = Jan | year = 2002 | doi =  | PMID = 11756756 }}</ref>
-Benign stripped endocervical epithelium is present. No squamous epithelium is apparent.
+==Endometritis==
+{{Main|Endometritis}}
-There are no back-to-back glands. No nuclear atypia is apparent. No thick-walled blood vessels are apparent.
+==Benign endometrial polyp==
+{{Main|Benign endometrial polyp}}
-==Endometrial changes of oral contraception==
+==Anovulatory endometrium==
-{{Main|Oral contraceptive pill}}
+{{Main|Anovulatory endometrium}}
-*[[AKA]] ''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===
+==Disordered proliferative endometrium==
-Features:<ref name=Ref_PBoD1082>{{Ref PBoD|1082}}</ref>
+*Abbreviated ''DPE''.
-*Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
+*[[AKA]] ''endometrium with disordered proliferative phase''.
-*Stroma decidualized -- mnemonic ''NEW'':
+*[[AKA]] ''disordered proliferative phase''.
-**Nucleus central.
+{{Main|Disordered proliferative endometrium}}
-**Eosinophilic cytoplasm.
-**Well-defined cell borders.
-Image:
+==Endometrium with changes due to exogenous hormones==
-*[http://commons.wikimedia.org/wiki/File:Endometrium_ocp_use3.jpg Endometrium of woman on an OCP (WC)].
+{{Main|Endometrium with changes due to exogenous hormones}}
 ==Atrophic endometrium==
 *[[AKA]] ''atrophy of the endometrium''.
 *[[AKA]] ''endometrial atrophy''.
-===General===
+{{Main|Inactive endometrium}}
-*Endometrium of normal postmenopausal women.
-**Menopause typically happens at around 50 years old.
-*Very common diagnosis.
-**Atrophy may be associated with bleeding and therefore biopsied to rule-out hyperplasia and malignancy.
-===Gross===
+==Ablated endometrium==
-*Thin endometrium.
+{{Main|Ablated endometrium}}
-===Microscopic===
+==Endometrium with squamous morules==
-Features:
+{{Main|Endometrium with squamous morules}}
-*Glands - small columnar cells:
-**Moderate quantity of eosinophilic cytoplasm.
-**Ovoid (palisaded) nuclei +/- nuclear pseudostratification.<ref name=pmid16873562>{{Cite journal  | last1 = McCluggage | first1 = WG. | title = My approach to the interpretation of endometrial biopsies and curettings. | journal = J Clin Pathol | volume = 59 | issue = 8 | pages = 801-12 | month = Aug | year = 2006 | doi = 10.1136/jcp.2005.029702 | PMID = 16873562 | PMC = 1860448 }}</ref>
-**Eosinophilic cytoplasm.
-**No mitoses.
-*Architecture:
-**+/-Cystic dilation.
-Notes:
-*If a woman is truly postmenopausal, mitoses in the glandular epithelium is pathologic until demonstrated otherwise.
-**The exceptions are [[benign endometrial polyp]], [[uterine prolapse]], and possibly inflammation (e.g. the person has had several biopsy attempts and was seeded with pathogens).
-DDx:
-*[[Proliferative phase endometrium]] - esp. if there is pseudostratification.
-*[[Serous carcinoma of the endometrium]].
-Images:
+==Endometrium with psammoma bodies==
-*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/figure/fig1/ Atrophic endometrium (nih.gov)].<ref name=pmid16873562/>
+{{Main|Endometrium with psammoma bodies}}
 ==Endometrial hyperplasia==
@@ Line 422: / Line 555: @@
 *[[Uterine tumours]].
 *[[Gynecologic pathology]].
+*[[Psammoma bodies]].
 =References=
@@ Line 427: / Line 561: @@
 [[Category:Gynecologic pathology]]
+[[Category:Endometrium]]

Difference between revisions of "Endometrium"

Latest revision as of 14:37, 2 March 2017

Indications for endometrial biopsy

Endometrial thickness on ultrasound

Normal microscopic findings

Glandular telescoping

Endometrial gland compression artifact

Image

Micro

See also

Endocervical epithelium versus endometrial epithelium

Table

List

Images

Metaplasias of the endometrium

Tamoxifen effects

Inadequate endometrial biopsy

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No stroma

Proliferative without definite stroma

Possible endometrium - insufficient

No endometrium

No tissue

Overview

A simple approach

Low power

High power

Tabular summary

Normal endometrium

Proliferative phase endometrium

Secretory phase endometrium

Menstrual endometrium

General

Microscopic

Images

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Block letters

Consistent with menstrual endometrium

Late menses

Specific entities/abnormalities

Adipose tissue on endometrial biopsy

General

Microscopic

Images

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Arias-Stella reaction

Endometritis

Benign endometrial polyp

Anovulatory endometrium

Disordered proliferative endometrium

Endometrium with changes due to exogenous hormones

Atrophic endometrium

Ablated endometrium

Endometrium with squamous morules

Endometrium with psammoma bodies

Endometrial hyperplasia

Endometrial carcinoma

See also

References

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