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 11: / Line 11: @@
 *[[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 39: / Line 42: @@
 *Focal [[complex endometrial hyperplasia]].
-Image:
+===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==
@@ Line 58: / Line 64: @@
 | hyperchromatic
 |-
-| Nuclear-to-cytoplasm ratio
+| [[Nucleus-to-cytoplasm ratio]]
 | moderate to high (1:2)
 | low (often 1:3)
@@ Line 100: / Line 106: @@
 ! Image
 |-
-| Morules
+| [[Endometrium with squamous morules|Morules]]
 | -
 |
@@ Line 234: / Line 240: @@
 - 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>
@@ Line 304: / Line 328: @@
 | [[endometrial hyperplasia with secretory changes]], late [[proliferative phase endometrium]]
 | normal
-| [[Image:Secretory_phase_endometrium.jpg|thumb|150px|center|Secretory phase endometrium. (WC)]]
+| [[Image:Secretory phase endometrium -- high mag.jpg|thumb|120px|center|Secretory phase endometrium. (WC)]]
 |-
 | [[Menstrual endometrium]]
@@ Line 316: / Line 340: @@
 | fibrous stroma, muscular blood vessels
 | polypoid shape (epithelium on 3 sides), +/-gland dilation
-| [[disordered proliferative phase]], [[simple endometrial hyperplasia]]
+| [[disordered proliferative endometrium]] (DPE), [[simple endometrial hyperplasia]] (SEH)
-| Other
+| DPE and SEH do ''not'' occur in polyps
-| Image
+| [[Image:Benign endometrial polyp -- low mag.jpg|thumb|150px|center|Benign endometrial polyp. (WC)]]
 |-
 | [[Endometrium with changes due to exogenous hormones]]
@@ Line 324: / Line 348: @@
 | inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses)
 | [[secretory phase endometrium]], [[endometrial hyperplasia with secretory changes]]
-| Other
+| variant of normal
-| [[Image:Endometrium ocp use3.jpg|thumb|150px|center|Endometrium with OCP changes. (WC)]]
+| [[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
@@ Line 356: / Line 394: @@
 DDx:
-*[[Small cell carcinoma]].
+*[[Small cell carcinoma]] - proliferative activity in the moulded (stromal condensation-like) cells.
 *[[Anovulatory endometrium]] - less neutrophils.
@@ Line 368: / Line 406: @@
 ===Sign out===
+<pre>
+Endometrium, Biopsy:
+- Consistent with menstrual endometrium.
+-- Weakly proliferative endometrial glands with apoptosis, fragmented.
+-- Abundant balls of condensed non-proliferative endometrial stroma and blood.
+</pre>
+====Block letters====
 <pre>
 ENDOMETRIUM, BIOPSY:
@@ Line 389: / Line 435: @@
 - BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
 - NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
+</pre>
+====Consistent with menstrual endometrium====
+<pre>
+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.
+</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.
 </pre>
@@ Line 405: / Line 468: @@
 =Specific entities/abnormalities=
-==Arias-Stella reaction==
+==Adipose tissue on endometrial biopsy==
-{{Main|Arias-Stella reaction}}
+*[[AKA]] ''fat on endometrial biopsy''.
-*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.
+*Benign.
-*May be spontaneous, e.g. tuberculous endometritis.
+*Raises the possibility of perforation - should prompt a phone call to the clinician.
 ===Microscopic===
-====Acute endometritis====
 Features:
-*Neutrophils clusters (>5 PMNs) in the:
+*Adipose tissue, benign - '''key finding'''.
-**Endometrial stroma.
+*Definite endometrium.
-**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 - usually marked.
-**May form lymphoid aggregates - '''low power''' finding.
-*+/-Eosinophils - presence should prompt a search for plasma cells.<ref name=pmid19801162>{{Cite journal  | last1 = Adegboyega | first1 = PA. | last2 = Pei | first2 = Y. | last3 = McLarty | first3 = J. | title = Relationship between eosinophils and chronic endometritis. | journal = Hum Pathol | volume = 41 | issue = 1 | pages = 33-7 | month = Jan | year = 2010 | doi = 10.1016/j.humpath.2009.07.008 | PMID = 19801162 }}</ref>
-Other findings:<ref name=pmid18476109/>
-*+/-Necrosis.
-*Edema - common.
-*Hemorrhage.
-Notes:
-*One [[plasma cell]] is not enough to call it.
 DDx:
-*Mentrual endometrium - endometrial stromal condensation.
+*Extraneous tissue.
+**[[Tissue floater]].
+**Pick-up.
 ====Images====
 <gallery>
-Image:Endometritis_-_2_-_high_mag.jpg | Endometritis - high mag. (WC/Nephron)
+Image: Endometrium and adipose tissue - alt -- intermed mag.jpg | EMB with fat - intermed. mag.
-Image:Endometritis_-_2_-_cropped_-_very_high_mag.jpg | Endometritis - very high mag. (WC/Nephron)
+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>
-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)].
 ===Sign out===
 <pre>
 ENDOMETRIUM, BIOPSY:
-- CHRONIC ENDOMETRITIS.
+- BENIGN ADIPOSE TISSUE, SEE COMMENT.
-</pre>
+- PROLIFERATIVE PHASE ENDOMETRIUM.
-====Not definite endometritis====
-<pre>
-ENDOMETRIUM, ASPIRATION:
-- PROLIFERATIVE PHASE ENDOMETRIUM WITH A MILD LYMPHOCYTIC INFILTRATE AND VERY RARE
-  PLASMA CELLS, SEE COMMENT.
-- NEGATIVE FOR HYPERPLASIA.
 COMMENT:
-The lymphocytic infiltrate and plasma cells raise the possibility of a mild chronic
+The presence of adipose tissue raises the possibility of perforation.
-endometritis; clinical correlation is suggested.
-</pre>
-====Nonspecific lymphocytic infiltrate====
+The findings were briefly discussed with Dr. Brown on November 6, 2009.
-If not more than one plasma cell is apparent after searching.
-<pre>
-ENDOMETRIUM, ASPIRATION:
-- PROLIFERATIVE PHASE ENDOMETRIUM WITH A MILD LYMPHOCYTIC INFILTRATE.
-- SMALL FRAGMENT OF ENDOCERVICAL MUCOSA WITHIN NORMAL LIMITS.
-- NEGATIVE FOR HYPERPLASIA.
 </pre>
-=====Micro=====
+==Arias-Stella reaction==
-The section show proliferative endometrium with a normal gland-to-stroma ratio.  Mitotic activity is seen in the glands and stroma. No cytologic atypia is apparent. A mild nonspecific lymphocytic infiltrate is present.
+{{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>
-No lymphoid aggregates are apparent. No eosinophils are apparent. No significant number of plasma cells is apparent.
+==Endometritis==
+{{Main|Endometritis}}
 ==Benign endometrial polyp==
@@ Line 492: / Line 513: @@
 ==Anovulatory endometrium==
-===General===
+{{Main|Anovulatory endometrium}}
-*May be used as a synonym for ''[[disordered proliferative phase]]''.<ref>URL: [http://www.surgpath4u.com/caseviewer.php?case_no=382 http://www.surgpath4u.com/caseviewer.php?case_no=382]. Accessed on: 9 May 2013.</ref>
-===Microscopic===
-Features:
-*Shedding:
-**Stromal condensation.
-**Apoptotic endometrial epithelium.
-*Nonproliferative glands.
-DDx:
-*[[Disordered proliferative phase]].
-*[[Simple endometrial hyperplasia]].
-*[[Menstrual endometrium]] - should have mitoses,<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref> abundant [[PMN]]s.
-===Sign out===
-<pre>
-ENDOMETRIUM, CURETTAGE:
-- NON-PROLIFERATIVE ENDOMETRIUM WITH SMALL ROUND GLANDS AND SHEDDING, SEE COMMENT.
-- BENIGN ENDOCERVICAL MUCOSA.
-- NEGATIVE FOR HYPERPLASIA.
-- NEGATIVE FOR MALIGNANCY.
-COMMENT:
-The changes are suggestive of anovulatory bleeding.
-</pre>
-<pre>
-ENDOMETRIUM, BIOPSY:
-- BENIGN ENDOCERVICAL POLYP WITH ACUTE AND CHRONIC INFLAMMATION, AND EVIDENCE
-  SUGGESTIVE OF EROSIONS (SIDEROPHAGES, INCREASED BLOOD VESSEL DENSITY).
-- SMALL NONPROLIFERATIVE ENDOMETRIAL GLANDS WITH RARE NEUTROPHILS AND RARE
-  APOPTOTIC CELLS, WITH BALLS OF CONDENSED ENDOMETRIAL STROMA, SEE COMMENT.
-- NEGATIVE FOR ENDOMETRIAL HYPERPLASIA AND NEGATIVE FOR DYSPLASIA.
-COMMENT:
-The changes are suggestive of anovulatory bleeding.
-</pre>
 ==Disordered proliferative endometrium==
@@ Line 535: / Line 519: @@
 *[[AKA]] ''endometrium with disordered proliferative phase''.
 *[[AKA]] ''disordered proliferative phase''.
+{{Main|Disordered proliferative endometrium}}
-===General===
-*Association: anovulation.
-*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>
-Treatment:
-*Progesterone<ref name=pmid16873562/> versus observation.<ref name=pmid17090792>{{Cite journal  | last1 = Ely | first1 = JW. | last2 = Kennedy | first2 = CM. | last3 = Clark | first3 = EC. | last4 = Bowdler | first4 = NC. | title = Abnormal uterine bleeding: a management algorithm. | journal = J Am Board Fam Med | volume = 19 | issue = 6 | pages = 590-602 | month =  | year =  | doi =  | PMID = 17090792 | url = http://www.jabfm.org/content/19/6/590.full }}</ref>
-Image:
-*[http://www.jabfm.org/content/19/6/590/F8.expansion.html Treatment algorithim based on endometrial biopsy results (jabfm.org)].<ref name=pmid17090792/>
-===Microscopic===
-Features:<ref name=Ref_PBoD1080>{{Ref PBoD|1080 and 1082}}</ref>
-*Proliferative type endometrium with:
-**Cystic dilation of glands focally that do not have (glandular) secretions - '''key feature'''.
-***Glands >2x normal size - usually 3-4x normal.
-***Irregular shape, e.g. gland contour has inflection points.
-***Greater than fours glands involved (dilated).
-*+/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).
-Notes:
-*Dilated glands often have tubal metaplasia.{{fact}}
-*Eosinophilic syncytial metaplasia - common.
-**Features: abundant eosinophilic cytoplasm, mild nuclear atypia +/-loss of nuclear stratification, no mitoses).
-DDx:
-*[[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.
-*[[Simple endometrial hyperplasia]] without atypia - architectural atypia diffuse.
-*[[Benign endometrial polyp]].
-====Images====
-www:
-*[http://www.sciencedirect.com/science/article/pii/S0740257010000997#fig15 DPE (sciencedirect.com)].
-*[http://www.sciencedirect.com/science/article/pii/S0740257010000997#fig18 DPE (sciencedirect.com)].
-*[http://www.glowm.com/resources/glowm/uploads/1225247516_03-50291-007_small.jpg DPE (glowm.com)].<ref name=glowm>URL: [http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=235 http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=235]. Accessed on: 11 December 2012.</ref>
-*[http://www.hsc.stonybrook.edu/gyn-atlas/UT3431B.htm DPE (stonybrook.edu)].
-<gallery>
-Image:Endometrial_stromal_condensation_high_mag.jpg | Endometrial stromal condensation - high mag. (WC/Nephron)
-</gallery>
-===Sign out===
-<pre>
-ENDOMETRIUM, BIOPSY:
-- DISORDERED PROLIFERATIVE ENDOMETRIUM.
-</pre>
-=====With endocervix=====
-<pre>
-ENDOMETRIUM, BIOPSY:
-- DISORDERED PROLIFERATIVE ENDOMETRIUM.
-- BENIGN ENDOCERVICAL MUCOSA.
-</pre>
-=====Waffle a bit=====
-<pre>
-ENDOMETRIUM, BIOPSY:
-- COMPATIBLE WITH DISORDERED PROLIFERATIVE ENDOMETRIUM (FRAGMENTS OF PROLIFERATIVE
-  ENDOMETRIUM WITH EVIDENCE OF SHEDDING AND VERY RARE GLAND DILATION).
-- VERY SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHOUT APPARENT PATHOLOGY.
-- NEGATIVE FOR ENDOMETRIAL HYPERPLASIA.
-- NEGATIVE FOR MALIGNANCY.
-</pre>
-====Micro====
-The sections show a well-sampled endometrium. Mitotic figures are identified within the
-glands and stroma. Irregular, moderately enlarged glands are seen (only) in one of several
-fragments; most of the endometrial glands are round, regular and small.
-No stromal condensation is apparent. No secretions are in the glands.
-There are no back-to-back glands. No nuclear atypia is apparent. No thick-walled blood
-vessels are apparent.
 ==Endometrium with changes due to exogenous hormones==
@@ Line 613: / Line 525: @@
 ==Atrophic endometrium==
-:''Inactive endometrium'' redirect here.
 *[[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===
-*Thin endometrium.
-===Microscopic===
-Features:
-*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:
-*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/figure/fig1/ Atrophic endometrium (nih.gov)].<ref name=pmid16873562/>
-===Sign out===
-<pre>
-ENDOMETRIUM, BIOPSY:
-- NON-PROLIFERATIVE ENDOMETRIUM.
-- BENIGN SQUAMOUS EPITHELIUM WITH METAPLASTIC CHANGE.
-- SCANT ENDOCERVICAL MUCOSA WITH REACTIVE CHANGES.
-</pre>
-<pre>
-ENDOMETRIUM, BIOPSY:
-- NON-PROLIFERATIVE ENDOMETRIUM.
-- BENIGN STRIPPED ENDOCERVICAL EPITHELIUM.
-- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
-</pre>
-=====Micro=====
+==Ablated endometrium==
-The sections show small fragments of endometrium. The gland-to-stroma ratio is normal. The glands are small and round, and have a pseudostratified epithelium.
+{{Main|Ablated endometrium}}
-Mitotic figures are not identified within the glands or stroma. No stromal condensation is apparent. No secretions are in the glands.  No nuclear atypia is apparent.
+==Endometrium with squamous morules==
+{{Main|Endometrium with squamous morules}}
-Scant benign endocervical tissue (stripped epithelium and mucosa) is present.
-====Limited stroma====
-<pre>
-ENDOMETRIUM, BIOPSY:
-- STRIPPED NONPROLIFERATIVE ENDOMETRIAL EPITHELIUM; NO APPRECIABLE STROMA PRESENT.
-- SCANT ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
-- MINUTE FRAGMENTS OF SQUAMOUS EPITHELIUM WITHOUT APPARENT PATHOLOGY.
-</pre>
-<pre>
-ENDOMETRIUM, BIOPSY:
-- SCANT STRIPPED NON-PROLIFERATIVE ENDOMETRIAL EPITHELIUM.
-- VERY SMALL FRAGMENT OF ENDOMETRIAL STROMA.
-- TUBAL METAPLASTIC EPITHELIUM.
-</pre>
-<pre>
-ENDOMETRIUM, ASPIRATION:
-- SMALL FRAGMENTS OF NONPROLIFERATIVE ENDOMETRIAL EPITHELIUM ATTACHED TO
-  A VERY SMALL AMOUNT OF STROMA.
-- MINUTE BENIGN FRAGMENT OF SQUAMOUS EPITHELIUM.
-- MUCOUS AND INFLAMMATORY CELLS.
-COMMENT:
-The sample is scant given the history of 'thickened endometrium'.
-</pre>
-=====Micro=====
+==Endometrium with psammoma bodies==
-The sections show stripped endometrial epithelium and stripped tubal-type epithelium.
+{{Main|Endometrium with psammoma bodies}}
-No mitotic activity is identified.  No nuclear atypia is apparent. A small fragment of
-definite endometrial stroma is present.  The gland-to-stroma ratio cannot be assessed due
-to the limited stroma.
 ==Endometrial hyperplasia==
@@ Line 717: / Line 555: @@
 *[[Uterine tumours]].
 *[[Gynecologic pathology]].
+*[[Psammoma bodies]].
 =References=

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

Sign out

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

Sign out

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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