Difference between revisions of "Endometrium"
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#*Some are normal during menses. | #*Some are normal during menses. | ||
= | =Normal endometrium= | ||
==Proliferative phase== | ==Proliferative phase endometrium== | ||
*Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion. | *Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion. | ||
**Key features: pseudostratification, mitoses. | **Key features: pseudostratification, mitoses. | ||
| Line 68: | Line 68: | ||
**Gynecologists prefer the ovarian descriptor, i.e. ''follicular phase''; pathologists go by what they see, i.e. ''proliferative'' endometrium. | **Gynecologists prefer the ovarian descriptor, i.e. ''follicular phase''; pathologists go by what they see, i.e. ''proliferative'' endometrium. | ||
==Secretory phase== | ==Secretory phase endometrium== | ||
*Early secretory phase - post-ovulatory day 1-5: | *Early secretory phase - post-ovulatory day 1-5: | ||
**Glands: secretory vacuoles. | **Glands: secretory vacuoles. | ||
Revision as of 12:38, 6 November 2011
The endometrium is typically biopsied because of abnormal bleeding.
Indications for endometrial biopsy
Biopsies done for bleeding:
- Too much bleeding (if premenopausal) - AUB = abnormal uterine bleeding.
- Post-menopausal bleeding.
- Dysfunctional uterine bleeding AKA DUB - may get D&C if they fail medical management.[1]
- DUB is diagnosed if other causes of bleeding are excluded.
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.
Endocervical glands vs. Endometrial glands
Endocervical
- Less hyperchromatic.
- Nuclei round & small.
- Cell borders usually well-defined.
Endometrial
- More hyperchromatic.
- Nuclei columnar.
Tamoxifen effects
- Endometrial hyperplasia.
- Endometrial cancer.
- Endometrial polyps.
- Atrophy.
A simple approach
Low power
- Decide whether you're look at endometrium.
- Gland-to-stroma ratio normal?
- 1:3 is normal.
- If gland-to-stroma ratio is increased... think endometrial hyperplasia.
- If 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.
- Glands pseudostratified?
- Pseudostratified glands are normal in the proliferative phase, hyperplasias, malignancy.
- Balls of cells?
- Blue - likely menstrual (stromal condensation).
- Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia).
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.
Normal endometrium
Proliferative phase endometrium
- Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion.
- Key features: pseudostratification, mitoses.
- Stroma: cellular stroma (spindle cells), mitoses.
Note:
- Proliferative phase = folicular phase.
- Gynecologists prefer the ovarian descriptor, i.e. follicular phase; pathologists go by what they see, i.e. proliferative endometrium.
Secretory phase endometrium
- 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).
- Glands: secretory vacuoles.
- Mid secretory phase - post-ovulatory day 6-8:
- Glands: Mucus in glands.
- Stroma: Edema (empty space around the glands).
- 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.
- Stroma:
- Premenstrual
- Stroma: Neutrophils, scattered lymphocytes, stromal balls ("blue balls"); "stromal condensation" (Image: Endometrial stromal condensation (WC)).
- Glands: apoptosis at the base of the gland.[2]
Notes:
- 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.
- When the patient is >40 years, some advocate the use of the term proliferative type endometrium (instead of the term proliferative endometrium).[5]
- Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.[6]
Specific entities/abnormalities
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.[7]
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:
Chronic endometritis
Features:
- Plasma cells with in the endometrial stroma - key feature.
Notes:
- One plasma cell is not enough to call it.
Images:
- Chronic endometritis (webpathology.com).
- Chronic endometritis (webpathology.com).
- Tuberculous endometritis (webpathology.com)
Benign endometrial polyp
- AKA endometrial polyp.
General
- Very common.
- May be a cause of menorrhagia (heavy & long menses).
Microscopic
Features:[8]
- 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.
Notes:
- Apparently benign polyps should be examined closely at the surface for in situ & invasive malignancies.
- Endometrial glands may be out of phase with surrounding endometrium.
- Often proliferative.
- +/-Cystic dilation of glands.
- Cellular stroma.
Other considerations:
Disordered proliferative phase
- AKA endometrium with disordered proliferative phase.
General
- Association: anovulation.
Microscopic
Features:[9]
- Proliferative type endometrium with:
- Cystic dilation of glands without secretions.
- +/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).
DDx:
- Simple endometrial hyperplasia without atypia - more architectural atypia.
Notes:
- 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.
Image: Endometrial stromal condensation - high mag. (WC).
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
Features:[10]
- Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
- Stroma decidualized -- mnemonic NEW:
- Nucleus central.
- Eosinophilic cytoplasm.
- Well-defined cell borders.
Image: Endometrium of woman on an OCP (WC).
Atrophic endometrium
General
- 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.
Microscopic
Features:
- Atrophy glands.
- Thin endometrium.
Notes:
- If a woman is truly postmenopausal, mitoses in the glandular epithelium is pretty much always pathologic.
- Exception is inflammation... e.g. the person has had several biopsy attempts and was seeded with pathogens.
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).[11]
See also
References
- ↑ URL: http://emedicine.medscape.com/article/257007-treatment. Accessed on: 15 July 2010.
- ↑ TC. 22 June 2009.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1081. ISBN 0-7216-0187-1.
- ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 237. ISBN 978-0470519035.
- ↑ GAG. Jan 2009
- ↑ GAG. 6 Oct 2009.
- ↑ Arias-Stella, J. (Jan 2002). "The Arias-Stella reaction: facts and fancies four decades after.". Adv Anat Pathol 9 (1): 12-23. PMID 11756756.
- ↑ URL: http://www.pathologyoutlines.com/uterus.html#endopolyp. Accessed on: 15 September 2011.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1080 and 1082. ISBN 0-7216-0187-1.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1082. ISBN 0-7216-0187-1.
- ↑ 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.