Endometrium

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The endometrium is typically biopsied because of abnormal bleeding.

Biopsies done for bleeding:

  • Too much bleeding (if premenopausal) - AUB = abnormal uterine bleeding.
  • Post-menopausal bleeding.
  • Dysfunctional uterine bleeding aka DUB (follow-up).
    • DUB is diagnosed if other causes of bleeding are excluded - these patients are followed.[1]

Micro.

  • 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.

A simple approach

Low power

  1. Decide whether you're look at endometrium.
  2. Gland-to-stroma ratio normal?
  3. Glands round?
    • Round is normal.
    • Irregular - may be seen in menses, endometrial hyperplasia other endometrial pathology.
  4. Glands pseudostratified?
    • pseudostratified glands are normal in the proliferative phase.

High power

  1. Mitoses present in the glands?
    • Present in the proliferative phase, hyperplasias, malignancies.
  2. Mitoses present in the stroma?
    • Present in the proliferative phase, hyperplasias, malignancies.
  3. Mucous present in the glands?
    • Present in the secretory phase.
  4. Inflammatory cells present?
    • Some are normal during menses.

Endometrial polyp

Epidemiology

  • Very common.

Microscopy

Features:[2]

  • 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:

  • Endometrial glands may be out of phase with surrounding endometrium.
    • Often proliferative.
  • +/-Cystic dilation of glands.
  • Cellular stroma.

Dating endometrium

Proliferative phase

  • 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

  • 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).
  • Mid secretory phase - post-ovulatory day 6-8:
    • GLANDS: Mucus in glands.
    • STROMA: Edema (empty space around the glands).
  • Late secretory phase (begining) - post-ovulatory day 9-12:
    • STROMA: Spiral arterioles.
    • STROMA: Predecidual changes -- mnemonic NEW:
      • Nucleus central.
      • Eosinophilic cytoplasm key feature (may be subtle to the novice).
      • Well-defined cell borders.
  • Premenstrual

General refs.: [4][5]

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).[6]
  • Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.[7]

Abnormalities of endometrium

Disordered proliferative phase

  • Association: anovulation.

Features:[8]

  • Proliferative type endometrium with:
    • Cystic dilation of glands without secretions.
  • +/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).

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.

Endometrium of a woman taking OCP

Features:[9]

  • Inactive glands.
  • Stroma decidualized -- mnemonic NEW:
    • Nucleus central.
    • Eosinophilic cytoplasm.
    • Well-defined cell borders.

Postmenopausal women

  • 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

Endometrial carcinoma

Main article: Endometrial carcinoma

See also

References

  1. ↑ need ref
  2. ↑ http://www.pathologyoutlines.com/uterus.html#endopolyp
  3. ↑ TC 22 June 2009.
  4. ↑ 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.
  5. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 237. ISBN 978-0470519035.
  6. ↑ GAG. Jan 2009
  7. ↑ GAG. 6 Oct 2009.
  8. ↑ 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.
  9. ↑ 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.
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