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==Indications for endometrial biopsy==
==Indications for endometrial biopsy==
Biopsies done for bleeding:  
Abnormal bleeding:  
*Too much bleeding (if premenopausal) - ''AUB'' = abnormal uterine bleeding.
*[[Abnormal uterine bleeding]] (AUB).
**[[Dysfunctional uterine bleeding]], abbreviated ''DUB'', is diagnosed if other causes of bleeding are excluded.
**[[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.<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>
*Post-menopausal bleeding.
**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=
=Normal microscopic findings=
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*[http://jcp.bmjjournals.com/content/59/8/801/F3.large.jpg Telescoping (bmjjournals.com)].<ref name=pmid16873562/>
*[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.
*Less hyperchromatic.
*Nuclei round & small.
*Nuclei round & small.
*Cell borders usually well-defined.
*Cell borders usually well-defined.
===Endometrial===
 
Endometrial:
*More hyperchromatic.
*More hyperchromatic.
*Nuclei columnar.
*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=
=Tamoxifen effects=
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==Sign out==
==Sign out==
===No stroma===
<pre>
<pre>
ENDOMETRIUM, BIOPSY:  
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>
</pre>


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</pre>
</pre>


=A simple approach=
===Proliferative without definite stroma===
==Low power==
<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.
#Decide whether you are looking at endometrium.
#Is the gland-to-stroma ratio normal?
#Is the gland-to-stroma ratio normal?
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#*Pink - consider [[uterine leiomyoma|leiomyoma]], squamous morules (associated with [[endometrial hyperplasia]], [[endometrioid endometrial carcinoma]], may be benign).
#*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?
#Mitoses present in the glands?
#*Present in the proliferative phase, hyperplasias, malignancies.
#*Present in the proliferative phase, hyperplasias, malignancies.
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#Inflammatory cells present?
#Inflammatory cells present?
#*Some are normal during menses.
#*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=
=Normal endometrium=
==Proliferative phase endometrium==
==Proliferative phase endometrium==
*Abbreviated ''PPE''.
{{Main|Proliferative phase endometrium}}
 
==Secretory phase endometrium==
{{Main|Secretory phase endometrium}}
 
==Menstrual endometrium==
===General===
===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===
===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.
* Inflammation (neutrophils, rare plasma cell) & stromal breakdown common early in the proliferative phase.<ref name=Ref_GP197>{{Ref GP|197}}</ref>


DDx:
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===
===Sign out===
<pre>
<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>
</pre>


====Not quite normal====
====Block letters====
<pre>
<pre>
ENDOMETRIUM, BIOPSY:
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>
</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===
====Early secretory phase====
Features - post-ovulatory day 1-5:<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
*Glands: secretory vacuoles.
**First basal to the epithelial nuclei (infranuclear vacuoles).
**Then apical to the epithelial nuclei (supranuclear vacuoles).
*Mitoses may be present - common when vacuoles are subnuclear.
====Mid secretory phase====
Features - post-ovulatory day 6-8:<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
*Glands: Mucus in glands.
*Stroma: Edema (empty space around the glands).
====Late secretory phase====
Features - post-ovulatory day 9-12:<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
*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>
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>
*Gland-to-stroma ratio is increased in late secretory phase and menstruation.<ref>URL: [http://www.pathologyoutlines.com/topic/uteruspatternapproach.html http://www.pathologyoutlines.com/topic/uteruspatternapproach.html]. Accessed on: 6 December 2012.</ref>
===Sign out===
<pre>
<pre>
ENDOMETRIUM, BIOPSY:  
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>


<pre>
<pre>
ENDOMETRIUM, BIOPSY:
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>
</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:
*Mentrual endometrium - 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>
<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>
<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>
</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/>
 
====Polyp with disordered proliferative phase in the background====
<pre>
<pre>
ENDOMETRIUM, BIOPSY:
ENDOMETRIUM, ASPIRATION:
- BENIGN ENDOMETRIAL POLYP WITH PROLIFERATIVE GLANDS AND FOCAL GLAND DILATION.
- ENDOMETRIAL GLANDS WITH APOPTOTIC CELLS, INFILTRATING NEUTROPHILS,
- SUSPICIOUS FOR A BACKGROUND OF DISORDERED PROLIFERATIVE
  AND GLANDULAR PROLIFERATIVE ACTIVITY.
  PHASE ENDOMETRIUM, SEE COMMENT.
- BALLS OF CONDENSED ENDOMETRIAL STROMA.
- STRIPPED BENIGN ENDOCERVICAL EPITHELIUM.
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- NEGATIVE FOR HYPERPLASIA.


COMMENT:
COMMENT:
The endometrium sampled is proliferative with focal gland dilation throughout. The
The findings are most in keeping with late menstrual endometrium.
features of a polyp (large muscular blood vessels, fibrous stroma and polypoid fragments of
endometrium) are only focally present, suggesting there is a background of disordered
proliferative phase endometrium.  Clinical correlation is suggested.
</pre>
</pre>


==Disordered proliferative endometrium==
=Specific entities/abnormalities=
*Abbreviated ''DPE''.
==Adipose tissue on endometrial biopsy==
*[[AKA]] ''endometrium with disordered proliferative phase''.
*[[AKA]] ''fat on endometrial biopsy''.
*[[AKA]] ''disordered proliferative phase''.
 
===General===
===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===
===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 focally that do not have (glandular) secretions - '''key feature'''.
*Definite endometrium.
***Glands >2x normal size - usu. 3-4x normal.
***Irregular shape, e.g. gland contour has inflection points.
*+/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).


DDx:
DDx:
*[[Proliferative phase endometrium]].
*Extraneous tissue.
*[[Simple endometrial hyperplasia]] without atypia - architectural atypia diffuse.
**[[Tissue floater]].
 
**Pick-up.
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.
*Eosinophilic syncytial metaplasia - common.
**Features: abundant eosinophilic cytoplasm, mild nuclear atypia +/-loss of nuclear stratification, no mitoses).


Images:
====Images====
*www:
<gallery>
**[http://www.sciencedirect.com/science/article/pii/S0740257010000997#fig15 DPE (sciencedirect.com)].
Image: Endometrium and adipose tissue - alt -- intermed mag.jpg | EMB with fat - intermed. mag.
**[http://www.sciencedirect.com/science/article/pii/S0740257010000997#fig18 DPE (sciencedirect.com)].
Image: Endometrium and adipose tissue -- intermed mag.jpg | EMB with fat - intermed. mag.
**[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>
Image: Endometrium and adipose tissue -- high mag.jpg | EMB with fat - high mag.
**[http://www.hsc.stonybrook.edu/gyn-atlas/UT3431B.htm DPE (stonybrook.edu)].
</gallery>
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Endometrial_stromal_condensation_high_mag.jpg Endometrial stromal condensation - high mag. (WC)].


===Sign out===
===Sign out===
<pre>
<pre>
ENDOMETRIUM, BIOPSY:
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>
</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:
*[http://commons.wikimedia.org/wiki/File:Endometrium_ocp_use3.jpg Endometrium of woman on an OCP (WC)].


===Sign out===
==Endometrium with changes due to exogenous hormones==
<pre>
{{Main|Endometrium with changes due to exogenous hormones}}
ENDOMETRIUM, BIOPSY:
- NON-PROLIFERATIVE ENDOMETRIAL GLANDS WITH STROMAL DECIDUALIZATION, CONSISTENT
  WITH EXOGENOUS HORMONES.
</pre>


==Atrophic endometrium==
==Atrophic endometrium==
*[[AKA]] ''atrophy of the endometrium''.
*[[AKA]] ''atrophy of the endometrium''.
*[[AKA]] ''endometrial atrophy''.
*[[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==
==Endometrial hyperplasia==
Line 462: Line 555:
*[[Uterine tumours]].
*[[Uterine tumours]].
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Psammoma bodies]].


=References=
=References=
Line 467: Line 561:


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]
[[Category:Endometrium]]
Michael
48,466

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