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==Indications for endometrial biopsy==
==Indications for endometrial biopsy==
Abnormal bleeding:  
Abnormal bleeding:  
*Abnormal uterine bleeding (AUB).
*[[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>
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*[[Products of conception]] - dealt with in a separate article.
*[[Products of conception]] - dealt with in a separate article.
*Dating of endometrium - infertility work-up.
*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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- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM, ENDOCERVICAL EPITHELIUM AND FOCALLY PROLIFERATIVE ENDOMETRIAL GLANDS.   
- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM, ENDOCERVICAL EPITHELIUM AND FOCALLY PROLIFERATIVE ENDOMETRIAL GLANDS.   
- ASSESSMENT LIMITED AS NO DEFINITE ENDOMETRIAL STROMA IS PRESENT.
- 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>
</pre>


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- SPECIMEN INADEQUATE; NO ENDOMETRIUM IDENTIFIED.
- SPECIMEN INADEQUATE; NO ENDOMETRIUM IDENTIFIED.
- ONE VERY TINY FRAGMENT OF ENDOCERVICAL MUCOSA WITHOUT APPARENT PATHOLOGY.
- 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>
</pre>


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| round spaced pseudostratified glands
| round spaced pseudostratified glands
| mitoses in glands and stroma
| mitoses in glands and stroma
| [[disordered proliferative phase]], [[simple endometrial hyperplasia]], [[complex endometrial hyperplasia]]
| [[disordered proliferative phase]], [[simple endometrial hyperplasia]], [[complex endometrial hyperplasia]], early [[secretory phase endometrium]]
| normal
| normal
| Image
| [[Image:Proliferative endometrium - very high mag.jpg|thumb|150px|center|Proliferative endometrium. (WC)]]
|-
|-
| [[Secretory phase endometrium]]
| [[Secretory phase endometrium]]
| irregular glands with secretions ''or'' simple glands with vacuoles
| irregular glands with secretions ''or'' simple glands with vacuoles
| decidual changes (nucleus central, eosinophilic cytoplasm, well-defined cell borders)
| 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
| normal
| Image <!--
| 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)]]
|-
|-
| Diagnosis
| [[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
| Key feature
| Additional features
| Additional features
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=Normal endometrium=
=Normal endometrium=
==Proliferative phase endometrium==
==Proliferative phase endometrium==
*Abbreviated ''PPE''.
{{Main|Proliferative phase endometrium}}
===General===
*Day 1-13 in the protypical menstrual cycle of 28 days.
**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/>
*Glands:
**Straight, tubular, composed of tall pseudostratified columnar cells - '''key feature'''.
**Mitotic figures - '''key feature'''. †
*Stroma:
**Cellular stroma (spindle cells).
**Mitoses.
***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:
*[[Endometrial polyp]].
*[[Disordered proliferative endometrium]].
*[[Endometrial hyperplasia]]:
**[[Simple endometrial hyperplasia]].
**[[Complex endometrial hyperplasia]].
*[[Secretory phase endometrium]], early - >=50% of gland have subnuclear vacuoles ''and'' >=50% of cells in the glands have subnuclear vacuoles.<ref name=Ref_EMB14>{{Ref EMB|14}}</ref>
 
 
Images:
*[http://library.med.utah.edu/WebPath/FEMHTML/FEM017.html Proliferative phase endometrium (utah.edu)].
*[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>
 
===Sign out===
<pre>
ENDOMETRIUM, BIOPSY:
- PROLIFERATIVE PHASE ENDOMETRIUM.
</pre>
 
<pre>
ENDOMETRIUM, BIOPSY:
- PROLIFERATIVE PHASE ENDOMETRIUM.
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
</pre>
 
====Not quite normal====
<pre>
ENDOMETRIUM, BIOPSY:
- EARLY SECRETORY PHASE ENDOMETRIUM.
- FOCUS OF CROWDED PROLIFERATIVE GLANDS, SEE COMMENT.
 
COMMENT: 
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>
 
====Post-menopausal====
<pre>
ENDOMETRIUM, BIOPSY:
- PROLIFERATIVE TYPE ENDOMETRIUM.
-- NEGATIVE FOR HYPERPLASIA.
-- NEGATIVE FOR MALIGNANCY.
</pre>
 
=====Micro=====
The sections show endometrium with proliferative glands without significant dilation or irregularity of shape. The gland-to-stroma ratio is within normal limits. Mitotic activity is mild. No nuclear atypia is apparent.


==Secretory phase endometrium==
==Secretory phase endometrium==
*Abbreviated ''SPE''.
{{Main|Secretory phase endometrium}}
===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.
 
===Gross===
*Thickened endometrium.
 
===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".
*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>
*Endocervical epithelium (ECE) has a morphology similar to the epithelium of secretory phase endometrium (SPE):
**ECE - grey foamy appearing cytoplasm.
**SPE - eosinophilic cytoplasm.
***Most useful feature to differentiate ECE and SPE is the accompanying stroma.
 
DDx:
*[[Endometrial hyperplasia with secretory changes]].
*[[Endometrium with hormonal changes]].
*[[Proliferative phase endometrium]] - may have some changes of secretory endometrium; <50% of gland have subnuclear vacuoles ''or'' <50% of cells in the glands have subnuclear vacuoles.<ref name=Ref_EMB14>{{Ref EMB|14}}</ref>
 
Image:
<gallery>
Image:Endometrial_stromal_condensation_high_mag.jpg | Endometrial stromal condensation. (WC/Nephron)
</gallery>
 
===Sign out===
<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
</pre>
 
====With additional stuff====
<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
- SCANT ENDOCERVICAL MUCOSA WITHIN NORMAL LIMITS.
</pre>
 
<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
</pre>
 
<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
- BENIGN SUPERFICIAL EXOCERVICAL EPITHELIUM.
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
</pre>


==Menstrual endometrium==
==Menstrual endometrium==
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===Microscopic===
===Microscopic===
Features:
Features:
*Non-proliferative endometrium.
*Proliferative endometrium (mitoses).<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
**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>
*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>
*Tightly packed cellular balls of stromal cells with nuclear moulding.
*Tightly packed cellular balls of stromal cells with nuclear moulding.
**Known as "blue balls".
**Known as "blue balls".
**Tightly packed cellular stromal cells known as "stromal condensation".
**Tightly packed cellular stromal cells known as "stromal condensation".
*Inflammation, esp. [[neutrophil]]s.
*Inflammation, especially abundant [[neutrophil]]s.


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


====Images====
====Images====
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===Sign out===
===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>
<pre>
ENDOMETRIUM, BIOPSY:
ENDOMETRIUM, BIOPSY:
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM:
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM:
-- STRIPPED NON-PROLIFERATIVE ENDOMETRIAL GLANDS.
-- STRIPPED WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- ABUNDANT NEUTROPHILS AND BLOOD.
-- ABUNDANT NEUTROPHILS AND BLOOD.
Line 378: Line 425:
ENDOMETRIUM, BIOPSY:
ENDOMETRIUM, BIOPSY:
- CONSISTENT WITH MENSTRUAL PHASE ENDOMETRIUM:
- CONSISTENT WITH MENSTRUAL PHASE ENDOMETRIUM:
-- NON-PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
-- WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- BLOOD.
-- BLOOD.
</pre>
</pre>


=Specific entities/abnormalities=
==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====
<gallery>
Image:Endometritis_-_2_-_high_mag.jpg | Endometritis - high mag. (WC/Nephron)
Image:Endometritis_-_2_-_cropped_-_very_high_mag.jpg | Endometritis - very high mag. (WC/Nephron)
</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>
<pre>
ENDOMETRIUM, BIOPSY:
ENDOMETRIUM, BIOPSY:
- CHRONIC ENDOMETRITIS.
- VERY WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
</pre>


==Benign endometrial polyp==
====Consistent with menstrual endometrium====
:''Uterine polyp'' redirects here.
*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>
<pre>
ENDOMETRIUM ("POLYPS"), REMOVAL:
ENDOMETRIUM, ASPIRATION:
- BENIGN ENDOMETRIAL POLYPS WITH CYSTIC GLANDULAR DILATION AND
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH SIMPLE
WITHOUT APPARENT PROLIFERATIVE ACTIVITY.  
  GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
</pre>
  (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>


==Anovulatory endometrium==
=Specific entities/abnormalities=
==Adipose tissue on endometrial biopsy==
*[[AKA]] ''fat on endometrial biopsy''.
===General===
===General===
*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>
*Benign.
 
*Raises the possibility of perforation - should prompt a phone call to the clinician.
===Microscopic===
===Microscopic===
Features:
Features:
*Shedding:
*Adipose tissue, benign - '''key finding'''.
**Stromal condensation.
*Definite endometrium.
**Apoptotic endometrial epithelium.
*Non-proliferative glands.


DDx:
DDx:
*[[Disordered proliferative phase]].
*Extraneous tissue.
*[[Simple endometrial hyperplasia]].
**[[Tissue floater]].
*[[Menstrual endometrium]].
**Pick-up.


===Sign out===
====Images====
<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>
 
==Disordered proliferative endometrium==
*Abbreviated ''DPE''.
*[[AKA]] ''endometrium with disordered proliferative phase''.
*[[AKA]] ''disordered proliferative phase''.
 
===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).
 
DDx:
*[[Proliferative phase endometrium]].
*[[Simple endometrial hyperplasia]] without atypia - architectural atypia diffuse.
*[[Benign endometrial polyp]].
 
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====  
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>
<gallery>
Image:Endometrial_stromal_condensation_high_mag.jpg | Endometrial stromal condensation - high mag. (WC/Nephron)
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>
</gallery>
===Sign out===
===Sign out===
<pre>
<pre>
ENDOMETRIUM, BIOPSY:
ENDOMETRIUM, BIOPSY:
- DISORDERED PROLIFERATIVE ENDOMETRIUM.
- BENIGN ADIPOSE TISSUE, SEE COMMENT.
</pre>
- PROLIFERATIVE PHASE ENDOMETRIUM.
 
COMMENT:
The presence of adipose tissue raises the possibility of perforation.


=====With endocervix=====
The findings were briefly discussed with Dr. Brown on November 6, 2009.
<pre>
ENDOMETRIUM, BIOPSY:
- DISORDERED PROLIFERATIVE ENDOMETRIUM.
- BENIGN ENDOCERVICAL MUCOSA.
</pre>
</pre>


====Micro====
==Arias-Stella reaction==
The sections show a well-sampled endometrium. Mitotic figures are identified within the
{{Main|Arias-Stella reaction}}
glands and stroma. Irregular, moderately enlarged glands are seen (only) in one of several
*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>
fragments; most of the endometrial glands are round, regular and small.


No stromal condensation is apparent. No secretions are in the glands.
==Endometritis==
{{Main|Endometritis}}


There are no back-to-back glands. No nuclear atypia is apparent. No thick-walled blood
==Benign endometrial polyp==
vessels are apparent.
{{Main|Benign endometrial polyp}}


==Endometrial changes of oral contraception==
==Anovulatory endometrium==
{{Main|Oral contraceptive pill}}
{{Main|Anovulatory endometrium}}
{{ Infobox external links
| Name          = Endometrial changes of oral contraception
| EHVSC          = 10170
| pathprotocols  =
| wikipedia      =
| pathoutlines  =
}}
:''Endometrium with hormonal changes'' redirects here.
*[[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.
 
DDx:
*[[Endometrial hyperplasia with secretory changes]] - proliferative activity.
*[[Secretory phase endometrium]] - glandular changes of the secretory phase (cytoplasmic vacuolization), secretions in the glands.


====Image====
==Endometrium with changes due to exogenous hormones==
<gallery>
{{Main|Endometrium with changes due to exogenous hormones}}
Image:Endometrium_ocp_use3.jpg | Endometrium of woman on an OCP. (WC/Nephron)
</gallery>
===Sign out===
<pre>
ENDOMETRIUM, BIOPSY:
- NON-PROLIFERATIVE ENDOMETRIAL GLANDS WITH STROMAL DECIDUALIZATION, CONSISTENT
  WITH EXOGENOUS HORMONES.
</pre>


==Atrophic endometrium==
==Atrophic endometrium==
:''Inactive endometrium'' redirect here.
*[[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===
*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===
==Ablated endometrium==
<pre>
{{Main|Ablated endometrium}}
ENDOMETRIUM, BIOPSY:
- NON-PROLIFERATIVE ENDOMETRIUM.
- BENIGN SQUAMOUS EPITHELIUM WITH METAPLASTIC CHANGE.
- SCANT ENDOCERVICAL MUCOSA WITH REACTIVE CHANGES.
</pre>


<pre>
==Endometrium with squamous morules==
ENDOMETRIUM, BIOPSY:
{{Main|Endometrium with squamous morules}}
- NON-PROLIFERATIVE ENDOMETRIUM.
- BENIGN STRIPPED ENDOCERVICAL EPITHELIUM.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
 
=====Micro=====
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.
 
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.
 
Scant benign endocervical tissue (stripped epithelium and mucosa) is present.
 
====Limited stroma====
<pre>
ENDOMETRIUM, BIOPSY:
- SCANT STRIPPED NON-PROLIFERATIVE ENDOMETRIAL EPITHELIUM.
- VERY SMALL FRAGMENT OF ENDOMETRIAL STROMA.
- TUBAL METAPLASTIC EPITHELIUM.
</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==
==Endometrial hyperplasia==
Line 738: Line 555:
*[[Uterine tumours]].
*[[Uterine tumours]].
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Psammoma bodies]].


=References=
=References=
Line 743: Line 561:


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

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