Difference between revisions of "Endometrium"

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Endometrium (view source)

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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 epithelium verus endometrial epithelium==
==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===
*[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===
===Table===
{| class="wikitable sortable"  
{| class="wikitable sortable"  
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| hyperchromatic
| hyperchromatic
|-
|-
| Nuclear-to-cytoplasm ratio
| [[Nucleus-to-cytoplasm ratio]]
| moderate to high (1:2)
| moderate to high (1:2)
| low (often 1:3)
| low (often 1:3)
Line 68: Line 89:
*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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| [[disordered proliferative phase]], [[simple endometrial hyperplasia]], [[complex endometrial hyperplasia]], early [[secretory phase endometrium]]
| [[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]]
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| [[endometrial hyperplasia with secretory changes]], late [[proliferative phase endometrium]]
| [[endometrial hyperplasia with secretory changes]], late [[proliferative phase endometrium]]
| normal
| normal
| Image  
| [[Image:Secretory phase endometrium -- high mag.jpg|thumb|120px|center|Secretory phase endometrium. (WC)]]
|-
|-
| [[Menstrual endometrium]]
| [[Menstrual endometrium]]
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| fibrous stroma, muscular blood vessels
| fibrous stroma, muscular blood vessels
| polypoid shape (epithelium on 3 sides), +/-gland dilation
| 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)]]
|-
|-
| 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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===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.
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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>
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.
</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>
</pre>


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=Specific entities/abnormalities=
=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===
===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===
===Microscopic===
====Acute endometritis====
Features:
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:
DDx:
*Mentrual endometrium - endometrial stromal condensation.
*Extraneous tissue.
**[[Tissue floater]].
**Pick-up.


====Images====
====Images====
<gallery>
<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>
</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===
===Sign out===
<pre>
<pre>
ENDOMETRIUM, BIOPSY:
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:
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>
</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==
==Benign endometrial polyp==
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==Anovulatory endometrium==
==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]] - more neutrophils, should have proliferative glands.{{fact}}
 
===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==
==Disordered proliferative endometrium==
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*[[AKA]] ''endometrium with disordered proliferative phase''.
*[[AKA]] ''endometrium with disordered proliferative phase''.
*[[AKA]] ''disordered proliferative phase''.
*[[AKA]] ''disordered proliferative phase''.
{{Main|Disordered proliferative endometrium}}


===General===
==Endometrium with changes due to exogenous hormones==
*Association: anovulation.
{{Main|Endometrium with changes due to exogenous hormones}}
*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.
 
==Endometrial changes of oral contraception==
{{ Infobox external links
| Name          = Endometrial changes of oral contraception
| EHVSC          = 10170
| pathprotocols  =
| wikipedia      =
| pathoutlines  =
}}
{{Main|Oral contraceptive pill}}
:''Endometrium with hormonal changes'' and ''OCP endometrium'' redirect 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===
Features:<ref name=Ref_PBoD1082>{{Ref PBoD|1082}}</ref>
*Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
*Stroma decidualized -- mnemonic ''NEW'':
**Nucleus central.
**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====
<gallery>
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>
 
====OCP effect and shedding endometrium====
<pre>
ENDOMETRIUM, ASPIRATION:
- ENDOMETRIUM WITH NONPROLIFERATIVE ENDOMETRIAL GLANDS AND
  STROMAL DECIDUALIZATION, COMPATIBLE WITH EXOGENOUS HORMONES.
- EVIDENCE OF ENDOMETRIAL SHEDDING (BALLS OF CONDENSED STROMA
  ASSOCIATED NEUTROPHILS, AND BLOOD).
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
</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:
- 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==
==Endometrial hyperplasia==
Line 653: Line 555:
*[[Uterine tumours]].
*[[Uterine tumours]].
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Psammoma bodies]].


=References=
=References=
Michael
48,470

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