Difference between revisions of "Endometrium"

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Endometrium (view source)

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→‎Endometrial gland compression artifact
 
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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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*Focal [[complex endometrial hyperplasia]].
*Focal [[complex endometrial hyperplasia]].


Image:
===Image===
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/figure/fig4/ Gland compression (bmjjournals.com)].<ref name=pmid16873562/>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/figure/fig4/ Gland compression (bmjjournals.com)].<ref name=pmid16873562/>


===Micro===
===Micro===
An increased gland density is seen focally, at the edge of one tissue fragment, in association with tearing of the stroma (compression artifact).
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==
==Endocervical epithelium versus endometrial epithelium==
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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)
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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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| [[endometrial hyperplasia with secretory changes]], late [[proliferative phase endometrium]]
| [[endometrial hyperplasia with secretory changes]], late [[proliferative phase endometrium]]
| normal
| normal
| [[Image:Secretory_phase_endometrium.jpg|thumb|150px|center|Secretory phase endometrium. (WC)]]  
| [[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)]]
|-
|-
| [[Endometrium with changes due to exogenous hormones]]
| [[Endometrium with changes due to exogenous hormones]]
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| inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses)
| inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses)
| [[secretory phase endometrium]], [[endometrial hyperplasia with secretory changes]]
| [[secretory phase endometrium]], [[endometrial hyperplasia with secretory changes]]
| Other
| variant of normal
| [[Image:Endometrium ocp use3.jpg|thumb|150px|center|Endometrium with OCP changes. (WC)]]  
| [[Image:Endometrium with hormone effect -- high mag.jpg|thumb|150px|center|Endometrium with changes due to exogenous hormones. (WC)]]  
|-  
|-  
| [[Atrophic endometrium]]
| [[Atrophic endometrium]]
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| normal postmenopausal finding
| normal postmenopausal finding
| [[Image:Nonproliferative endometrial epithelium - alt -- high mag.jpg|thumb|150px|center|Inactive endometrium. (WC)]]  
| [[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
|  Diagnosis
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DDx:
DDx:
*[[Small cell carcinoma]].
*[[Small cell carcinoma]] - proliferative activity in the moulded (stromal condensation-like) cells.
*[[Anovulatory endometrium]] - less neutrophils.
*[[Anovulatory endometrium]] - less neutrophils.


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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:
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- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
- 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]] - should have mitoses,<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref> abundant [[PMN]]s.
 
===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===
*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).
 
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.


==Endometrium with changes due to exogenous hormones==
==Endometrium with changes due to exogenous hormones==
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*[[AKA]] ''endometrial atrophy''.
*[[AKA]] ''endometrial atrophy''.
{{Main|Inactive endometrium}}
{{Main|Inactive endometrium}}
==Ablated endometrium==
{{Main|Ablated endometrium}}


==Endometrium with squamous morules==
==Endometrium with squamous morules==
{{Main|Endometrium with squamous morules}}
{{Main|Endometrium with squamous morules}}
==Endometrium with psammoma bodies==
{{Main|Endometrium with psammoma bodies}}


==Endometrial hyperplasia==
==Endometrial hyperplasia==
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*[[Uterine tumours]].
*[[Uterine tumours]].
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Psammoma bodies]].


=References=
=References=
Michael
48,466

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