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The '''endometrium''' is typically biopsied because of abnormal bleeding.
The '''endometrium''' is typically biopsied because of abnormal bleeding.  [[Endometrial hyperplasia]] and [[endometrial carcinoma]] are dealt with in separate articles.  An overview of gynecologic pathology is in the ''[[gynecologic pathology]]'' article.


==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).
*Post-menopausal bleeding.
**[[Dysfunctional uterine bleeding]], abbreviated ''DUB'', is diagnosed if other causes of bleeding are excluded.
*Dysfunctional uterine bleeding [[AKA]] ''DUB'' - may get 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>
**DUB is diagnosed if other causes of bleeding are excluded.
**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=
Line 17: Line 24:
**This is 'cause the gynecologist scrapes some off on the way in or out.
**This is 'cause the gynecologist scrapes some off on the way in or out.


===Endocervical glands vs. Endometrial glands===
==Glandular telescoping==
====Endocervical====
:[[AKA]] ''gland-within-a-gland''.
:[[AKA]] ''gland intussusception''.
:[[AKA]] ''telescoping''.
*Considered an artifact of tissue processing, i.e. normal.<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 }}</ref>
 
Image:
*[http://jcp.bmjjournals.com/content/59/8/801/F3.large.jpg Telescoping (bmjjournals.com)].<ref name=pmid16873562/>
 
==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===
{| 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.


==Tamoxifen effects==
===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=
*[[Endometrial hyperplasia]].
*[[Endometrial hyperplasia]].
*Endometrial cancer.
*[[Endometrial cancer]].
*[[Endometrial polyps]].
*[[Endometrial polyps]].
*Atrophy.
*[[Endometrial atrophy|Atrophy]].
 
=Inadequate endometrial biopsy=
*Endometrial biopsies often have scant tissue. 
**This is normal in post-menopausal women.
*Ideally, the biopsy should have some endometrial stroma.
**Without stroma it is ''not'' possible to assess the gland-to-stroma ratio.


=A simple approach=
==Sign out==
==Low power==
===No stroma===
#Decide whether you're look at endometrium.
<pre>
#Gland-to-stroma ratio normal?
ENDOMETRIUM, BIOPSY:
- VERY SCANT STRIPPED NON-PROLIFERATIVE COLUMNAR EPITHELIUM, PROBABLY FROM THE LOWER UTERINE SEGMENT.
- 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>
ENDOMETRIUM, BIOPSY:
- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM AND DETACHED NON-PROLIFERATIVE ENDOMETRIAL GLANDS.
- ASSESSMENT LIMITED AS VERY SCANT ENDOMETRIAL STROMA IS PRESENT.
</pre>
 
<pre>
ENDOMETRIUM, BIOPSY:
- ENDOMETRIUM: STRIPS OF EPITHELIUM, NON-PROLIFERATIVE.
- ENDOCERVIX: SCANT BENIGN EPITHELIUM.
- EXOCERVIX: SCANT BENIGN EPITHELIUM.
- OTHER: TUBAL METAPLASIA.
</pre>
 
<pre>
ENDOMETRIUM, BIOPSY:
- STRIPS OF NON-PROLIFERATIVE ENDOMETRIUM.
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
- SCANT BENIGN SQUAMOUS EPITHELIUM.
- TUBAL METAPLASIA.
</pre>
 
<pre>
ENDOMETRIUM, BIOPSY:
- STRIPS OF BENIGN ENDOMETRIAL EPITHELIUM/TUBAL METAPLASIA, NON-PROLIFERATIVE.
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
- RARE SQUAMOUS METAPLASTIC CELLS.
</pre>
 
===Proliferative without definite stroma===
<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.
#Is the gland-to-stroma ratio normal?
#*1:3 is normal.
#*1:3 is normal.
#*If gland-to-stroma ratio is increased... think ''[[endometrial hyperplasia]]''.
#*If the gland-to-stroma ratio is increased... think ''[[complex endometrial hyperplasia]]''.
#*If glands are fused to one another or [[cribriform]]... think ''[[endometrial carcinoma]]''.
#*If the glands are fused to one another or [[cribriform]]... think ''[[endometrial carcinoma]]''.
#Glands round?
#Glands round?
#*Round is normal.
#*Round is normal.
#*Irregular - may be seen in menses, endometrial hyperplasia, disordered proliferative endometrium.
#*Irregular - may be seen in [[secretory phase endometrium]], menses, [[disordered proliferative endometrium]] (focal), [[simple endometrial hyperplasia]] (diffuse).
#Glands pseudostratified?
#Glands pseudostratified?
#*Pseudostratified glands are normal in the proliferative phase, hyperplasias, malignancy.
#*Pseudostratified glands are normal in the [[proliferative phase endometrium]], hyperplasias, malignancy.
#Balls of cells?
#Balls of cells?
#*Blue - likely menstrual (stromal condensation).
#*Blue - likely menstrual (stromal condensation).
#*Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia).
#*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.
Line 58: Line 307:
#*Some are normal during menses.
#*Some are normal during menses.


=Dating endometrium=
==Tabular summary==
==Proliferative phase==
{| class="wikitable sortable"
*Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion.
! Diagnosis
**Key features: pseudostratification, mitoses.
! Key feature (low power)
*Stroma: cellular stroma (spindle cells), mitoses.
! 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 -->
|}


Note:
=Normal endometrium=
*Proliferative phase = folicular phase.
==Proliferative phase endometrium==
**Gynecologists prefer the ovarian descriptor, i.e. ''follicular phase''; pathologists go by what they see, i.e. ''proliferative'' endometrium.
{{Main|Proliferative phase endometrium}}


==Secretory phase==
==Secretory phase endometrium==
*Early secretory phase - post-ovulatory day 1-5:
{{Main|Secretory phase endometrium}}
**Glands: secretory vacuoles.
***First basal to the epithelial nuclei (infranuclear vacuoles).
***Then apical to the epithelial nuclei (supranuclear vacuoles).


*Mid secretory phase - post-ovulatory day 6-8:
==Menstrual endometrium==
**Glands: Mucus in glands.
===General===
**Stroma: Edema (empty space around the glands).
*Technically part of the ''proliferative phase'' or ''follicular phase''.


*Late secretory phase (beginning) - post-ovulatory day 9-12:
===Microscopic===
**Stroma:  
Features:
***Spiral arterioles.
*Proliferative endometrium (mitoses).<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
***Predecidual changes -- mnemonic ''NEW'':
*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>
***#Nucleus central.
*Tightly packed cellular balls of stromal cells with nuclear moulding.
***#Eosinophilic cytoplasm '''key feature''' (may be subtle to the novice).
**Known as "blue balls".
***#Well-defined cell borders.
**Tightly packed cellular stromal cells known as "stromal condensation".
*Inflammation, especially abundant [[neutrophil]]s.


*Premenstrual
DDx:
**Stroma: Neutrophils, 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)]).
*[[Small cell carcinoma]] - proliferative activity in the moulded (stromal condensation-like) cells.
**Glands: [[apoptosis]] at the base of the gland.<ref>TC. 22 June 2009.</ref>
*[[Anovulatory endometrium]] - less neutrophils.


General refs.: <ref>{{Ref PBoD|1081}}</ref><ref>{{Ref DCHH|237}}</ref>
====Images====
<gallery>
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)].


Notes:  
===Sign out===
*Secretory phase = luteal phase.
<pre>
**Gynecologists prefer the ovarian descriptor, i.e. ''luteal phase''; pathologists go by what they see, i.e. ''Secretions'' in the (endometrial) glands.
Endometrium, Biopsy:
*When the patient is >40 years, some advocate the use of the term ''proliferative type endometrium'' (instead of the term ''proliferative endometrium'').<ref>GAG. Jan 2009</ref>
- Consistent with menstrual endometrium.
*Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.<ref>GAG. 6 Oct 2009.</ref>
-- Weakly proliferative endometrial glands with apoptosis, fragmented.
-- Abundant balls of condensed non-proliferative endometrial stroma and blood.
</pre>


=Specific entities/abnormalities=
====Block letters====
==Arias-Stella reaction==
<pre>
{{Main|Arias-Stella reaction}}
ENDOMETRIUM, 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>
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM:
-- STRIPPED WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- ABUNDANT NEUTROPHILS AND BLOOD.
</pre>


==Endometritis==
<pre>
===General===
ENDOMETRIUM, BIOPSY:
*Usually post-delivery or post-instrumentation, e.g. previous biopsy.
- CONSISTENT WITH MENSTRUAL PHASE ENDOMETRIUM:
*May be spontaneous, e.g. tuberculous endometritis.
-- WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- BLOOD.
</pre>


===Microscopic===
<pre>
====Acute endometritis====
ENDOMETRIUM, BIOPSY:
Features:
- VERY WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
*Neutrophils clusters (>5 PMNs) in the:
- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
**Endometrial stroma.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
**Within uterine glands.
</pre>


Notes:
====Consistent with menstrual endometrium====
*Neutrophils are normal in the context of menses.
<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.


Image:
</pre>
*[http://www.hsc.stonybrook.edu/gyn-atlas/UT53.10.1.htm Acute endometritis (stonybrook.edu)].


====Chronic endometritis====
====Late menses====
Features:
<pre>
*Plasma cells with in the endometrial stroma - '''key feature'''.
ENDOMETRIUM, ASPIRATION:
- ENDOMETRIAL GLANDS WITH APOPTOTIC CELLS, INFILTRATING NEUTROPHILS,
  AND GLANDULAR PROLIFERATIVE ACTIVITY.
- BALLS OF CONDENSED ENDOMETRIAL STROMA.
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- NEGATIVE FOR HYPERPLASIA.


Notes:
COMMENT:
*One plasma cell is not enough to call it.
The findings are most in keeping with late menstrual endometrium.
</pre>


Images:
=Specific entities/abnormalities=
*[http://www.webpathology.com/image.asp?n=2&Case=565 Chronic endometritis (webpathology.com)].
==Adipose tissue on endometrial biopsy==
*[http://www.webpathology.com/image.asp?n=3&Case=565 Chronic endometritis (webpathology.com)].
*[[AKA]] ''fat on endometrial biopsy''.
*[http://www.webpathology.com/image.asp?n=6&Case=565 Tuberculous endometritis (webpathology.com)]
===General===
*Benign.
*Raises the possibility of perforation - should prompt a phone call to the clinician.
===Microscopic===
Features:
*Adipose tissue, benign - '''key finding'''.
*Definite endometrium.


==Endometrial polyp==
DDx:
*[[AKA]] ''benign endometrial polyp''.
*Extraneous tissue.
**[[Tissue floater]].
**Pick-up.


===General===
====Images====
*Very common.
<gallery>
*May be a cause of menorrhagia (heavy & long menses).
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>


===Microscopic===
===Sign out===
Features:<ref>URL: [http://www.pathologyoutlines.com/uterus.html#endopolyp http://www.pathologyoutlines.com/uterus.html#endopolyp]. Accessed on: 15 September 2011.</ref>
<pre>
#Large blood vessels (muscular) - '''key feature'''.
ENDOMETRIUM, BIOPSY:
#Fibrotic stroma - '''key feature'''.
- BENIGN ADIPOSE TISSUE, SEE COMMENT.
#Polypoid shape - epithelium on three sides.
- PROLIFERATIVE PHASE ENDOMETRIUM.
#*May not be seen... as polyp is fragmented on removal.


Notes:
COMMENT:
#Apparently benign polyps should be examined closely at the surface for in situ & invasive malignancies.
The presence of adipose tissue raises the possibility of perforation.
#Endometrial glands may be out of phase with surrounding [[endometrium]].
#*Often proliferative.
#+/-Cystic dilation of glands.
#Cellular stroma.


Other considerations:
The findings were briefly discussed with Dr. Brown on November 6, 2009.
*[[Adenofibroma]].
</pre>
*[[Cervical polyp]].


==Disordered proliferative phase==
==Arias-Stella reaction==
===General===
{{Main|Arias-Stella reaction}}
*Association: anovulation.
*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>


===Microscopic===
==Endometritis==
Features:<ref name=Ref_PBoD1080>{{Ref PBoD|1080 and 1082}}</ref>
{{Main|Endometritis}}
*Proliferative type endometrium with:
**Cystic dilation of glands without secretions.
*+/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).
 
DDx:
*Simple [[endometrial hyperplasia]] without atypia - more architectural atypia.


Notes:
==Benign endometrial polyp==
*Proliferative phase endometrium:
{{Main|Benign endometrial polyp}}
**Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, NO vacuolation, NO mucus secretion, abundant mitoses.
**Stroma: cellular, stroma (spindle cells), mitoses.


Image: [http://upload.wikimedia.org/wikipedia/commons/a/ab/Endometrial_stromal_condensation_high_mag.jpg Endometrial stromal condensation - high mag. (WC)].
==Anovulatory endometrium==
{{Main|Anovulatory endometrium}}


==Oral contraceptive effect==
==Disordered proliferative endometrium==
===General===
*Abbreviated ''DPE''.
*Very common.
*[[AKA]] ''endometrium with disordered proliferative phase''.
*Most pills a mix of progesterone and estrogen.
*[[AKA]] ''disordered proliferative phase''.
**The progesterone is what generates the characteristic appearance -- that is similar to pregnancy.
{{Main|Disordered proliferative endometrium}}


===Microscopic===
==Endometrium with changes due to exogenous hormones==
Features:<ref name=Ref_PBoD1082>{{Ref PBoD|1082}}</ref>
{{Main|Endometrium with changes due to exogenous hormones}}
*Inactive glands (round/ovoid glands, simple cuboidal epithelium, no mitoses).
*Stroma decidualized -- mnemonic ''NEW'':
**Nucleus central.
**Eosinophilic cytoplasm.
**Well-defined cell borders.


Image: [http://commons.wikimedia.org/wiki/File:Endometrium_ocp_use3.jpg Endometrium of woman on an OCP (WC)].
==Atrophic endometrium==
*[[AKA]] ''atrophy of the endometrium''.
*[[AKA]] ''endometrial atrophy''.
{{Main|Inactive endometrium}}


==Postmenopausal women==
==Ablated endometrium==
===General===
{{Main|Ablated endometrium}}
*Menopause happens at around 50 years old.


===Microscopic===
==Endometrium with squamous morules==
Features:
{{Main|Endometrium with squamous morules}}
*Atrophy glands.
*Thin endometrium.


Notes:
==Endometrium with psammoma bodies==
*If a woman is truly postmenopausal, mitoses in the glandular epithelium is pretty much always pathologic.
{{Main|Endometrium with psammoma bodies}}
**Exception is inflammation... e.g. the person has had several biopsy attempts and was seeded with pathogens.


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


=References=
=References=
Line 229: Line 561:


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]
[[Category:Endometrium]]
Michael
48,469

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