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Diseases Of Uterus

Endometrial Polyps and Tumors


  1. Endometrial polyps are common in peri-menopausal and post-menopausal endometrium, and may be single or multiple. Q
  2. They are the result of the inappropriate reaction of foci of endometrium to oestrogenic stimulation. Q
  3. They are composed of variably sized glands, which are often cystic and are set in a cellular stroma which characteristically contains thick-walled blood vessels.
  4. The epithelium lining the glands may show variable metaplasia, and secondary inflammatory changes may occur. Malignant change is rare.
1.     1. Endometrial hyperplasia


  1. The endometrium undergoes hyperplasia in response to unopposed oestrogenic stimulation. The source of oestrogenic stimulation may be endogenous, such as an ovarian tumour, the polycystic ovary syndrome (see below) or exogenous.
  2. Obesity is an important cause of a hyperoestrogenic state, as there is increased peripheral conversion of androstenedione to oestrone by the enzyme, aromatase, in fat cells.
  3. The various types of endometrial hyperplasia discussed below are associated with a variable risk of malignant change.
  4. The precise factors which determine which type will develop in a particular patient are unknown.
2.  Simple hyperplasia
  1. Simple hyperplasia is a diffuse abnormality affecting the whole of the endometrium.
  2. Many of the glands are dilated, and the epithelium shows increased nuclear stratification.
  3.  The stroma also shows increased mitotic activity but there is no nuclear atypia.

3. Complex Hyperplasia

  1. Complex hyperplasia is usually a focal architectural change in the endometrium.
  2. Characteristically, the glands are crowded and irregularly branched  Q
  3. There is a low risk of malignant change (3%).
4. Atypical hyperplasia  
  1. In atypical hyperplasia (endometrial intraepithelial neoplasia) architectural and cytological changes are combined. Q
  2. The nuclei of the epithelial cells may show a variable degree of cytological atypia).
  3. There is a close correlation between the risk of malignant change and the severity of the atypia
5. Endometrial adenocarcinoma 
  1. May result from unopposed oestrogenic action or in atrophic post-menopausal endometrium
  2. Spreads via lymphatic and haematogenous routes  
6. There are two clinicopathological types of endometrial adenocarcinoma.
  1. The first type is endometrioid adenocarcinoma and is usually due to unopposed oestrogenic stimulation and arises from endometrial intraepithelial neoplasia (EIN).
    1. This type of tumour characteristically occurs in young women with the polycystic ovary syndrome or in association with obesity.
    2. It also affects perimenopausal women, and may complicate post-menopausal oestrogen replacement therapy. Q
    3. It is generally associated with a good prognosisQ
  2. The second type of endometrial adenocarcinoma is non-endometrioid, affects elderly post-menopausal women, is not associated with oestrogenic stimulation,
    1. It probably arises on the basis of a pre-existing inactive or atrophic endometrium.
    2. High grade serous and clear cell carcinoma are in this category and are associated with a poor prognosis. Q 
Endometrial adenocarcinoma :
  1. It may be confined to the endometrium. Since the endometrium is composed of glands and stroma, it is possible for a carcinoma to invade its own stroma and still be intra-endometrial. Alternatively, there may be invasion of the myometrium . Q
  2. The extent of myometrial invasion at the time of diagnosis is the single most important prognostic factor. Q
  3. Involvement of the endocervix also has an adverse effect on prognosis.
  4. Thereafter, spread of the tumour occurs via the lymphatic and venous routes to the vagina and pelvic and para-aortic lymph nodes. Q
Endometrial stromal sarcoma
  1. Neoplastic change can occur in the endometrial stroma as well as the endometrial glands, but stromal neoplasms are much less common.
  2. Low-grade stromal sarcoma occurs in the uterus of peri- and post-menopausal women and may be diagnosed as an incidental finding in a hysterectomy specimen or following a clinical diagnosis of fibroids.
  3. Nodules of bland-looking stroma infiltrate the myometrium, with little or no mitotic activity. The natural history of these tumours is one of local recurrence, sometimes after many years. Histologically, these recurrences resemble the original tumour.
  4. High-grade stromal sarcoma is a highly malignant tumour which may show extensive invasion of the myometrium at the time of diagnosis, with high mitotic activity and focal necrosis.


  1. Endometriosis is the presence of endometrial glands and stroma in sites other than the uterine corpus.
  2. It is a very important cause of morbidity in women and may be responsible for pelvic inflammation, infertility and pain. Q
  3. The common sites include the pouch of Douglas, the pelvic peritoneum and the ovary. Endometriosis may also involve the serosal surface of the uterus, cervix, vulva and vagina, and extra-genital sites such as the bladder and the small and large intestines.
  4. The occurrence of endometriosis in extra-abdominal sites is very rare.
  5. The aetiology of endometriosis is unknown, but retrograde menstruation into the peritoneal cavity along the fallopian tube, or metaplasia of mesothelium to Müllerian-type epithelium are possible explanations. Q
  6. The glands and stroma are usually subject to the same hormone-induced changes that occur in the endometrium.
  7. Thus, haemorrhage in endometriotic foci may cause pain. In the ovary especially, recurrent haemorrhage may produce cysts containing altered blood, so-called 'chocolate cysts'. Uncommonly, hyperplastic or atypical changes may be seen in the epithelial component, with appearances similar to those that affect the endometrium
Abnormalities of the Myometrium
  1. Adenomyosis
  1. Adenomyosis is a common finding in hysterectomy specimens and refers to the presence of endometrial glands and stroma deep within the myometrium.
  2. It characteristically occurs in peri-menopausal multiparous women and is of uncertain aetiology, although it may be regarded as a form of 'diverticulosis', as there is continuity between adenomyotic foci and the lining endometrium of the uterine cavity. Q
  3. Neoplastic change may occur within these foci but should not be regarded as evidence of myometrial invasion. Q
Leiomyoma uterine
  1. The commonest tumour of the female genital tract is the benign fibroid or leiomyoma. These commonly present in later reproductive life and around the time of the menopause. They are associated with low parity, although it is uncertain whether this is a common cause or an effect.
  2. The precise aetiology of leiomyomas is unknown.
  3. They may present clinically with:
  1. Abdominal mass
  2. Urinary problems due to pressure on the bladder
  3. Abnormal uterine bleeding.
  1. Characteristically, they are multiple, round, well-circumscribed tumours varying in diameter from 5 mm to, in some cases, 200 mm or more.
  2. They may show cystic change or focal necrosis.
  3. On section, they have a white, whorled appearance.
  4. Histologically, they are composed of complex interlacing bundles of smooth muscle fibres showing little or no mitotic activity.
  5. Sometimes, nodules of tumour may be seen within veins (intravenous leiomyomatosis); this is not a sinister feature.
  6. Smooth muscle tumours contain steroid hormone receptors, and at least a proportion are oestrogen-dependent.

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