Female Genital Diseases - Uterine Disorders

Female Genital Diseases - Uterine Disorders

• Congenital uterine anomalies occur in less than 5% of women but up to 25% of women with miscarriages or premature births.
• Types of uterine anomalies include:
  • Didelphys: the two halves of the uterus are separate.
  • Arcuate: a uterus with an indentation on the top.
  • Unicornuate: only one half of the uterus has developed.
  • Bicornuate: a heart-shaped uterus.
  • Septate: uterus with a partition in the middle.

Disorders of the Uterine Body

• Abnormal uterine bleeding: a term for bleeding that doesn't have an underlying structural abnormality. Hormonal imbalances are a common cause.
  • Dysfunctional uterine bleeding (DUB): uterine bleeding that lacks an underlying structural abnormality. It is caused by hormonal abnormalities.
  • Menorrhagia: excessive prolonged menstrual bleeding.
  • Metrorrhagia: bleeding between menstrual periods.

Organic Causes of Uterine Bleeding

• Complications of pregnancy: (abortion, trophoblastic disease, ectopic pregnancy)
• Infections: cervicitis, endometritis
• Tumors: leiomyoma, endometrial polyps, cancer cervix
• Blood diseases

Non-Organic (Hormonal) Causes of (Dysfunctional) Uterine Bleeding

• Hyper-estrogenic states with anovulation: such as polycystic ovarian disease, cortical stromal hyperplasia, and functioning ovarian tumors.
• Other systemic endocrine disorders: thyroid or adrenal diseases or pituitary tumors.

Inflammation of the Endometrium (Endometritis)

• Acute endometritis: caused by gonorrhea or puerperal sepsis.
• Chronic endometritis:
  • Patients with Chlamydia and other intrauterine infections.
  • Post-abortion or partial abortions due to retained gestational tissue.
  • Intrauterine contraceptive devices.
  • Endometrial tuberculosis (granulomatous).

Endometriosis and Adenomyosis

• Endometriosis: endometrial glands or stroma in abnormal locations outside the uterus (ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, laparotomy scars, umbilicus, vagina, vulva, or appendix). The tissue undergoes cyclic changes with periodic bleeding and presents with pelvic pain.
• Adenomyosis: Presence of endometrial foci in the myometrium, causing diffuse enlargement and irregular thickening of the uterus. Cut sections show hemorrhagic spots.

Endometrial Polyps

• Sessile mass composed of endometrial glands and stroma.
• Benign, but occasionally may show endometrial hyperplasia or cancerous changes.

Endometrial Hyperplasia

• Characterized by glandular and stromal proliferation.
• Results from an abnormally high and prolonged level of estrogen (e.g., Stein-Leventhal syndrome, granulosa and theca cell tumors, estrogen therapy).
• Types of endometrial hyperplasia:
  • Simple hyperplasia (cystic glandular hyperplasia): some glands show cystic dilation, and stromal cells are plump.
  • Complex hyperplasia without atypia: glands of varying size are crowded in clusters with no cytologic changes.
  • Complex hyperplasia with atypia (EIN): gland crowding is accompanied by cytologic changes.

Carcinoma of the Endometrium

• Peak incidence is 55-65 years (post-menopause).
• Less common than cervical cancer.
• Risk factors include: obesity, diabetes mellitus, infertility, endometrial hyperplasia, and hyperestrogenemia.
• Morphology (gross): localized polypoid tumor; diffuse spreading lesion.
• Morphology (microscopic): well-differentiated adenocarcinoma (endometrioid) with squamous, secretory, or mucinous differentiation (metaplasia); poorly differentiated carcinoma (pattern of clear cell carcinoma and/or pattern of papillary serous carcinoma).
• Clinical features: abnormal uterine bleeding or abnormal Pap smear.
• Prognosis depends on tumor type and grade; good in localized well-differentiated tumors; poor in spreading or poorly differentiated tumors.

Malignant Mixed Mesodermal Tumors

• Rare tumors derived from primitive stromal cells in postmenopausal women.
• Gross: protruding into the endometrial cavity and vagina, bulky and polypoid.
• Microscopic: composed of glandular structures and stromal sarcomatous elements (muscle, cartilage, osteoid tissue).
• Prognosis: highly malignant; 5-year survival rate is 25%.

Tumors of the Myometrium (Leiomyomas)

• Most common tumor in women in their 30s and 40s.
• Related to estrogenic stimulation.
• Types of myomas:
  • Intramural: arises within the uterine interstitium.
  • Subserous: grows outward, covered by peritoneum.
  • Submucosal: lies below the endometrium, projecting into the uterine cavity.
  • Cervical: occurs within the cervical stroma.
• Morphology (gross): enlarged uterus, may be irregular with multiple myomas; cut section shows round, firm, gray-white masses that are well-circumscribed but not encapsulated, with a whorl appearance.
• Morphology (microscopic): interlacing bundles of smooth muscle fibers and fibrous tissue; mitotic figures are scarce.
• Effects/complications: menorrhagia or metrorrhagia, pressure on the bladder causing urinary frequency, infertility, degenerations (hyaline, red, cystic, necrosis), rare malignant change (leiomyosarcoma).

Leiomyosarcoma

• Uncommon tumor, bulky, fleshy masses in the uterine wall.
• Microscopic: fascicles of eosinophilic spindled cells with blunt-ended nuclei showing variable pleomorphism; presence of 10 mitoses per 10 high-power fields.
• The tumor disseminates throughout the abdominal cavity and metastasizes aggressively.
• 5-year survival rate is 40%.

Diseases of the Fallopian Tubes

• Inflammation (salpingitis):
  • Suppurative salpingitis: infection with pyogenic organisms (streptococci, staphylococci, gonococci).
  • Tuberculous salpingitis: hematogenous spread of tuberculosis into the tubes or associated with tuberculous endometritis.
  • Effects: fibrosis, which may cause infertility (bilateral).
• Tumors: rare, adenocarcinoma usually arises in the fimbriated portion of the tube.
• Ectopic (tubal) pregnancy: implantation of the fertilized ovum outside the uterine cavity in the fallopian tube; tube enlarges, then ruptures, causing hemorrhage and acute abdomen (severe pain).