Female Genital Diseases-2 (Uterine Disorders) PDF

Female genital diseases-2 (uterine disorders) BY DR. HUSAMELDIN OMER  Uterine anomalies Congenital uterine anomalies occur in less than 5% of all women, but have been noted in up to 25% of women who have had miscarriages and/or deliveries of premature babies...

Female genital diseases-2 (uterine disorders) BY DR. HUSAMELDIN OMER  Uterine anomalies Congenital uterine anomalies occur in less than 5% of all women, but have been noted in up to 25% of women who have had miscarriages and/or deliveries of premature babies. The types of uterine anomalies beside absent uterus include: ❖ Didelphys: the two halves of the uterus remain separate ❖ Arcuate: a uterus with a dent (indentation) on the top part ❖ Unicornuate: only one half of the uterus has developed ❖ Bicornuate: a heart-shaped uterus) ❖ Septate: uterus with partition in the middle  Disorders of uterine body Abnormal uterine bleeding: These terms are important Dysfunctional uterine bleeding (uterine bleeding that lacks any underlying structural (organic) abnormality like anovulatory cycle. The hormonal disturbances is the base Menorrhagia: excessive prolonged bleeding during menstruation. Metrorrhagia: bleeding between periods. Organic causes of uterine bleeding:  Complications of pregnancy (abortion, trophoblastic disease, & ectopic pregnancy).  Infections as cervicitis & endometritis.  Tumors of the uterus as 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 ( secretory) ovarian tumors.  Other systemic endocrine disorders e.g. thyroid or adrenal diseases or pituitary tumors. Inflammation of the endometrium (endometritis): Acute endometritis: The causes may be gonorrhea or puerperal sepsis. Chronic endometrial inflammation occurs in:  Patients with Chlamydia and other intrauterine infections.  Post-abortal or partal, due to retained gestational tissue.  Intrauterine contraceptive devices.  Endometrial tuberculosis (granulomatous). Granulomatous endometritis Endometriosis and adenomyosis: Endometriosis  Endometrial glands or stroma in abnormal location outside the uterus.  It can occur in ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, laparotomy scars, umbilicus, vagina, vulva or appendix.  The tissue ungdergoes cyclic changes with periodic bleeding, and presents with pelvic pain. Adenomyosis:  Presence of endometrial foci in the myometrium, which causes diffuse enlargement of the uterus and irregular thickening.  Cut section shows hemorrhagic spots.  Endometrial polyps Endometrial polyps:  Sessile mass composed of endometrial glands and stroma.  They are 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 (as in Stein-Leventhal syndrome, granulosa and theca cell tumors, & estrogen therapy) Types of endometrial hyperplasia:  Simple hyperplasia (cystic glandular hyperplasia): some of the glands show cystic dilatation, & the stromal cells are plump.  Complex hyperplasia without atypia, the gland of varying size are crowded together in clusters, & no cytologic changes.  Complex hyperplasia with atypia (EIN), the gland crowding is accompanied by cytologic changes. Simple endometrial hyperplasia Carcinoma of the endometrium: The peak incidence is 55-65 years (after menopause). Less common than cancer cervix. Risk factors include:  Obesity & diabetes mellitus.  Infertility.  Endometrial hyperplasia & hyperestrogenemia. Morphology: Gross:  Localized polypoid tumor.  Diffuse spreading lesion. Microscopic: the tumor takes one of the following forms:  Well differentiated adenocarcinoma (endometrioid), with squamous, secretory, or mucinous differentiation (metaplasia).  Poorly differentiated carcinoma: including pattern of clear cell carcinoma and / or pattern of papillary serous carcinoma Clinical features: the patient presents by:  Abnormal uterine bleeding or  Abnormal (Pap) smear. Prognosis depends on the type and grade of the tumor:  Good in localized well differentiated tumors and  Poor in spreading or poorly differentiated tumors. Malignant mixed mesodermal tumors: Rare tumors, derived from primitive stromal cells in post menopausal women. Gross: The tumor protrude into the endometrial cavity and vagina and is bulky and polypoid. Microscopic: It is composed of glandular structures and stromal sarcomatous elements (muscle, cartilage, osteoid tissue). Prognosis: The tumor is highly malignant, has a 5 year survival rate of 25%. Tumors of the myometrium: Leiomyomas: The most common tumor in women in 3rd and 4th decades. Related to estrogenic stimulation. The site of myoma may be: ❖ Intramural: arises within the interstitium of the uterus. ❖ Subserous: grows outward covered by peritoneum. ❖ Submucosal, lies just below the endometrium projecting into the uterine cavity. ❖ Cervical: occurs within the cervical stroma.  Morphology: Grossly, the uterus is:  Enlarged, may be irregular in multiple myomas.  Cut section shows round firm gray-white masses, well circumscribed, not encapsulated, with whorl appearance. Microscopically, myoma is composed of:  Interlacing bundles of smooth muscle fibers and fibrous tissue.  Mitotic figures are scarce (few). Effects and complications of myomas:  Menorrhagia or metrorrhagia.  Pressure on the bladder causing frequency of micturition.  Infertility.  Degenerations: hyaline, red degeneration, cystic change and necrosis.  Malignant change is rare (leiomyosarcoma)). Leiomyosarcoma:  Uncommon tumor.  Gross: Forms bulky, fleshy masses in the uterine wall.  Microscopic: Fascicles of eosinophilic spindled cells with blunt ended nuclei showing variable pleomorphism. the presence of 10 mitoses per 10 high power fields.  The tumor disseminates throughout the abdominal cavity and aggressively metastasizes. 5-year survival is 40%. Leiomyosarcoma, gross Leiomyosarcoma, microscopic  Diseases of the fallopian tubes Inflammation: “salpingitis”  Suppurative salpingitis: is due to infection with pyogenic organisms as including streptococci, staphylococci and gonococci.  Tuberculous salpingitis: is due to hematogenous spread of tuberculosis into the tubes, or associated with tuberculous endometritis. Effects of inflammation: fibrosis, which may cause infertility if bilateral. Tumors of the fallopian tubes:  Rare.  The most common one is adenocarcinoma, arises usually in the fimbriated portion of the tube. Ectopic (tubal) pregnancy: Implantation of the fertilized ovum outside the uterine cavity in the fallopian tube. The tube will enlarge, then rupture causing hemorrhage and acute abdomen (severe pain).