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Uterine disorders: Pathology review

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Uterine disorders: Pathology review

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USMLE® Step 1 style questions USMLE

13 questions
Preview

A 55-year-old woman presents to the office because of vaginal spotting, abdominal distention and constipation for the past 3 months. She is also having difficulty defecating and often has to put her index and middle finger in her vagina to aid in pushing the stools out. Menopause was at age 48. Past history is significant for breast cancer treated by breast-sparing mastectomy and tamoxifen. Vitals are within normal limits. BMI is 33 kg/m2. Physical examination shows an enlarged irregular uterus and normal rectal tone. Transvaginal doppler ultrasound shows mixed echogenic masses with increased vascularity and central necrosis, bulging into the uterine cavity. Hysterectomy is performed which reveals a poorly-demarcated large yellow soft mass with areas of hemorrhage and necrosis. Histology of the specimen is shown.  


Reproduced from: Wikimedia Commons  
Which of the following is the most likely diagnosis in this patient?  

Transcript

Content Reviewers:

Yifan Xiao, MD

29-year-old Carmen presents to the physician’s office complaining of severe lower abdominal pain during her menstrual periods as well as pain during intercourse.

She has been trying unsuccessfully to get pregnant for the first time for the past 2 years.

Pelvic examination shows a normal sized uterus.

Later that day, 44-year-old Susanna comes to her physician reporting heavy menstrual periods that last about 10 days.

This has been occurring for the past 6 months and is accompanied with a feeling of “fullness” in the lower abdomen as well as fatigue.

On further history, she has never been pregnant.

Physical examination shows an enlarged uterus with multiple round masses.

Laboratory studies reveal iron deficiency anemia.

Based on the initial presentation, Carmen and Susanna both have some form of uterine disorder.

Let’s first review physiology real quick.

The uterus consists of 3 layers, an outer layer called the perimetrium or the serosa, a middle smooth muscle layer called the myometrium, and the innermost layer, the endometrium.

The endometrium has two layers, an inner functional layer made up mainly of glands and supporting connective tissue, called stroma, and an outer thin basal layer which regenerates the overlying functional layer after each menstrual cycle.

Okay, now, the first uterine disorder is endometritis or inflammation of the endometrium.

This is usually caused by normal bacterial flora of the lower genital tract, meaning the cervix, vagina or external genital organs, that travel upwards into the endometrium.

A high yield risk factor to remember is the retention of products of conception, like parts of the placental or fetal tissues, following delivery or abortion.

Another risk factor is the presence of a foreign body, like an intrauterine contraceptive device.

Both can provide a good environment for bacteria to grow and cause an infection in the uterus.

Less commonly, endometritis can be caused by outside bacteria such as Chlamydia trachomatis or Neisseria gonorrhoeae, which are transmitted sexually, or Mycobacterium tuberculosis, which spreads from the lungs into the blood and travels to other organs such as the uterus.

Now, endometritis can be acute or chronic.

On your test, an individual with acute endometritis, typically presents with symptoms like fever, abnormal uterine bleeding, lower abdominal pain, dysuria, which is painful urination, or dyspareunia, which means pain during sexual intercourse.

In contrast, in chronic endometritis, people often have no symptoms and normal physical examination, however, some may experience similar symptoms to those of acute endometritis, although milder.

Diagnosis of is usually based on clinical findings.

An endometrial biopsy can help make the diagnosis, although it’s not routinely done.

What you absolutely have to remember is that microscopic examination of acute endometritis shows neutrophils in the endometrium, which are the hallmark of acute inflammation, while in chronic endometritis, the presence of lymphocytes, especially plasma cells, in the endometrium is diagnostic.

When endometritis is caused by tuberculosis, an additional finding is the presence of granulomas in the endometrium, which is why it’s also called chronic granulomatous endometritis.

Treatment of endometritis is based on antibiotics.

Next, there is Asherman syndrome.

This occurs when the basal layer of the endometrium undergoes fibrosis so it’s unable to regenerate the functional layer.

Sections of the normal tissue in the uterus is replaced by multiple bands of collagen which leads to intrauterine adhesions where the bands make the uterine walls stick to each other.

This whole process causes the endometrium to fail to respond to hormonal stimulation, leading to amenorrhea, or the absence of menstrual bleeding.

In severe cases, these fibrous bands can cover the whole uterus, causing infertility or recurrent pregnancy loss.

Now, for your exams, it’s important to remember that this typically occurs in a female who has undergone uterine instrumentation in the past, like dilation and curettage.

Another uterine disorder that’s high yield is endometrial hyperplasia.

This is hyperplasia or excessive growth of the endometrial glands.

What drives this process, in most cases, is long- standing increased exposure to estrogen without the counteracting effect of progesterone.

For your exams, it’s important to remember that this can be caused by a variety of conditions such as obesity, where the extra adipose tissue converts androgens to estrogen.

It could also be caused by estrogen secreting tumors, such as granulosa cell tumors of the ovaries.

People with polycystic ovarian syndrome are also at risk of endometrial hyperplasia.

In this condition, the ovary is full of cystic follicles that secrete estrogen.

To make things even worse, these follicles don’t ovulate most of the time, a condition known as chronic anovulation, so there’s no luteal body to secrete progesterone.

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