BENIGN DISORDER OF THE REPRODUCTIVE ORGAN~dr.

David Lotisna

by:

Dr.Ezyan
Non-neoplastic Disorders
Iatrogenic endometrium
- Exogenous hormones
- Tamoxifen
- IUD's
Endometritis
Metaplasias
Hyperplasia

Abnormal proliferation of
endometrial glandular epithelium
(and often stroma) that lacks
stromal invasion.
Wide spectrum of patients
Associated with prolonged,
unopposed exposure to estrogen
Therapy depends on type /
patient / setting

Metaplasias
Tubal metaplasia occurs in
setting of estrogen excess or
postmenopausal.
Squamous metaplasia
frequently occurs in
hyperplasia, neoplasia,
CEMI.
Mucinous, papillary and
eosinophic types are less
common
Endometrial Hyperplasia
Current Terminology:
Simple hyperplasia
Complex hyperplasia
(adenomatous)
Simple atypical hyperplasia
Complex atypical
hyperplasia

Endometritis
Acute:
- Microabcesses - stroma /
glands
- Classically postabortal
- Strep., Staphy., GC
Stroma:
- Stromal cells
- Stromal granulocytes

Early studies had lots of

problems
Endometrium is histologically
complex
Cytologic changes are
difficult to judge
Can't follow without biopsy

Sampling of the Endometrium

Office biopsy procedures (Pipelle,
Vabra aspirator, Karman cannula) will
agree with a D&C performed in the
OR ~95% of the time
Office biopsy has a 16% false negative
rate when the lesion is in a polyp or
the cancer covers less than 50% of
the endometrium
Guido et al. J Reprod Med.
1995;40:553
Patients with persistent PMB after
negative office biopsy should have
D&C (+/- hysteroscopy)
D&C is the gold standard sampling
method
preoperative D&C will agree with
diagnosis at hysterectomy 94% of
the time

Mid-secretory phase

Proliferative phase

Early secretory

Post-menopousal atrophy

Endometrial Simple Hyperlasia

Endometrial Hyperlasia - Complex

Endometrial Hyperplasia - Atypical

Endometrial Hyperplasia Classification and Risk of Progression to Cancer:

Kurman, et al. (Cancer. 1985 Jul 15;56(2):403-12.)
Type of
Hyperpl
asia

Total
Cases
(n=17
0)

Years of
Follow up
(mean=13
.4)

#
Progress
ed to
Cancer

%
Progress
ed to
Cancer

%
Persisten
t
Hyperpla
sia

%
Spont.
Regressi
on

Simple

93

15.2

1%

19%

80%

Comple

29

13.5

3%

17%

80%

Combined No Atypia (n=122)

1.6%
Combined with Atypia (n=48)
23%
(P=0.001)
Mean age at study entry= 40y/o
Mean study F/U=13.4yrs

x
Atypical
,
simple

13

11.4

8%

23%

69%

Atypical
,
complex

35

11.4

10

29%

14%

57%

Treatment for Endometrial

Hyperplasia without atypia:
Progestin therapy continuous or
cyclical
Childbearing age:
Progestin dominant OCPs or
Depo-Provera 150mg IM q3
months or
Provera 10mg po 10
days/month and
May follow with ovulation
induction after normal biopsy
if pregnancy desired
Peri or Postmenopausal:
Provera 20mg po 10
days/month or
Depo-Provera 200mg IM q2
months
Repeat biopsy in 3-4 months

Treatment for Atypical Endometrial Hyperplasia:

23% risk of progression to

carcinoma (over 10 years) if
untreated.
Standard treatment when
childbearing is complete is
total hysterectomy (abdominal
or vaginal)
Frozen section to rule out
carcinoma (up to 20% have
coexisting endometrial cancer)

Conservative medical therapy

can be attempted in younger
patients who request
preservation of fertility.
D&C prior to initiation of
medical therapy to rule out
carcinoma
Megace 40-80mg/day,
Norethindrone acetate
5mg/day
Conservative therapy may also
be attempted in young
patients with early, well
differentiated endometrial
carcinomas.
Megace 120200mg/day,
Norethindrone acetate
5-10mg/day

Conservative/Medical Therapy:
Randall TC, Kurman RJ. Progestin treatment of atypical hyperplasia and well-differentiated carcinoma of the

endometrium in women under age 40. Obstet Gynecol. 1997 Sep;90(3):434-40.

Objective
Results
Add notes:
Determine efficacy of
Among 29 pts treated with
conservative treatment of
progestins
AH/ECA in patients <40 yrs. of
16/17 (94%) w/ AH regressed
age
9/12 (75%) w/ ECA regressed
Methods
Median length of treatment
required for regression was 9
Retrospective Study of
mos.
pathology records of women age
At a mean f/u of 40 mos all pts
< 40 diagnosed with AH or ECA
were alive w/o evidence of
at Johns Hopkins Jan/90 - Jan/96
progressive dz.
5 of 25 women attempting
pregnancies delivered healthy
full term infants.
Kim YB, Holschneider CH, Ghosh K,
Conclusion
Nieberg RK, Montz FJ. Progestin
Treatment of AH/ECA
alone as primary treatment of
with progestins appears
endometrial carcinoma in
to be a safe alternative
premenopausal women. Report of
to hysterectomy in
seven cases and review of the
women < 40 yrs of age
literature. Cancer. 1997 Jan
in whom fertility is
15;79(2):320-7.
desired.
13 of 20 patients (62%) with
Perform hysterectomy
well differentiated endometrial
after childbearing is
carcinoma regressed with
completed.
progestins (3 later recurred).
Gotlieb WH, Beiner ME, Shalmon B,
Korach Y, Segal Y, Zmira N,
Koupolovic J, Ben-Baruch G.
Outcome of fertility-sparing
treatment with progestins in young
patients with endometrial cancer.

Obstet Gynecol. 2003

Oct;102(4):718-25.
13 of 13 patients regressed
with progestin therapy, 6 later
recurred

Endometroid carcinoma,
Grading
FIGO - Gr 1 - < 5% solid
tumor
- Gr 2 - 6 % - 50% solid
- Gr 3 - > 50% solid
tumor
NUCLEAR GRADE
Size, shape , staining
and chromatin,
variability, prominent
nucleoli.
High nuclear grade
adds one point to FIGO
grade
Nabothian Cysts
Cause: Obstructed
endocervical gland
Raised yellow or blue nodules
1-3 mm in diameter
Require no treatmenr

Neoplastic Disorders
Endometrial polyps
Endometrial stromal lesions
Endometrial carcinomas
Mesenchymal tumors
Mixed tumors

Endometriomas
Endometriosis
Cervical surgery?
Red or blue
1-3 mm in diamters
Contact bleeding
Treatment in same as

BENIGN CONDITION OF CERVIX

Allergic
Infection:
Reaction
- Trichomonas
Foreign Bodies - Chlamydia
- Gonorrhea
Nabothian
- Herpes
cysts
Endometrioma - Syphillis
s
Myomas
Cervical
Polyps

Myomas (Fibroid)
Cervix rare site
If large may cause pressure
symptoms
Menorrhagia
May obstruct vaginal delivery
Diagnosis ultrasound

endometriosis

Uterine Leiomyoma
Proliferation of Pathogenesis:
In reproductive yrs - rare
smooth muscle
cells
after menopause
Lesion of
Contain estrogen /
reproductive
progesterone receptors
years
Hormones thought to play
20 - 30% of
a role
women 30
Gonadotropin releasing
years and
hormone agonists cause
older
regression
More common
Lesions are monoclonal in blacks
G6PD or PCR
Present with
Non-random
bleeding, pain,
chromosomal
pressure
abnormalities quite
common (40% of cases)
30% of abnormal
karotypes involve region
12q14-15 (same area as
involved in lipomas and
rhabdosarcomas)

Treatment same as other

location

Cervical Polyps
Most common cervical
tumor
Consist of:
- Ectocervical
- Endocervical
Friable, soft, red
protrusions, Stalk ?
Size few mm to several
cm
Sign and symptoms:
- Vaginal discharge
- Postcoital bleeding
- Generally do not become
malignant
- May reoccur
Cytology Inflammatory
atypia

Diagnosis Biopsy
Differential
Diagnosis:
Endometrial
polyps
May be
precancerous
lession
Treatment:
Remove by
twisting on the
stalk or excision
Do not remove in
pregnancy
Sent to
pathology

Endometrial polyps
Definition
Clinical features
Are quite common, especially 40 - Prevalence ~ 24%
50 yrs.
Classical feature: Fibrotic stroma,
Develop as focal hyperplasia of
Prominent vascularity , Glands out
basalis.
of phase, Irregular gland
Benign localised overgrowth of
architecture

More common in women > 40

endometrial glands and stroma,
covered by epithelium, projecting

Pathological findings
Sessile or pedunculated
Size: 1 mm and beyond may
fill the endometrial cavity and
project through the cervical os
May be multiple
May originate anywhere, but

above the adjacent epithelium

Clonal lesions
chromosome 6

Histopathology
Irregularly outlined glands that
may be out of phase with
endometrium
Fibrovascular stalk or fibrous
stroma with numerous thick walled
vessels
Metaplastic epithelium particularly
squamous may be present
Those in the lower uterine
segment may contain endocervical
glands
Mesenchymal component contains
endometrial stroma, fibrous tissue
or smooth muscle.
Absence of cytological atypia
hyperplasia, carcinoma (any type)
and carcinosarcoma may involve
or be entirely confined to a polyp
endometrial intraepithelial
carcinoma may be identified in an
atrophic polyp

Present with
intermenstrual or postmenopausal bleeding
Infertility
Persistent bleeding following
curettage
Common association with
Tamoxifen use

Benign polyp in a hysterectomy

specimen
Note
Endometrial epithelium on three
surfaces
Dilated glands
Fibrotic stroma
Scattered dilated thick walled
blood vessels

most commonly fundus

Note:
Dilated thick-walled blood
vessels
Stromal fibrosis (less than
previous image)
Proliferative endometrial glands

Endometrial polyp (low power)

features cystically dilated glands of
various sizes and shapes

Endometrial polyp (high power)

characteristic features of thick walled
blood vessels in a fibrous core

Tamoxifen related polyps

Larger, sessile with a
honeycomb appearance
bizarre stellate shape of
glands and frequent epithelial
and stromal metaplasias
often periglandular stromal

Differential Diagnosis
Endometrial hyperplasia
diffuse process, majority
of fragments in
curettage, absence of
thick walled vessels
polypoid endometrial

Classification
Morphologically diverse lesions
that are difficult to subclassify.
Most are either hyperplastic,
atrophic or functional.
Hyperplastic
resemble diffuse non
polypoid endometrial
hyperplasia
no evidence that these
have the same significance
as diffuse hyperplasia, so
best to avoid the term
hyperplastic in the
diagnosis
Atrophic
low columnar or cuboidal
cells lining cystically
dilated glands
typically in postmenopausal patients
Functional
resemble normal cycling
endometrium
relatively uncommon
Clinical behavior and treatment
At most 5% of polyps contain
carcinoma
polyps may represent a
marker of increased cancer
risk, but no evidence
suggests they are more likely

condensation
malignant transformation in up
to 3%
interestingly the cytogenetic
profile is similar to noniatrogenic lesions

carcinoma
malignant epithelial cells
adenofibroma
adenosarcoma
stromal cells
cytologically atypical and
mitotically active
stromal cells packed
tightly around non
malignant glands
leaf like pattern

to become cancer than the

adjacent endometium
those containing atypical
hyperplasia or carcinoma
should be treated as per
similar flat lesions

Hysteroscopy Not satisfactory for screening test

Studies of the efficacy of hysteroscopy as a diagnostic tool vary widely
Sensitivity reported ranging from 60-95% compared to D&C obtained at the same time
Specificity 50-99%

DISEASES OF THE OVARY

Ovarian Cysts
Follicular
cysts
Corpus
Luteum
Dermoid

Benign Ovarian Cysts

Follicular cysts
Most common type
of ovarian cyst
Formed during first
half of menstrual
cycle dominant
follicle fails to
ovulate
Can be up to 6 cm,
most smaller can
be very large with
hyperstimulation
from exogenous

Follicular Cysts
Symptoms
No specific symptoms
May have effects on
menses
Cycts are estrogen rich
and may produce
irregular menses
If large enough may
produce feeling of
heaviness, congestion
and aching on affected
side

Torsion rare
Occasionally may
experience sharp
abdominal pain and
bleeding with rupture
This set of symptoms may
resemble ectopic pregnancy
Diagnosis:
Menopause and women on
oral contraceptives should
have NO cycts at any time
of the menstrual cycle but
new OCs such as triphasics

gonadotropins

and 20 mcg pills may allow

ovulation
Follicular cysts should be no
larger than 6 cm, may be
multiple, and often bilateral

Corpus Luteum Cysts

Formed by hematoma or
excessive growth of corpus
luteum
Less common but more
clinically significant than
follicular cysts
Formed in the latter half of
menstrual cycle
Normal corpus luteum of
menstruation and pregnancy is
no longer than 6 cm and noncystic

Cysts can rupture anytime during

luteal phase
usually 1 week prior to menses
causes generalized, severe
abdominal pain
may have pain radiating to
back, shoulder, legs,
rectal/bladder discomfort
depending on amount of

Formed due to excess

physiologic bleeding during
the vascularization (second)
stage of corpus luteum
formation
Rupture may occur from a
normal size corpus luteum in
the vascular stage as well as
from a corpus luteum cyst
Hyperstimulation from
fertility drugs may cause
multiple corpus luteum cysts

Symptoms strongly resemble

ruptured ectopic pregnancy or
appendicitis
Pregnancy test must be done
to rule out ectopic pregnancy
Menstrual and contraceptive
history
On physical exam most
common finding is a small

Persistents corpus luteum cycts

produces menstrual
irregularities generally a delay
in onset of menses, normally 34 weeks but can rarely be up 6
months
Subsequent menses can be
prolonged and heavy
Crampy, dull, unilateral pain is
common (ovarian distention
from bleeding into the cavity)

bleeding
Actual rupture may be preceded
by several days of slow bleeding
into cysts capsule, resulting in
adnexal discomfort
Bleeding with corpus luteum cyst
is often extensive

tender swelling on the side of

adnexa that corresponds to
the pain

Dermoid Cysts
Benign cystic teratoma
Most common ovarian germ
cell neoplasm
18-25% of all ovarian tumors
Most frequently encountered
ovarian tumor in women
under age 20
Incidence peaks between age
20-40

Dermoids fell light and floaty

secondary to their sebaceous
content
May torse intermittently may
twist and be painful during
activity, but go back to normal
during rest
Diagnosis:
12% of cases of dermoids are
bilateral

Consists of tissue from all

three embryonic germ cell
layers: ectoderm, mesoderm,
and endoderm
Has thick, formed capsule
lined with squamous
epithelium beneath are
sweat, apocrine, and
sebaceous glands
Cartilage, nervous tissue, and
hair may be found
Most notable component in
component in 50% of
dermoids is teeth
Pregnancy test must be
performed to rule out ectopic
X-ray helpful because teeth
will show up
Ultrasound is now the most
used method of diagnosis
because certain tumor
characteristics can now be
seen on TVS

Dermoid are founds on the

long ovarian pedicle
Torsion occurs in about 16% of
cases
No specific symptoms
- May have feeling of
heaviness or
aching in pelvis
- Pain may occur with torsion
Management and diagnosis
- often palpated in abdomen or
anterior to uterus because
of long
pedicle

 Most measure 5-10 cm in diameter

Consistency on exam is tensely
cystic