Difference between revisions of "Uterus"

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Other tumours are dealt with in [[uterine tumours]].
Other tumours are dealt with in [[uterine tumours]].


==Operations==
=Operations=
*Myomectomy.
**Indication: [[uterine leiomyoma]]s.
*Subtotal hysterectomy.
*Subtotal hysterectomy.
**Discouraged... as the cervix remains and can develop a cancer.
*Total hysterectomy.
*Total hysterectomy.
**Indications:
***Endometrial cancer (low stage, good histologic type), [[endometrial hyperplasia]].
***[[Uterine prolapse]].
***[[Uterine adenomyosis]].
***[[Uterine leiomyoma]]s.
***Chronic pelvic pain.<ref name=pmid21508759>{{Cite journal  | last1 = Lamvu | first1 = G. | title = Role of hysterectomy in the treatment of chronic pelvic pain. | journal = Obstet Gynecol | volume = 117 | issue = 5 | pages = 1175-8 | month = May | year = 2011 | doi = 10.1097/AOG.0b013e31821646e1 | PMID = 21508759 }}</ref>
*Radical hysterectomy - total hysterectomy + parametrial tissue.<ref name=pmid19546764>{{Cite journal  | last1 = Frumovitz | first1 = M. | last2 = Sun | first2 = CC. | last3 = Schmeler | first3 = KM. | last4 = Deavers | first4 = MT. | last5 = Dos Reis | first5 = R. | last6 = Levenback | first6 = CF. | last7 = Ramirez | first7 = PT. | title = Parametrial involvement in radical hysterectomy specimens for women with early-stage cervical cancer. | journal = Obstet Gynecol | volume = 114 | issue = 1 | pages = 93-9 | month = Jul | year = 2009 | doi = 10.1097/AOG.0b013e3181ab474d | PMID = 19546764 }}</ref>
**Indications: cervical cancers, advanced uterine cancers.
***This is typically done by gynecologists with additional training at larger centres.
***Usually done with a bilateral salpingo-opherectomy (both tubes and ovaries) and pelvic lymph node dissection.


Notes:
Notes:
*There are almost no quality of life differences between total & subtotal hysterectomy.<ref name=pmid12397189>{{Cite journal  | last1 = Thakar | first1 = R. | last2 = Ayers | first2 = S. | last3 = Clarkson | first3 = P. | last4 = Stanton | first4 = S. | last5 = Manyonda | first5 = I. | title = Outcomes after total versus subtotal abdominal hysterectomy. | journal = N Engl J Med | volume = 347 | issue = 17 | pages = 1318-25 | month = Oct | year = 2002 | doi = 10.1056/NEJMoa013336 | PMID = 12397189 }}</ref>
*There are almost no quality of life differences between total & subtotal hysterectomy.<ref name=pmid12397189>{{Cite journal  | last1 = Thakar | first1 = R. | last2 = Ayers | first2 = S. | last3 = Clarkson | first3 = P. | last4 = Stanton | first4 = S. | last5 = Manyonda | first5 = I. | title = Outcomes after total versus subtotal abdominal hysterectomy. | journal = N Engl J Med | volume = 347 | issue = 17 | pages = 1318-25 | month = Oct | year = 2002 | doi = 10.1056/NEJMoa013336 | PMID = 12397189 }}</ref>
*''Simple hysterectomy'' is removal of the uterus and cervix;<ref>{{Cite journal  | last1 = Somashekhar | first1 = SP. | last2 = Ashwin | first2 = KR. | title = Management of Early Stage Cervical Cancer. | journal = Rev Recent Clin Trials | volume =  | issue =  | pages =  | month = Sep | year = 2015 | doi =  | PMID = 26411950 }}</ref> it can be used as a synonym for ''total hysterectomy''.<ref>URL: [http://www.baymoon.com/~gyncancer/library/glossary/bldefhyster.htm http://www.baymoon.com/~gyncancer/library/glossary/bldefhyster.htm]. Accessed on: 8 October 2015.</ref>


==Tumours of the corpus==
==Grossing hysterectomy specimens==
*[[Hysterectomy for endometrial cancer grossing]].
*[[Hysterectomy for endometrial hyperplasia grossing]].
*[[Hysterectomy for fibroids grossing]].
 
===Hysterectomy specimens - orientation===
Orientation:
*Less peritoneum on anterior (as the [[urinary bladder]] is there).
**'''P'''osterior '''p'''eritoneal edge: '''p'''ointy (upside down triangle).
***Anterior peritoneal edge: rounded/non-pointy.
*Tubes on anterior-lateral aspect.<ref>{{Ref Lester3|425}}</ref>
**Round ligaments posterior to tubes.
 
=Normal uterine wall=
===Gross===
*Firm.
*Pear-shaped.
**Not quite true -- it is usu. flattened at the anterior and posterior.
 
Negatives:
*No nodules.
*No trabeculations.
 
===Microsopic===
Features:
*Smooth muscle arranged in fascicles.
 
===IHC===
*ER +ve.
*PR +ve.
 
=Tumours of the corpus=
{{Main|Uterine tumours}}
{{Main|Uterine tumours}}
The most common is ''[[leiomyoma]]'' (uterine fibroids).
The most common is ''[[leiomyoma]]'' (uterine fibroids).


==Endometrium==
=Endometrium=
{{Main|Endometrium}}
{{Main|Endometrium}}
Dealt with in ''[[endometrium]]'', ''[[endometrial hyperplasia]]'' and ''[[endometrial carcinoma]]'' articles.
Dealt with in ''[[endometrium]]'', ''[[endometrial hyperplasia]]'' and ''[[endometrial carcinoma]]'' articles.
==Congenital absence==
=Specific conditions=
*Often in association with vaginal absence; ergo ''congenital absence of the uterus and vagina'' (CAUV).  
==Congenital absence of the uterus==
**[[AKA]] Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.<ref name=pmc1832178>URL: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1832178/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1832178/].</ref>
===General===
*Often associated with absence of the deep portion of the vagina; thus, may be ''congenital absence of the uterus and vagina'' (CAUV).  
*May go by the name ''Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome''.<ref name=pmc1832178>URL: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1832178/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1832178/].</ref>
*May be seen in the context of ''Müllerian agenesis''. (???)


Features:<ref name=pmc1832178/>
Features:<ref name=pmc1832178/>
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Treatment:
Treatment:
*Uterine transplant - attempted.<ref>URL: [http://singularityhub.com/2011/06/18/in-a-medical-first-infertile-daughter-will-receive-uterus-from-mother-video/ http://singularityhub.com/2011/06/18/in-a-medical-first-infertile-daughter-will-receive-uterus-from-mother-video/]. Accessed on: 17 June 2011.</ref>
*Uterine transplant - attempted.<ref>URL: [http://singularityhub.com/2011/06/18/in-a-medical-first-infertile-daughter-will-receive-uterus-from-mother-video/ http://singularityhub.com/2011/06/18/in-a-medical-first-infertile-daughter-will-receive-uterus-from-mother-video/]. Accessed on: 17 June 2011.</ref>
==Uterus didelphys==
===General===
*Benign - though may adversely affect fertility.<ref name=pmid18155200>{{Cite journal  | last1 = Taylor | first1 = E. | last2 = Gomel | first2 = V. | title = The uterus and fertility. | journal = Fertil Steril | volume = 89 | issue = 1 | pages = 1-16 | month = Jan | year = 2008 | doi = 10.1016/j.fertnstert.2007.09.069 | PMID = 18155200 }}</ref>
*Rare - seen in < 0.3% deliveries.<ref name=pmid6019679/>
*Can be thought of as ''double uterus'' - a consequence of the Muellerian ducts '''not''' fusing.
Related conditions:
*Arcuate uterus - fundus has a concave contour towards the uterine cavity.
*Septate uterus.
*Bicornuate uterus.
*Uterus didelphys.
Image:
*[http://www.msdlatinamerica.com/ebooks/RadiologyReviewManual/files/1de384e713476a71768c20e3b1f8c51b.gif Schematic of uterine abnormalities (msdlatinamerica.com)].<ref>URL: [http://www.msdlatinamerica.com/ebooks/RadiologyReviewManual/sid1652818.html http://www.msdlatinamerica.com/ebooks/RadiologyReviewManual/sid1652818.html]. Accessed on: 28 April 2012.</ref>
===Gross===
*Two uteri - each have a cervix, each connect to one [[fallopian tube]]/[[ovary]].
*+/-Vaginal septum ''or'' double [[vagina]].<ref name=pmid6019679>{{Cite journal  | last1 = Brown | first1 = DC. | last2 = Nelson | first2 = RF. | title = Uterus didelphys and double vagina with delivery of a normal infant from each uterus. | journal = Can Med Assoc J | volume = 96 | issue = 11 | pages = 675-7 | month = Mar | year = 1967 | doi =  | PMID = 6019679 |    PMC = 1936081}}</ref>
===Microscopic===
*Non-specific - gross diagnosis.


==Uterine adenomyosis==
==Uterine adenomyosis==
*[[AKA]] ''adenomyosis of the uterus''.
{{Main|Uterine adenomyosis}}
==Uterine prolapse==
:''Urogenital prolapse'' redirects here.
{{main|Uterine prolapse}}
==Dysfunctional uterine bleeding==
*Abbreviated ''DUB''.
===General===
===General===
*Common - may be a cause of bleeding.<ref>{{Cite journal  | last1 = Reinhold | first1 = C. | last2 = Tafazoli | first2 = F. | last3 = Mehio | first3 = A. | last4 = Wang | first4 = L. | last5 = Atri | first5 = M. | last6 = Siegelman | first6 = ES. | last7 = Rohoman | first7 = L. | title = Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. | journal = Radiographics | volume = 19 Spec No | issue =  | pages = S147-60 | month = Oct | year = 1999 | doi =  | PMID = 10517451 | URL = http://radiographics.rsna.org/content/19/suppl_1/S147.full }}</ref>
*Clinical diagnosis based on negative pathology - specifically a negative [[endometrium|endometrial biopsy]].
*Associated with [[endometriosis]]. (???)
 
Clinical:
*[[Menorrhagia]].


===Microscopic===
===Microscopic===
Features:
Features:
*Endometrial glands within uterine muscle - '''key feature'''.
*Endometrium within normal limits - see [[proliferative phase endometrium]] and [[secretory phase endometrium]].
**Endometrial glands:
 
***Circular.
===Sign out===
***Simple epithelial or pseudostratified epithelium +/- mitoses.
<pre>
**+/-Surrounded by endometrial stroma.
Uterus, Cervix, and Bilateral Uterine Tubes, Total Hysterectomy and Bilateral Salpingectomy:
***Densely packed spindle cells without [[nuclear atypia]].
- Uterine cervix within normal limits.
**Blood:
- Proliferative phase endometrium with focal fibrosis, compatible with prior ablation.
***Within glands.
- Uterine leiomyomas.
***Hemosiderin-laden macrophages.
- Bilateral uterine tubes without significant pathology.
- NEGATIVE for malignancy.
</pre>
 
====Block letters====
<pre>
A. OMENTUM, BIOPSY:
- FIBROADIPOSE TISSUE WITHIN NORMAL LIMITS -- CONSISTENT WITH OMENTUM.
 
B. UTERUS, SUBTOTAL HYSTERECTOMY:
- SECRETORY PHASE ENDOMETRIUM.
- UTERINE WALL WITHIN NORMAL LIMITS.
</pre>
 
<pre>
UTERUS, CERVIX, AND BILATERAL UTERINE TUBES, TOTAL HYSTERECTOMY AND BILATERAL SALPINGECTOMY:
- UTERINE CERVIX WITHIN NORMAL LIMITS.
- PROLIFERATIVE PHASE ENDOMETRIUM WITH FOCAL FIBROSIS, COMPATIBLE WITH PRIOR ABLATION.
- UTERINE LEIOMYOMAS.
- BILATERAL UTERINE TUBES WITHOUT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
==BRCA carrier==
===General===
*Prophylatic bilateral salpingo-oophorectomies (BSOs) done in [[BRCA1|BRCA carrier]]s to reduce risk of [[serous carcinoma]].<ref name=pmid27241111>{{Cite journal  | last1 = Shaw | first1 = PA. | last2 = Clarke | first2 = BA. | title = Prophylactic Gynecologic Specimens from Hereditary Cancer Carriers. | journal = Surg Pathol Clin | volume = 9 | issue = 2 | pages = 307-28 | month = Jun | year = 2016 | doi = 10.1016/j.path.2016.02.002 | PMID = 27241111 }}</ref>


Note:
Incidence of pathology in prophylatic BSOs in a series of 226 cases:<ref name=pmid22710074>{{Cite journal  | last1 = Mingels | first1 = MJ. | last2 = Roelofsen | first2 = T. | last3 = van der Laak | first3 = JA. | last4 = de Hullu | first4 = JA. | last5 = van Ham | first5 = MA. | last6 = Massuger | first6 = LF. | last7 = Bulten | first7 = J. | last8 = Bol | first8 = M. | title = Tubal epithelial lesions in salpingo-oophorectomy specimens of BRCA-mutation carriers and controls. | journal = Gynecol Oncol | volume = 127 | issue = 1 | pages = 88-93 | month = Oct | year = 2012 | doi = 10.1016/j.ygyno.2012.06.015 | PMID = 22710074 }}</ref>
*Can be thought of as [[endometriosis]] of the myometrium.
*Invasive carcinoma ~ 0.9%.
*STIC ~ 6.2%
 
===Grossing===
*In prophylatic procedures, the ovaries and tubes, endometrium, and lower uterine segment should all be [[submitted in total]].<ref name=pmid24495259>{{Cite journal  | last1 = Downes | first1 = MR. | last2 = Allo | first2 = G. | last3 = McCluggage | first3 = WG. | last4 = Sy | first4 = K. | last5 = Ferguson | first5 = SE. | last6 = Aronson | first6 = M. | last7 = Pollett | first7 = A. | last8 = Gallinger | first8 = S. | last9 = Bilbily | first9 = E. | title = Review of findings in prophylactic gynaecological specimens in Lynch syndrome with literature review and recommendations for grossing. | journal = Histopathology | volume = 65 | issue = 2 | pages = 228-39 | month = Aug | year = 2014 | doi = 10.1111/his.12386 | PMID = 24495259 }}</ref>
===Microscopic===


DDx:
DDx:
*[[Endometrioid endometrial carcinoma]].
*Early [[serous carcinoma]] of the fallopian tube or ovary.
*[[STIC]].
 
===IHC===
*p53 -ve.
*p16 -ve.
*Ki-67 low.
 
===Sign out===
<pre>
Uterus, Cervix, Fallopian Tubes and Ovaries, Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy:
    - Uterus with fibrous serosal adhesions.
    - Cervix within normal limits.
    - Atherosclerosis, moderate.
    - Inactive endometrium with cystic changes.
    - Uterine adenomyosis.
    - Fallopian tubes within normal limits.
    - Ovaries with benign cysts.
    - NEGATIVE for malignancy.
</pre>


==See also==
=See also=
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]

Latest revision as of 19:33, 6 June 2018

The uterus is essential for survival of the species. It is commonly afflicted with tumours.

Endometrium and its pathology is dealt with in the endometrium, endometrial hyperplasia and endometrial carcinoma articles.

Other tumours are dealt with in uterine tumours.

Operations

  • Myomectomy.
  • Subtotal hysterectomy.
    • Discouraged... as the cervix remains and can develop a cancer.
  • Total hysterectomy.
  • Radical hysterectomy - total hysterectomy + parametrial tissue.[2]
    • Indications: cervical cancers, advanced uterine cancers.
      • This is typically done by gynecologists with additional training at larger centres.
      • Usually done with a bilateral salpingo-opherectomy (both tubes and ovaries) and pelvic lymph node dissection.

Notes:

  • There are almost no quality of life differences between total & subtotal hysterectomy.[3]
  • Simple hysterectomy is removal of the uterus and cervix;[4] it can be used as a synonym for total hysterectomy.[5]

Grossing hysterectomy specimens

Hysterectomy specimens - orientation

Orientation:

  • Less peritoneum on anterior (as the urinary bladder is there).
    • Posterior peritoneal edge: pointy (upside down triangle).
      • Anterior peritoneal edge: rounded/non-pointy.
  • Tubes on anterior-lateral aspect.[6]
    • Round ligaments posterior to tubes.

Normal uterine wall

Gross

  • Firm.
  • Pear-shaped.
    • Not quite true -- it is usu. flattened at the anterior and posterior.

Negatives:

  • No nodules.
  • No trabeculations.

Microsopic

Features:

  • Smooth muscle arranged in fascicles.

IHC

  • ER +ve.
  • PR +ve.

Tumours of the corpus

Main article: Uterine tumours

The most common is leiomyoma (uterine fibroids).

Endometrium

Main article: Endometrium

Dealt with in endometrium, endometrial hyperplasia and endometrial carcinoma articles.

Specific conditions

Congenital absence of the uterus

General

  • Often associated with absence of the deep portion of the vagina; thus, may be congenital absence of the uterus and vagina (CAUV).
  • May go by the name Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.[7]
  • May be seen in the context of Müllerian agenesis. (???)

Features:[7]

  • Subdivided - as etiologies differ.
  • Thought to have a genetic component - autosomal dominant with variable penetration.

Treatment:

  • Uterine transplant - attempted.[8]

Uterus didelphys

General

  • Benign - though may adversely affect fertility.[9]
  • Rare - seen in < 0.3% deliveries.[10]
  • Can be thought of as double uterus - a consequence of the Muellerian ducts not fusing.

Related conditions:

  • Arcuate uterus - fundus has a concave contour towards the uterine cavity.
  • Septate uterus.
  • Bicornuate uterus.
  • Uterus didelphys.

Image:

Gross

Microscopic

  • Non-specific - gross diagnosis.

Uterine adenomyosis

  • AKA adenomyosis of the uterus.
Main article: Uterine adenomyosis

Uterine prolapse

Urogenital prolapse redirects here.
Main article: Uterine prolapse

Dysfunctional uterine bleeding

  • Abbreviated DUB.

General

  • Clinical diagnosis based on negative pathology - specifically a negative endometrial biopsy.

Clinical:

Microscopic

Features:

Sign out

Uterus, Cervix, and Bilateral Uterine Tubes, Total Hysterectomy and Bilateral Salpingectomy:
- Uterine cervix within normal limits.
- Proliferative phase endometrium with focal fibrosis, compatible with prior ablation.
- Uterine leiomyomas.
- Bilateral uterine tubes without significant pathology.
- NEGATIVE for malignancy.

Block letters

A. OMENTUM, BIOPSY:
- FIBROADIPOSE TISSUE WITHIN NORMAL LIMITS -- CONSISTENT WITH OMENTUM.

B. UTERUS, SUBTOTAL HYSTERECTOMY:
- SECRETORY PHASE ENDOMETRIUM.
- UTERINE WALL WITHIN NORMAL LIMITS.

UTERUS, CERVIX, AND BILATERAL UTERINE TUBES, TOTAL HYSTERECTOMY AND BILATERAL SALPINGECTOMY:
- UTERINE CERVIX WITHIN NORMAL LIMITS.
- PROLIFERATIVE PHASE ENDOMETRIUM WITH FOCAL FIBROSIS, COMPATIBLE WITH PRIOR ABLATION.
- UTERINE LEIOMYOMAS.
- BILATERAL UTERINE TUBES WITHOUT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR MALIGNANCY.

BRCA carrier

General

Incidence of pathology in prophylatic BSOs in a series of 226 cases:[13]

  • Invasive carcinoma ~ 0.9%.
  • STIC ~ 6.2%

Grossing

  • In prophylatic procedures, the ovaries and tubes, endometrium, and lower uterine segment should all be submitted in total.[14]

Microscopic

DDx:

IHC

  • p53 -ve.
  • p16 -ve.
  • Ki-67 low.

Sign out

Uterus, Cervix, Fallopian Tubes and Ovaries, Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy:
     - Uterus with fibrous serosal adhesions.
     - Cervix within normal limits.
     - Atherosclerosis, moderate.
     - Inactive endometrium with cystic changes.
     - Uterine adenomyosis.
     - Fallopian tubes within normal limits.
     - Ovaries with benign cysts.
     - NEGATIVE for malignancy.

See also

References

  1. ↑ Lamvu, G. (May 2011). "Role of hysterectomy in the treatment of chronic pelvic pain.". Obstet Gynecol 117 (5): 1175-8. doi:10.1097/AOG.0b013e31821646e1. PMID 21508759.
  2. ↑ Frumovitz, M.; Sun, CC.; Schmeler, KM.; Deavers, MT.; Dos Reis, R.; Levenback, CF.; Ramirez, PT. (Jul 2009). "Parametrial involvement in radical hysterectomy specimens for women with early-stage cervical cancer.". Obstet Gynecol 114 (1): 93-9. doi:10.1097/AOG.0b013e3181ab474d. PMID 19546764.
  3. ↑ Thakar, R.; Ayers, S.; Clarkson, P.; Stanton, S.; Manyonda, I. (Oct 2002). "Outcomes after total versus subtotal abdominal hysterectomy.". N Engl J Med 347 (17): 1318-25. doi:10.1056/NEJMoa013336. PMID 12397189.
  4. ↑ Somashekhar, SP.; Ashwin, KR. (Sep 2015). "Management of Early Stage Cervical Cancer.". Rev Recent Clin Trials. PMID 26411950.
  5. ↑ URL: http://www.baymoon.com/~gyncancer/library/glossary/bldefhyster.htm. Accessed on: 8 October 2015.
  6. ↑ Lester, Susan Carole (2010). Manual of Surgical Pathology (3rd ed.). Saunders. pp. 425. ISBN 978-0-323-06516-0.
  7. ↑ 7.0 7.1 URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1832178/.
  8. ↑ URL: http://singularityhub.com/2011/06/18/in-a-medical-first-infertile-daughter-will-receive-uterus-from-mother-video/. Accessed on: 17 June 2011.
  9. ↑ Taylor, E.; Gomel, V. (Jan 2008). "The uterus and fertility.". Fertil Steril 89 (1): 1-16. doi:10.1016/j.fertnstert.2007.09.069. PMID 18155200.
  10. ↑ 10.0 10.1 Brown, DC.; Nelson, RF. (Mar 1967). "Uterus didelphys and double vagina with delivery of a normal infant from each uterus.". Can Med Assoc J 96 (11): 675-7. PMC 1936081. PMID 6019679. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936081/.
  11. ↑ URL: http://www.msdlatinamerica.com/ebooks/RadiologyReviewManual/sid1652818.html. Accessed on: 28 April 2012.
  12. ↑ Shaw, PA.; Clarke, BA. (Jun 2016). "Prophylactic Gynecologic Specimens from Hereditary Cancer Carriers.". Surg Pathol Clin 9 (2): 307-28. doi:10.1016/j.path.2016.02.002. PMID 27241111.
  13. ↑ Mingels, MJ.; Roelofsen, T.; van der Laak, JA.; de Hullu, JA.; van Ham, MA.; Massuger, LF.; Bulten, J.; Bol, M. (Oct 2012). "Tubal epithelial lesions in salpingo-oophorectomy specimens of BRCA-mutation carriers and controls.". Gynecol Oncol 127 (1): 88-93. doi:10.1016/j.ygyno.2012.06.015. PMID 22710074.
  14. ↑ Downes, MR.; Allo, G.; McCluggage, WG.; Sy, K.; Ferguson, SE.; Aronson, M.; Pollett, A.; Gallinger, S. et al. (Aug 2014). "Review of findings in prophylactic gynaecological specimens in Lynch syndrome with literature review and recommendations for grossing.". Histopathology 65 (2): 228-39. doi:10.1111/his.12386. PMID 24495259.
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