Difference between revisions of "Uterus"

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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>
==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=
=Normal uterine wall=
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==Uterine adenomyosis==
==Uterine adenomyosis==
:''Uterine adenomyoma'' redirects here.
*[[AKA]] ''adenomyosis of the uterus''.
*[[AKA]] ''adenomyosis of the uterus''.
===General===
{{Main|Uterine adenomyosis}}
*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>
*Dysmenorrhea - painful menses.<ref name=pmid22594861>{{Cite journal  | last1 = Cockerham | first1 = AZ. | title = Adenomyosis: a challenge in clinical gynecology. | journal = J Midwifery Womens Health | volume = 57 | issue = 3 | pages = 212-20 | month =  | year =  | doi = 10.1111/j.1542-2011.2011.00117.x | PMID = 22594861 }}</ref>
*Associated with [[endometriosis]].{{fact}}


===Gross===
==Uterine prolapse==
Features:
:''Urogenital prolapse'' redirects here.
*Trabeculated cut surface +/- small foci of hemorrhage.<ref name=Ref_Lester3_432>{{Ref Lester3|432}}</ref>
{{main|Uterine prolapse}}
**Often described as "basket-weave" pattern.
*Globoid, slightly enlarged.<ref name=pmid20291238>{{Cite journal  | last1 = HUNTER | first1 = WC. | last2 = SMITH | first2 = LL. | last3 = REINER | first3 = WC. | title = Uterine adenomyosis; incidence, symptoms, and pathology in 1,856 hysterectomies. | journal = Am J Obstet Gynecol | volume = 53 | issue = 4 | pages = 663-8 | month = Apr | year = 1947 | doi =  | PMID = 20291238 | URL = http://journals.lww.com/obgynsurvey/Citation/1947/10000/The_Uterus__Uterine_Adenomyosis__Incidence,.61.aspx }}</ref>


Note:
==Dysfunctional uterine bleeding==
*May form a mass - known as ''[[adenomyoma]]''.<ref name=pmid16990713>{{Cite journal  | last1 = Tahlan | first1 = A. | last2 = Nanda | first2 = A. | last3 = Mohan | first3 = H. | title = Uterine adenomyoma: a clinicopathologic review of 26 cases and a review of the literature. | journal = Int J Gynecol Pathol | volume = 25 | issue = 4 | pages = 361-5 | month = Oct | year = 2006 | doi = 10.1097/01.pgp.0000209570.08716.b3 | PMID = 16990713 }}
*Abbreviated ''DUB''.
</ref>
===General===
*Clinical diagnosis based on negative pathology - specifically a negative [[endometrium|endometrial biopsy]].


Image:
Clinical:
*[http://www.flickr.com/photos/34342634@N02/5036818444/ Uterine adenomyosis (flickr.com/infopathic)].
*[[Menorrhagia]].
*[http://www.flickr.com/photos/34342634@N02/5036818516/ Uterine adenomyosis - close-up (flickr.com/infopathic)].


===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.
***Simple epithelial or pseudostratified epithelium +/- mitoses.
**+/-Surrounded by endometrial stroma.
***Densely packed spindle cells without [[nuclear atypia]].
**Blood:
***Within glands.
***Hemosiderin-laden macrophages.


Note:
===Sign out===
*Can be thought of as [[endometriosis]] of the myometrium.
<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>
 
====Block letters====
<pre>
A. OMENTUM, BIOPSY:
- FIBROADIPOSE TISSUE WITHIN NORMAL LIMITS -- CONSISTENT WITH OMENTUM.


DDx:
B. UTERUS, SUBTOTAL HYSTERECTOMY:
*[[Endometrioid endometrial carcinoma]].
- SECRETORY PHASE ENDOMETRIUM.
- UTERINE WALL WITHIN NORMAL LIMITS.
</pre>


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


==Uterine prolapse==
==BRCA carrier==
:''Urogenital prolapse'' redirects here.
===General===
===General===
*'''Clinical diagnosis'''.
*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>
*A common indication for a total hysterectomy. 
*Hysterectomy specimen usually comes with some [[vagina]]l mucosa.


===Gross===
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>
*Long cervix.
*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===
===Microscopic===
Features:
*Uterus: non-specific.
*Vaginal mucosa: (focal) keratinization due to rubbing - '''common finding'''.


===Sign out===
DDx:
<pre>
*Early [[serous carcinoma]] of the fallopian tube or ovary.
UTERUS AND CERVIX, TOTAL HYSTERECTOMY:
*[[STIC]].
- UTERINE CERVIX WITH FOCAL KERATINIZATION OTHERWISE WITHIN NORMAL LIMITS.
- NON-PROLIFERATIVE ENDOMETRIUM.
</pre>


==Dysfunctional uterine bleeding==
===IHC===
*Abbreviated ''DUB''.
*p53 -ve.
===General===
*p16 -ve.
*Clinical diagnosis based on negative pathology - specifically a negative [[endometrium|endometrial biopsy]].
*Ki-67 low.
 
===Microscopic===
Features:
*Endometrium within normal limits - see [[proliferative phase endometrium]] and [[secretory phase endometrium]].


===Sign out===
===Sign out===
<pre>
<pre>
A. OMENTUM, BIOPSY:
Uterus, Cervix, Fallopian Tubes and Ovaries, Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy:
- FIBROADIPOSE TISSUE WITHIN NORMAL LIMITS -- CONSISTENT WITH OMENTUM.
    - Uterus with fibrous serosal adhesions.
 
    - Cervix within normal limits.
B. UTERUS, SUBTOTAL HYSTERECTOMY:
    - Atherosclerosis, moderate.
- SECRETORY PHASE ENDOMETRIUM.
    - Inactive endometrium with cystic changes.
- UTERINE WALL WITHIN NORMAL LIMITS.
    - Uterine adenomyosis.
    - Fallopian tubes within normal limits.
    - Ovaries with benign cysts.
    - NEGATIVE for malignancy.
</pre>
</pre>


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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