Endometriosis and Endometrial Hyperplasia

Endometriosis

Endometriosis is when the endometrial tissue is found outside of the uterus, usually in the peritoneal cavity. 

Pathological diagnosis of endometriosis can be confirmed by seeing endometrial glands and stroma in tissue biopsies. If glands and stroma are not seen, endometriosis can’t be diagnosed!

***super-important*** 

Endometriosis may be asymptomatic or not.

·         It may cause dysmenorrhea (cramps). Women get cramps because the endometrial tissue cycles with the regular menstrual cycle since it’s hormonally sensitive.

·         It may be related to infertility. The cause is unknown, but apparently, a small amount of endometrial tissue can cause infertility.

·         It can cause dyspareunia (painful intercourse) because endometrial tissue is usually found behind the uterus by the uterine ligaments and in the cul-de-sac where the tissue can be hit during intercourse. 

Symptoms of endometriosis don’t correspond to the extent of the disease. You may have a great deal of endometrial tissue outside of the uterus, but very little pain, and vice versa.

Powder burn lesions on the uterus and endometriomas (endometrial cysts) on the ovaries may also be present.

·         Ovarian cysts are also called chocolate cysts. Since ovarian cysts follow the menstrual cycle like normal endometrial tissue, after the cysts hemorrhage, the blood has nowhere to go and resembles chocolate syrup. Yuck…

·         Many masses of endometrial tissue compress the structures around them because of bleeding from menstrual flow. The lining of the ovaries may be smushed due to hemorrhage.

·         Glandular epithelium from the endometrium may not form glands as expected but line neighboring surfaces instead.

CA-125 levels are elevated in endometriosis. It can be measured in blood and stained in tissue. However, it’s non-specific; CA-125 levels are also elevated in ovarian cancer and is sometimes used as an ovarian cancer marker.

There are several theories of endometriosis.

·         Sampson hypothesized that endometriosis was caused by retrograde menses that blew out of the Fallopian tubes. However, this was proved improbable because all women who underwent menstruation would get endometriosis, and that’s not true.

·         Hematogenous spread

·         Lymphatic spread

·         Metaplastic spread was considered, in which one benign tissue type is converted to another tissue type.

The most common sites of endometriosis are:

·         Bladder

·         Ovaries

·         Uterine Ligaments

·         Cul-de-sac

·         Other peritoneal structures

Endometrial Hyperplasia

Endometrial hyperplasia is an overgrowth of the endometrium due to excess or unopposed estrogen. Progesterone is needed occasionally to counteract estrogen in order to stabilize the endometrium and prevent hyperplasia. Therefore, it’s important for post-menopausal women to incorporate some progesterone with their hormonal therapy. 

There are 3 types of endometrial hyperplasia. 

• Simple

o        There is little glandular crowding. The cells are in the proliferative stage and cystic dilatations are noted. There is a lot of intervening stroma.

o        It is not considered pre-cancerous.

o        The treatment is usually progesterone therapy. 
 

·         Complex

o        There is increased glandular crowding with intervening stroma still visible.

o        It is not considered pre-cancerous.

o        The treatment is usually progesterone therapy. 
 

·         Atypical

o        Nuclear atypia is characteristic. The nuclei are big and funky-looking, not oval.

o        There is a great deal of glandular crowding.

o        This is the only endometrial hyperplasia that is considered pre-cancerous.

o        The risk of developing cancer is 25% if an atypical

endometrial hyperplasia is not treated or if the woman already has a type of cancer without knowing that there’s atypical hyperplasia on the other.

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