2. Straight tubules of proliferative endometrium

3. Early secretory endometrium with subnuclear vacuoles

4. Basal vacuoles (arrow) appear 36 to 48 hours after ovulation

5. Tortuous glands of late secretory endometrium with luminal secretions

6. Menses - endometrium is fragmented and mixed with blood

7. Accumulation of plasma cells in chronic endometritis

8. UTERUS: INFLAMMATION l Acute bacterial u only in puerperium (strep, staph, clostridium, mixed) u NOT gonococcal, chlamydia l Chronic bacterial u chronic PID (pelvic inflammatory disease) u tuberculosis u IUD u retained placental products

9. Multiple granulomas within endometrium from TB

10. UTERUS: ADENOMYOSIS (ENDOMETRIOSIS INTERNA) l Islands of endometrial glands and stroma deep in myometrium probably in continuity with endometrium l Benign but may cause  u Menorrhagia u Dysmenorrhea u Dyspareunia u Pelvic pain l Seen in up to 20% of uteri

11. Ademomyosis (arrow marks the deep level of the endometrium)

12. Adenomyosis with circumscribed area of glands within myometrium

13. UTERUS: ENDOMETRIOSIS (EXTERNAL) l Endometrium at ectopic sites (tubes, ovary [most common site], sigmoid wall, uterine serosa, bladder, vulva, peritoneum, umbilicus, eye). l Causes: ?menstrual reflux, metaplasia, lymphatic dissemination? induction? Iatrogenic (laproscopic hysterectomy) l Problem: they respond to hormones of menstrual cycle  bleed (pain), infertility, intestinal obstruction, “chocolate” cysts  infertility, dysmenorrhea, pelvic pain l Dx: biopsy  endometrial glands, stroma, and/or hemosiderin pigment (need 2 of 3) l Rx: hormonal; surgical. Often unsatisfactory.

15. Chocolate cysts of endometriosis

16. Bilateral chocolate cysts flank opened uterus

17. Opened cyst of endometriosis

18. Wall of endometrial cyst

19. Serosal nodules within intestinal wall

20. Endometriosis within intestinal wall Mucosa Fat

21. Wall of cyst of endometriosis containing numerous hemosiderin-laden macrophages

22. Multiple areas of endometriosis in muscular wall of colon

23. Endometrial type glands and stroma within muscularis propria of colon

24. Early secretory endometrium in focus of endometriosis

25. Umbilical cyst of endometriosis

26. Dysfunctional Uterine Bleeding l Excessive bleeding during or between menstrual periods l DDx includes polyps, endometrial hyperplasia, trophoblastic disease, adenomyosis, & carcinoma l Bx endometrium to rule out malignancy l Most often due to anovulatory cycle which leads to prolonged estrogenic stimulation. l See Robbins Pathology

27. Other Endometrial Changes l Oral contraceptives: u Inactive glands u Predecidualized stroma (abundant cytoplasm as in pregnancy) l Postmenopausal: u Senile cystic atrophy u Atrophic endometrium with cystic dilatation of glands

28. Widely spaced glands and stromal cells with abundant cytoplasm 2  to oral contraceptives (predecidual)

29. Senile cystic atrophy

30. UTERUS: ENDOMETRIAL HYPERPLASIA l Clinical presentation: abnormal uterine bleeding l Mechanism: prolonged estrogenic stimulation (polycystic ovary, estrogen-producing tumors, estrogen Rx, etc.) l Histo: simple or complex cystic hyperplasia, adenomatous or atypical hyperplasia (25% of latter  ca) l Dx and Rx: D&C; hormonal, surgery

31. Endometrial hyperplasia (arrow is at deep border of endometrium)

32. Benign simple cystic hyperplasia

33. Atypical endometrial hyperplasia with epithelial stratification and crowding of glands

34. UTERUS: POLYPS l Pathology: cystic endometrial glands with stroma; benign (rarely cancer may arise within polyp) l Age: any but especially perimenopausal l Sx: ulceration  bleeding l Rx: D&C

35. Opened uterus with endometrial polyp filling lumen

36. Infarcted endometrial polyp

37. UTERUS: LEIOMYOMA (“FIBROID”) l Location: submucosal, intramural, subserosal, broad ligament, cervix l Common; benign; estrogen-responsive. l CSx: bleeding; large obstruct birth (dystocia); spontaneous abortion l Histo: whorled fascicles of smooth muscle cells; clear cell and pleomorphic variations; also “intravenous leiomyomyosis” l Leiomyosarcoma: arise de novo; sarcomatous histo; usually fatal

39. Uterine architecture distorted by large leiomyoma

40. Previous specimen opened to demonstrate leiomyoma

41. Cut surface of leiomyoma. Tumor is firm, white, and usually has a whorled appearance

42. Submucosal leiomyoma

43. Large, submucosal leiomyoma filling lumen

44. Cut surface of submucosal “fibroid”

45. Infarcted submucosal leiomyoma extending through cervical os

46. Multiple leiomyomata

48. Pedunculated subserosal leiomyoma

49. Distorted uterus from multiple leiomyomata

50. Fascicles of smooth muscle cells of leiomyoma

51. Fascicles of smooth muscles: individual nuclei are cigar- shaped and there are no mitoses. When bundle is cut in cross-section you get a halo around the nucleus

52. Cellular leiomyoma

53. Leiomyosarcoma with focus of necrosis

54. Fascicular pattern in leiomyosarcoma

55. Nuclear pleomorphism and mitoses in leiomyosarcoma

56. Leiomyosarcoma

57. UTERUS: ENDOMETRIAL ADENOCARCINOMA (1) l Epidemiology: risk factors u postmenopausal u Obesity – common risk factor, likely has to do with estrogen u diabetes u hypertension u infertility u hyperestrinism 4 nulliparous 4 anovulatory cycles 4 estrogenic tumors 4 Rx

58. UTERUS: ENDOMETRIAL ADENOCARCINOMA (2) l Histology: u most endometrioid (adenocarcinomas with villoglandular histology) u some adenoca with foci of squamous metaplasia (adenoacanthoma) u some adenoca with malignant squamous foci (10% then truly called adenosquamous ca) u variations: 4 clear cell ca 4 papillary serous ca Very aggressive

59. UTERUS: ENDOMETRIAL ADENOCARCINOMA (3) l Staging: similar to cervix l Grading: FIGO system, I 50% solid (serous papillary & clear cell are grade III tumors) l Sx: postmenopausal bleeding l Dx and Rx: D&C; hysterectomy; radiation l Prognosis: stage 1 = 90%; III = 20% 5 yr

60. Stage I endometrial adenocarcinoma. Endometrium is thickened and irregular.

61. Endometrial carcinoma: tumor is friable and focally ulcerated.

62. Uterine cancer with partial obliteration of lumen and compression of myometrium (arrow)

63. Stage 4 endometrial carcinoma has crossed the myometrial wall to invade the adjacent intestine (arrow)

64. Complex glands of endometrial adenocarcinoma

65. Back to back glands of endometrial adenocarcinoma

66. Solid area within endometrial adenocarcinoma

67. Adenoacanthoma: squamous metaplasia is present (arrow)

68. Clear cell adenocarcinoma of uterus

69. Serous papillary carcinoma of uterus: tumor usually has high-grade histology and is very aggressive

70. UTERUS: Carcinosarcoma (Malignant Mixed Mullerian Tumor) l Histo: endometrial adenocarcinoma with malignant stromal differentiation (sarcomatous differentiation) u Muscle, cartilage, osteoid u Some things never seen in uterus (cartilage, bone), others are (smooth muscle) l Otherwise similar to poorly differentiated endometrial adenocarcinoma l Prognosis: overall = 25% 5 yr survival

71. Malignant cartilage within endometrial adenocarcinoma

72. Osteoid within carcinosarcoma

73. Endometrial Stromal Tumors l Two classes: u Benign stromal nodules  well- circumscribed aggregate of stromal cells within myometrium u Stromal sarcoma  neoplastic endometrial stroma invading myometrium: 4 Diffuse between muscle bundles, or 4 Intralymphatic u High recurrence rate (80% for stage III/IV) u 5 yr survival~ 50%

74. Multiple nests of stromal cells have invaded myometrium

75. Stromal sarcoma has invaded lymphatic channel within the myometrium