Are you a woman of 50?
Do you see losses from your genitals immediately after sexual relationship and do you think it's normal?
Do you think the menstrual cycle has returned? Have you ever had a pap test? It is not so!
Never neglect the loss of blood outside of your cycle, this is metrorrhagia.
You must immediately go to your gynecologist specialist and pay a visit: it could be a uterine lesion, a cancerous polyp, endometrial or cervical cancer.
The body of the uterus is constituted for the most part by the myometrium, that
is, by smooth musculature, and by the endometrium which constitutes the mucous
portion which undergoes cyclic modifications. Myometrium is the compact smooth
muscle that responds to hormones, which grows during pregnancy and is stimulated
during the estrogenic phase of the cycle.
The endometrial mucosa also undergoes cyclic changes: the transition from the
proliferative phase to the initial secretive phase is highlighted by the
appearance of vacuoles in the cytoplasm.
The pathology of the uterine body consists of:
• malformations, which can be of any type;
• inflammatory, acute or chronic diseases;
• dysfunctional endometrium in which there is a dissociation of the two
components: the glandular component and the stromal component (we speak of
cytogenic stroma).
These stromal cells undergo changes during the cycle: in the proliferative phase
we have a compact stroma, with cells placed next to each other, while in the
initial secretory phase they begin to dissociate and in the progestogen phase
these cells are even more detached and they have the largest cytoplasm (they
recall those of pregnancy but do not have the same characteristics as the cells
of decidua gravidica, we speak of deciduous transformation).
In endometrial dysfunction, the stroma does not follow the modifications of the
glands, so we can have secretory glands with a still compact stroma of the
proliferative phase or the opposite. This dysfunction can cause problems in the
menstrual cycle.
• Postmenopausal glandular hyperplasia: it is distinguished in simple, complex
or atypical. The atypical one precludes endometrioid adenocarcinoma which is the
most frequent endometrial tumor.
• Endometrial polyps are other hyperplastic diseases but they are different from
cervical polyps because the latter have a genesis especially of inflammatory
type, while those of the body of the uterus are due to a persistence of
estrogenic stimulation. In some women, persistence is iatrogenic because
postmenopausal hormone stimulation is maintained, while in other women, even
older women, there is a persistence of the ovarian stroma that in some way also
leads to a greater production of estrogen in postmenopausal women (these women
they show breasts and uterus similar to those of a woman of childbearing age and
are women at greater risk for neoplastic diseases both of the breast and of the
body of the uterus).
• Estrogen-dependent endometrial carcinoma is the most common carcinoma. Some
adenocarcinomas that are not of an endometrioid nature and which are less
frequent can also affect the body of the uterus. Finally we have both benign and
malignant mesenchymal tumors, which are the most frequent tumors of the uterine
body.
They can be:
• Bacterial endometritis, which develops when the bacteria pass the
cervical barrier in the course of vaginitis or cervicitis or for postpartum
complications;
• Non-specific chronic endometritis, a bit more rare, may be due to
contraceptive intrauterine devices that cause inflammation, or other factors
that cause nonspecific inflammation;
• Specific endometritis, such as the tuberculous endometritis.
Cytomegalovirus endometritis may be present in immunosuppressed women.
Endometritis is especially important for their postpartum component. The
endometrial dysfunction determines symptoms that mainly affect the cycle
disorders: instead of normal menstruation we can have bleeding that then stop or
repeated bleeding, like two or three apparent periods in a month because there
is no synchronism in the answer to hormonal stimulation.
As regards the group of hyperplasias we find lesions of different types
ranging from benign to pre-cancerous; the symptom is the bleeding in post
menopause, a sign certainly serious but at the same time precocious because
anything that makes a postmenopausal endometrium bleed is still in a phase so
early that it can be treated surgically with the healing of the subject.
Hyperplasia is distinguished in simple, complex or atypical.
Atypical hyperplasia strongly recalls endometrial cancer even if it is
not yet cancer. In the presence of bleeding, scraping is performed which is a
non-invasive examination and the histological preparation is observed to
diagnose hyperplasia.
In simple hyperplasia we have small, oval glands that are equal to each other as
if they were in the estrogenic phase, even if the woman is in menopause and
should therefore have an atrophic endometrium. Atypical hyperplasia, on the
other hand, is characterized by cells that exhibit nuclear anomalies. However,
the cells of the stroma remain distinct from one another without vessels or
fibrosis; if there were vases and if there were fibrous we would already be
facing a differentiated endometrial carcinoma.
Endometrial polyps (called "polyps of the matrons") normally affect postmenopausal women and cause bleeding: they are structures that are formed in the endometrium and are stimulated by the sex hormones exactly like the hyperplastic endometrial mucosa; this structure can sometimes provoke the contractions of the uterine musculature because the presence of a foreign body is felt and in this case the uterus tends to expel it: so the so-called polyp's birth can be obtained. The architecture of these polyps is a mixture of stroma and glands, the size can vary, the cut is smooth.
Adenocarcinoma is the most common epithelial tumor of the endometrium, it prefers post-menopausal women. Nulliparity is one of the elements that favors its development (as for breast cancer) because there are many cycles without pregnancy and a longer exposure to the estrogenic stimulus.High estrogen blood levels stimulate the endometrial mucosa, which may result in excessive endometrial growth and type 1 endometrial cancer. Conditions such as diabetes, infertility, obesity, and polycystic ovarian syndrome (PCOS) are associated with an increased risk to develop type 1 endometrial carcinoma.
The symptom is, as in hyperplasia, postmenopausal bleeding: when it occurs, we must urgently
proceed to a cavity revision.
The most frequent variety of adenocarcinoma is the estrogen dependent and
represents 85% of all adenocarcinomas: it can be well differentiated, moderately
differentiated or poorly differentiated; other varieties are the serous one,
with clear cells, the poorly differentiated one and all these tumors have a more
unfavorable prognosis.
This tumor hardly goes beyond the endometrial wall because it is a thick and
hard tumor. Sometimes there may be the coexistence of a scaly component: we will
then have the adenosquamous intraepithelial carcinoma, characterized by the same
prognosis because the squamous component does not make it more aggressive.
When we have a stage I, the tumor affects half the thickness of the endometrium
and the postoperative prognosis is excellent; in stage II it reaches the deep
cervical canal; in stage III it is extrauterine, so it affects serous and
attached or pelvic lymph nodes. We will have lymphatic metastasis to the lymph
nodes, the hematogenous ones to the lung because the uterus is tributary of the
inferior cava. Hematogenous metastases in adenocarcinoma are very rare, we find
them more frequently in the mesenchymal malignant tumor of the body of the
uterus.
In the more advanced stages we will have metastases to the bladder, to the
rectum or distant metastases.
Stromal tumors are almost all constituted by leiomyoma: very frequent noise,
almost all women have some, it is asymptomatic and does not create problems. In
some cases, however, it tends to grow and disturbs the menstrual cycle: the
symptom may be bleeding and in some cases menorrhagia. The menorrhagia is due to
the disorder created by the tumor, in the submucosa, in the process of
hemostatic contraction of the uterus: therefore, not being adequately hemostasis,
the menstruation is much more abundant. Pain can be associated with a sense of
pressure and heaviness, sometimes we also have compressive symptoms on the
bladder and therefore polychrosis.
The headquarters is:
-sottomucosa, the most frequent;
-intramural, in the thickness of the wall;
- sub-acute, which does not create a disturbance, so it is asymptomatic;
-treatment, inside the wide ligaments.
Sometimes the leiomyoma can be born thanks to the contractions of the uterus
that make it slide beyond the cervical canal.
Among the varieties of leiomyoma we distinguish the plastic, the one with
mitotic activity, the atypical or bizarre, the apoplectic one in which there are
regressive phenomena.
These tumors can undergo cystic degeneration and become softer.
We generally distinguish leiomyoma from leiomyosarcoma by counting
mitosis: if there are more than two or three mitoses per field at high
magnification or 15 mitoses for 10 fields (therefore more than one per field) we
can hypothesize that it is a very differentiated leiomyosarcoma not a bizarre,
lively and polymorphic leiomyoma.
Leiomyosarcoma is a rare tumor, with a frequency of about 1 in 800; it can be
asymptomatic, has a rapid growth because the mitotic index is high and therefore
the ultrasound monitoring can allow to identify lesions that grow quickly; It is
soft at palpation, has a macroscopic necrotic appearance in fish meat. We can
observe cell polymorphisms.
indice dei tumori