Endometriosis



Endometriosis


Sharon K. Bihlmeyer, MD





Key Facts


Terminology



  • Diagnosis requires 2 of 3 findings



    • Glands, stroma, or hemorrhage


Etiology/Pathogenesis



  • Unopposed estrogen therapy increased risk of malignancy in endometriosis


Clinical Issues



  • Affects intestinal tract in 15-37% of women with pelvic endometriosis


  • Present with abdominal pain or abdominal mass


  • May present with bowel obstruction or perforation


  • Often eventually require hysterectomy


  • Treat with hormonal suppressive therapy


  • Endometrial glands have malignant potential


  • Endometrioid adenocarcinoma and Müllerian adenosarcoma


Macroscopic Features



  • Involves sigmoid, rectosigmoid colon, or rectum in 70-85%


Microscopic Pathology



  • Endometrioid glands embedded in endometrial stroma


  • Columnar epithelium-lining glands


  • Stroma composed of densely packed small fusiform cells


  • Marked concentric smooth muscle hyperplasia and hypertrophy


  • CD10 marks normal, ectopic, and neoplastic endometrial stromal cells







Hematoxylin & eosin at low power shows endometriosis involving muscularis propria of the colon. Note the lobular configuration of glands with surrounding cellular stroma image.






Hematoxylin & eosin shows endometriosis involving the colonic mucosa and mimicking an adenoma (low-grade dysplasia). It can be difficult to correctly identify as endometriosis on biopsy alone.


TERMINOLOGY


Definitions



  • Endometrial glands and stroma outside of uterus



    • Diagnosis requires 2 of 3 findings



      • Glands, stroma, or hemorrhage


  • Endosalpingiosis is endometriosis without stroma (just glands lined by ciliated tubal-type epithelium)


ETIOLOGY/PATHOGENESIS


Developmental Anomaly



  • Theory: Endometriosis due to Müllerian rests outside of uterus



    • Rests develop with hormonal stimulation


  • Theory: Backwash of uterine contents through fallopian tubes (retrograde menstruation)



    • Backwash → deposits outside of uterus, which develop into endometriosis


Environmental Exposure



  • Unopposed estrogen therapy increases risk of malignancy in endometriosis


CLINICAL ISSUES


Epidemiology



  • Incidence



    • Affects 2-22% of asymptomatic women


    • Incidence in women with dysmenorrhea is 40-60%


    • Affects intestinal tract in 15-37% of women with pelvic endometriosis


  • Age



    • Reproductive age


    • Peaks at age 40


    • Postmenopausal


  • Gender



    • Women


Presentation



  • Abdominal pain


  • Deep mass


  • Hematochezia


  • Bowel obstruction


  • Bowel perforation


  • May be asymptomatic


Natural History



  • May cause bowel perforation, more commonly seen in pregnancy


  • Bowel obstruction may ensue


  • Usually associated with infertility


Treatment



  • Surgical approaches



    • Surgical management for perforation or obstruction usually requires partial colectomy


    • Laparoscopic approaches with superficial or partial-thickness excisions


    • Often eventually require hysterectomy


  • Adjuvant therapy



    • Norgestrel intrauterine device


  • Drugs



    • Hormonal suppressive therapy



      • Nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives are initial approach


      • Progestins


      • Gonadotropin-releasing hormone agonists


Prognosis



  • May be difficult to preserve fertility


  • Endometrial glands have malignant potential



    • May have glandular atypia


    • Hyperplasia


    • Endometrioid adenocarcinoma and Müllerian adenosarcoma



IMAGE FINDINGS


General Features

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Jul 6, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Endometriosis

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