1.

       Case: A 40-year-old G2P2 (2002) consulted at the OPD due to vaginal spotting. An
endometrial biopsy was done using a manual vacuum aspirator (MVA) and the specimen was
sent for histopathologic analysis. The specimen was signed out as a case of endometrial
hyperplasia with atypia.
a.       Discuss the histologic features of the different phases of normal endometrium.
b.      What are the differential diagnoses for a patient of reproductive age having abnormal
uterine bleeding? Discuss the histopathologic features of each.

Answers:
a. Proliferative Phase:
- After the menstrual phase, the uterine mucosa is relatively thin (~0.5 mm)
- During the proliferative phase, the endometrial lining is a simple columnar surface
epithelium and the uterine glands are relatively straight tubules with narrow, nearly
empty lumens
- Mitotic figures can be found among both the epithelial cells and fibroblasts. Spiral
arteries lengthen as the functional layer is reestablished and grows and extensive
microvasculature forms near the surface of the functional layer. At the end of the
proliferative phase, the endometrium is 2 to 3 mm thick.
b. Secretory Phase
- Progesterone stimulates epithelial cells of the uterine glands that formed during the
proliferative phase and these cells begin to secrete and accumulate glycogen, dilating
the glandular lumens and causing the glands to become coiled
- The superficial microvasculature now includes thin-walled, blood-filled lacunae
- The endometrium reaches its maximum thickness (5 mm) during the secretory phase as
a result of the accumulation of secretions and edema in the stroma.
c. Menstruation Phase
- The basal layer of the endometrium, not dependent on the progesterone-sensitive spiral
arteries, is relatively unaffected by these activities. However, major portions of the
functional layer, including the surface epithelium, most of each gland, the stroma and
blood-filled lacunae, detach from the endometrium and slough away as the menstrual
flow or menses.

Differential Diagnosis of Abnormal Uterine bleeding and its histologic features:

1. Anovulatory Cycle- stromal condensation and eosinophilic epithelial metaplasia similar to
those seen in menstrual endometrium. The endometrium however lacks progesterone-
dependent morphologic features such as glandular secretory changes and stromal pre-
decidualization. It is comprised of pseudostratified glands and contains scattered mitotic
figures.
2. Polyp- localized overgrowths of endometrial tissues, containing glands, stroma, and
blood vessels covered with epithelium
3. Adenomyosis- presence of endometrial glands and stroma in the uterine myometrium;
poor definition of endometrial junction with pseudo-widening of the endometrial echo
complex
4. Leiomyoma or fibroids- can be of different types such as subserous, intramural, and
submucous
5. Endometriosis- ectopic endometrial tissues and glands outside the uterus with or without
the presence of hemosiderin.

Carlos D. Achondo Jr.

Clinical Clerk
 6. Endometrial hyperplasia- increased proliferation of endometrial glands relative to stroma,
resulting to an increased gland-to-stroma ratio.

2.       A saline – infusion sonohysterography (SISH) was done on a multiparous patient

complaining of intermenstrual spotting. A dilatation and curettage was done thereafter. The
specimen submitted for study was signed out as endometrial polyp in fragments. Discuss the
histopathologic feature of an endometrial polyp and differentiate it from an endocervical polyp.

Endometrial Polyp- these are exophytic masses of variable size that project into the
endometrial cavity. They can be single or multiple and
are usually sessile. The glands in polyps may be
hyperplastic or atrophic, and may occasionally
demonstrate secretory changes (functional polyps).
Polyps may by become hyperplastic in association
with generalized endometrial hyperplasia and are
responsive to estrogen but show little or no response
to progesterone.

Endocervical Polyp- Endocervical polyps are

common benign exophytic growths that arise within
the endocervical canal. They vary from small, sessile
“bumps” to large polypoid masses that may protrude
through the cervical os. Histologically, they are
composed of a loose fibromyxomatous stroma
covered by mucus-secreting endocervical glands,
often accompanied by inflammation.

3.       A multiparous woman in her early second trimester spontaneously passed out a 15 week
male fetus with several congenital anomalies and a small placenta. Admixed with normal
placental villi are several 0.3 – 0.5 cm cream white grape – like cysts containing clear fluid. A
sample of placental tissue are sent for histopathologic analysis.

a.       Compare histopathologically partial and complete molar pregnancies

b.      Which type of molar pregnancy has a greater predisposition to the development of

choriocarcinoma?

A.

Carlos D. Achondo Jr.

Clinical Clerk
 Complete Mole
- Diffuse swelling of chorionic villi
- Proliferation of trophoblasts
- No fetus or membranes
Partial Mole
- Localized swelling of chorionic villi
- Presence of embryo/fetus or fetal
membranes
- Edematous villi with scalloping
- Presence of normal placental villi with
blood vessels.

B. 15-20% of cases of Complete H. mole is likely to develop into Gestational Trophoblastic

neoplasia such as choriocarcinoma.

4.       A 44 year old G3P2 (2012) has consulted due to gradual abdominal enlargement that is
accompanied by vaginal spotting for the last 1 year. Ultrasound revealed a myomatous mass
measuring 3.0 x 2.0 cm connected posteriorly by a vascular stalk. The patient was advised for
total abdominal hysterectomy (TAHBS). The specimen was signed out as a case of submucous
myoma. Describe the histopathologic features of a leiomyoma and differentiate the types of
leiomyoma.

Carlos D. Achondo Jr.

Clinical Clerk
 LEIOMYOMA: Uterine leiomyoma (commonly called fibroids) is perhaps the most
common tumor in women. They are benign smooth muscle neoplasms that may occur singly,
but more often are multiple. They can occur within the myometrium (intramural), just beneath

the endometrium (submucosal) or beneath the serosa (subserosal). Whatever their size, the
characteristic whorled pattern of smooth muscle bundles on cut section usually makes these
lesions readily identifiable. Large tumors may develop areas of yellow-brown to red softening.
Leiomyomas are typically composed of bundles of smooth muscle cells that resemble the
uninvolved myometrium. Usually, the individual muscle cells are uniform in size and shape and
have the characteristic oval nucleus and long, slender bipolar cytoplasmic processes. Mitotic
figures are scarce. Benign variants of leiomyoma include atypical or bizarre (symplastic) tumors
with nuclear atypia and giant cells, and cellular leiomyomas. Both have a low mitotic index,
helping to distinguish these benign tumors from leiomyosarcomas.

5.       A 42 year old G3P2 (2002) 36 weeks AOG sought consult at the emergency room due to
painless vaginal bleeding. She had a previous cesarean section secondary to non-reassuring
fetal status. Emergency ultrasound revealed a placenta that is densely adherent to the lower
uterine segment, completely covering the endocervical os. A peripartum hysterectomy was
done.

a.       Define the different types of abnormal placentation.

Carlos D. Achondo Jr.

Clinical Clerk
b.      What are the risk factors for the development of placenta accreta syndrome?

ABNORMAL PLACENTATION:

1. Placenta Previa- a condition in which the placenta implants in the lower uterine
segment or cervix, often leading to serious thirdtrimester bleeding. A complete placenta
previa covers the internal cervical os and thus requires delivery via cesarean section to
avert placental rupture and fatal maternal hemorrhage during vaginal delivery.
2. Placenta Accreta- is caused by partial or
complete absence of the decidua, such that
the placental villous tissue adheres directly
to the myometrium, which leads to a failure
of placental separation at birth. It is an
important cause of severe, potentially
lifethreatening postpartum bleeding.

Risk Factors for Placenta Accreta:

- Associated placenta previa
- Prior cesarean delivery
- Classical hysterotomy incision
- Dysfunctional decidual formation also may
follow any other type of myometrial trauma
such as curettage or endometrial ablation
- widespread use of MSAFP and human chorionic gonadotropin (hCG) screening for
neural-tube defects and aneuploidies

7. A specimen designated as “right ovary” is submitted for histopathologic analysis.

Opening the ovary revealed greasy, cream white material with tufts of hair and pieces of
cartilage and tooth. The case is signed out as mature cystic teratoma. Differentiate
between mature and immature cystic teratoma.

TERATOMAS are divided into three categories: (1) mature (benign), (2) immature
(malignant), and (3) monodermal or highly specialized.

Mature (Benign) Teratomas. Most benign

teratomas are cystic and are often referred to as
dermoid cysts, because they are almost always
lined by skin-like structures. Cystic teratomas
are usually found in young women during the
active reproductive years. They may be
discovered incidentally, but are occasionally
associated with clinically important

Carlos D. Achondo Jr.

Clinical Clerk
 paraneoplastic syndromes, such as inflammatory limbic encephalitis, which may remit
upon removal of the tumor.

Benign teratomas are bilateral in 10% to 15% of

cases. Characteristically they are unilocular cysts
containing hair and sebaceous material. Sectioning
reveals a thin wall lined by an opaque, gray-white,
wrinkled epidermis, frequently with protruding hair
shafts. Within the wall, it is common to find grossly
evident tooth structures and areas of calcification.
Microscopically, the cyst wall is composed of
stratified squamous epithelium with underlying
sebaceous glands, hair shafts, and other skin
adnexal structures.

Immature Malignant Teratomas. These are rare

tumors that differ from benign teratomas in that the component tissues resemble
embryonal and immature fetal tissue. The tumor is found chiefly in prepubertal
adolescents and young women, the mean age being 18 years.

The tumors are bulky and have a smooth

external surface and tend to be solid on
sectioning. Hair, sebaceous material,
cartilage, bone, and calcification may be
present, along with areas of necrosis and
hemorrhage. On microscopic examination
there are varying amounts of immature
neuroepithelium, cartilage, bone, muscle,
and other elements. An important risk for
subsequent extraovarian spread is the
histologic grade of tumor (I through III),
which is based on the proportion of tissue
containing immature neuroepithelium.

Carlos D. Achondo Jr.

Clinical Clerk
 References:

Aster. Robbins and Cotran Pathologic Basis of Disease. Ninth edition. Philadelphia, PA:
Elsevier/Saunders, 2015.

Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014.

Carlos D. Achondo Jr.

Clinical Clerk