ENDOMETRIAL

BIOPSY
INTERPRETATION
-Endometrium is mucosal lining of uterus,
provides environment for fetal development.

-Endometrium is variable in thickness, measuring

between 1 and 5 mm at different stages of
menstrual cycle.
Endometrium is divided into three
histologically and functionally distinct
layers-

1. Stratum Basalis layer- Deepest and basal layer of endometrium,

not shed during menstruation.

2. Stratum Spongiosum- Broad intermediate layer. It is characterised

by stroma with a spongy appearance.

3. Stratum Compactum- Thinner superficial layer , which has

compact stromal appearance.
LAYERS OF ENDOMETRIUM-
 EPITHELIAL SURFACE OF ENDOMETRIUM-
Epithelium is tall and columnar in form, some of cells bear cilia and remainder having surface microvilli.
The cycle of changes in the endometrium
proceeds through three distinct phases-
1. Menstruation phase
2. Proliferation phase
3. Secretion phase

. These changes involve both the epithelium

and supporting stroma.
Endometrium thickness-
* Proliferative phase = up to 4-5 mm
* Secretory phase= up to7-8 mm
*In pregnant women= >8mm
*In post menopausal women= < 4-5mm
Indication of endometrial biopsy-

1. Determine the cause of abnormal uterine

bleeding.
2. Status of endometrium in infertile patients.
3. Assessment of response of the endometrium
to hormone treatment.
4. In post menopausal bleeding
5. Cancer screening
Contraindication of endometrial biopsy-

1. Pregnancy
2. Cervical stenosis
3. Coagulopathy
4. Obstructing cervical lesion
Endometrial biopsy taken at-
Secretory phase

- In evaluating any endometrial specimen, an

adequate clinical history is important,
including the age of patient and reason of
biopsy, last menstrual period and length of
menstrual cycle, menopausal status, and any
medication history.
Adequate endometrial biopsy-

An adequate sample as one or more pieces

of endometrium large enough to determine
the glands to stroma ratio and endometrial
morphological features.
It is adequate endometrial biopsy having
same glands and stromal ratio
Inadequate endometrial biopsy sample-

1. If biopsy taken after menses

2. Atrophic or scarred uterus
3. Denuded endometrium
4. Hypoestrogenic state
5. Prolonged uterine bleeding

( If sample consisting only of blood or cervical mucous with

fragments of benign endocervical, or a large amount of blood.)
SCANTY ENDOMETRIAL BIOPSY
Procedure of endometrial biopsy-

Curetting ( D and C)
Pipelle biopsy
Hysteroscopy and direct biopsy
Endometrial cytology
DISTINCT PHASES OF
ENDOMETRIUM-

. Menstrual phase
. Proliferative phase
. Secretory phase
Endometrium, the onset of menstruation- Characterised bt stromal anad glandular
breakdown
A and B- Stromal cells disaggregate and the endometrial glands collapse.
C- Nuclear debris of endometrial cells.
The stroma is condensed and collapsed, the stromal cells
aggregate into tightly packed balls and separate from glands.
This image include presence of necrotic debris, neutrophil
infiltration, interstitial hemorrhage and fibrin deposition.
Apoptotic bodies identified within both glands and stroma.
PROLIFERATIVE PHASE
Straight tubular glands , proliferating glandular epithelium is
seen to consist of columnar cells with basally located nuclei
exhibiting prominent nucleoli.
Mitotic figures can be seen in both glands and stroma.
SECRETORY ENDOMETRIUM
Coiled appearance of glands , basal vacuolation of the
cells
Angulated glands, stromal oedema, absent mitosis,
intraluminal secretion.
Glands are closely packed, having saw-tooth appearance of glands and
containing cupios thick glycogen end glycogen-rich secretions and
predecidual stromal changes increase.
POST MENOPAUSAL ENDOMETRIUM-

* The age of menopause with cessation of

ovulation and resultant diminution of hormone
production by the ovaries is variable.

* Endometrium become thin and atrophic.

POST-MENOPAUSAL ENDOMETRIUM
The glands do not exhibit proliferative activity and vary from
consisting entirely of small widely spaced atrophic tubules to
cystically dilated glands.
Cystically dilated glands
GESTATIONAL ENDOMETRIUM

Pregnancy is characterized by morphological changes involving the endometrial glands and stroma.

1. Glandular ferning with epithelial and intraluminal

secretions.
2. Stromal edema and vascular congestion.
3. Decidual reaction of the stromal cells.
Stromal granulated lymphocytes are present
during early pregnancy.
Arias-stella reaction, which is response to the presence
of trophoblastic tissue in the uterus or at an ectopic site.
Optically clear nuclei due to intranuclear
accumulation of biotin.
 ENDOMETRITIS

- Endometritis is histological diagnosis based upon

the identification within the endometrium of an
abnormal pattern of inflammatory infiltrate.

- Presentation is typically with abnormal uterine

bleeding, most commonly intermenstrual bleeding or
menorrhagia
In acute endometritis predominantly inflammatory cells
are neutrophils and collection of these may be seen
within the glandular lumine, forming microabscesses.
 In chronic endometritis besides plasma cells
there are also increased numbers of lymphocytes.
It is may occur in association with an endometrial hyperplasia
or carcinoma and secondary to cervical stenosis and obstruction.
 ENDOMETRIAL GRANULOMA

- Granuloma within endometrium are rare.

- Most common cause is tuberculosis
- Tb of endometrium usually occurs in premenopausal
women and rare in postmenopausal women.
- Endometrial granuloma in patients with tuberculosis
are noncaseating.
Granulomatous endometritis
DYSFUNCTIONAL UTERINE
BLEEDING-

DUB is abnormal uterine bleeding in

premenopausal women resulting from
alterations in normal cyclical changes in
endometrium
Estrogen related DUB, including endometrium associated with anovulatory cycles-

This endometrium morphology is most common in the perimenopausal years, where it is usually secondary to anovulatory cycles
with resultant absence of development of corpus luteum and decrease progesterone secretion. Here estrogen withdrawal
bleeding occur. The histological feature involve the entire endometrial compartment and are those of proliferative endometrium.
DISORDERED PROLIFERATIVE ENDOMETRIUM

With chronic anovulatory cycles, there is abundant proliferative endometrium, and mild degree of disorganization with
dilated glands may occur. This result in a picture that is neither normal proliferative nor hyperplastic, which is reffered
to as disordered proliferative endometrium. Here glands to stromal ratio is maintained.
There is increased risk of an endometrioid adenocarcinoma
EFFECTS OF EXOGENOUS HPRMONAL
AGENTS AND DRUGS

Exogenous hormonal agents in widespread use for a

variety of indications including contraception,
alleviation of menopausal symptoms, managements of
organic lesions or DUB, treatment of infertility,
management of endometrial hyperplasia or carcinoma.
 ESTROGEN-ONLY HRT

- In women with a uterus, estrogen-only HRT is contraindicated due to increase risk of endometrial proliferative lesion, including hyperplasia and endometrioid
adenocarcinoma.

- The morphological feature in endometrium vary, but there may be proliferative activity, a picture identical to disordered proliferative endometrium, any type of
endometrial hyperplasia, or an endometrioid adenocarcinoma.
COMBINED ESTROGEN AND
PROGESTIN HRT
 PROGESTIN-ONLY COMPOUNDS
Endometrium associated with progestin-only compound.
With progestin-only compounds, the stroma is typically
expanded and composed of predecidualized cells
ENDOMETRIAL POLYP

Polyps occur in pre and postmenopausal women and are thought to be related in some way to hyperestrogenism, possibly originating as a localized hyperplasia of endometrial
basalis secondary to hormonal influence.

An increase incidence of endometrial polyps with HRT, either estrogen only HRT or combined preparation.
Glands are dilated and atrophic or exhibit poorly developed
secretory or proliferative activity and having fibrous stroma.
ENDOMETRIAL POLYP
ARTIFACTS IN ENDOMETRIAL BIOPSY-

There are several common artifacts in endometrial biopsy specimen, these may be misinterpreted as an endometrial hyperplasia
or even a carcinoma.

Telescoping is common artifact in endometrial biopsy specimen.

Results of mechanical disruption of the
glands during biopsy
Since adipose tissue within endometrial biopsy specimen is an
alarming finding that would indicate iatrogenic uterine
perforation.
Artifacts in endometrial bioipsy
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