Hormonal Pathology Of The Uterus

Hormonal influences, both natural and iatrogenic, are implicated in the most frequent health issues of women. Endometrial cancer is now the most common gynecologic cancer in the United States and the industrialized world. This cancer is strongly related to hormonal and metabolic factors. In addition, breast cancer treated with hormone therapy (Tamoxifen) may, in some cases, be associated with uterine pathology. Hormone therapy is used to improve the physiological effects and counteract abnormal and deleterious effects of “natural” hormonal activity. Millions of women receive hormone therapy at some point of their life: using oral contraceptives, reproductive technology, treatment for post-menopausal symptoms, among other uses. This book addresses a range of women’s health issues, from fertility to neoplasms, and their relationship with natural and iatrogenic hormonal effects. Chapters include clinical and pathological descriptions, theoretical and practical medical issues, and original studies and cases. Controversial issues in certain hormone therapies are presented with updated concepts based on clinical studies and novel statistical methods. The book will be useful for specialized and general physicians, oncologists, endocrinologists, researchers, medical students, and others in the field of women’s health.

Changing approaches to diagnosis and clinical management of the uterus are comprehensively examined in this book. It gives a concise update of new concepts in physiology and pathology and their application in clinical practice. The book is designed especially for the gynecologist actively involved in patient care. Topics discussed include the pathophysiology of diethylstilbestrol (DES) changes, the immunology of the uterus, papillomaviruses and cervical neoplasia, endocervical carcinoma, mesenchymal tumors and diagnostic procedures such as colposcopy of the cervix, hysterosalpingography, and magnetic resonance imaging. The status of contemporary management is presented for hysteroscopy and hysteroscopic surgery, the congenital absence of the uterus and vagina, anovulatory dysfunctional uterine bleeding of the adolescent, uterine leiomyomata, genital prolapse, endometrial adenocarcinoma and childhood rhabdomyosarcoma of the vagina and uterus.

As compared with cytology’s use in other organ systems, direct cytological examination of the endometrium is not a widely practiced diagnostic procedure. This is an anomaly, because the endometrium is exceedingly available for cytological sampling, cytological sampling is comparably simple to perform, and, from the patient’s perspective, it is a gentle procedure as compared to other methods of specimen attainment. Over the years, as we personally gained more and more experience with specimen acquisition, processing and interpretation, we have come to look upon endometrial cytology as an effective method for ensuring endometrial normalcy and discovering and diagnosing malignant and premalignant states. In comparing endometrial cytology to endometrial biopsy, we have found that, in samples obtained by individuals experienced in specimen collection, cytology outperforms outpatient biopsy with regard to the patient’s tolerance of the procedure, adequacy of sampling among postmenopausal women, and detection of occult neoplasms. By devising a highly effective technical strategy to ensure the simultaneous creation of cell blocks and cytological samples from a single collection (that is detailed in the technical appendix of this work), we have moved endometrial brush collection into an arena of significance equaling—indeed exceeding—other methods of specimen collection and interpretation. Cytology, even in the absence of cell blocks, performs equally as well as biopsy in detecting outspoken hyperplasia or carcinoma. If nothing else, by reliably identifying benign, normal endometrial states, it serves to exclude more than 70% of women from unnecessary follow up testing with a high degree of confidence. Because brush sampling of the endometrium is limited to a depth of 1.5 to 2 mm, the method is not definitive for the detection of endometrial polyps, fibroids, stromal tumors, or tumors of the uterine wall musculature. However, endometrial cytology is useful for detecting benign estrogen-excess states such as disordered proliferation and various degrees of benign hyperplasia, for separating these states from frankly neoplastic states such as EIN and cancer, but not for subclassifying benign hyperplastic states in the absence of cell block preparations. When endometrial brushing with liquid fixation is used in conjunction with other techniques such as immunohistochemistry, concomitant biopsy or, more practically, hysteroscopy or sonohysterography, endometrial benignancy can be assured with a very high level of confidence (> 99%); indeed, manufacturing concomitant cell blocks of endometrial tissue fragments and using immunohistochemistry in selected cases significantly enhances the diagnostic specificity of the technique. In a woman with a patent cervix, endometrial brushing successfully collects material, even from late postmenopausal atrophic endometrium. It allows for the detection of serious diseases such as endometrial intraepithelial carcinoma under conditions where suction biopsy might miss or otherwise obviate the diagnosis. This work focuses on the background, collection technique, and reliability of endometrial cytology; it then overviews diagnostic criteria and diagnostic pitfalls encountered in the day-to-day practice of the art. Since endometrial cytology interpretation relies on intuiting tissue patterns from cytology preparations, a great deal of time is spent on cytohistological correlations and, where effective as part of a diagnostic strategy, on ancillary immunohistochemical staining. The discussion moves from normal states of the endometrium, through otherwise benign changes induced by an altered hormonal milieu or surface irritants, into neoplastic premalignant and malignant endometrial conditions. Finally, fixative and slide preparation techniques, that we deem as expeditious while serving to get the most information out of an endometrial cytology collection, are discussed in detail for the benefit of those who wish to recapitulate our work in their own practice.

Endometrial cancer remains the most frequent gynaecological cancer in first world countries.This bench book on endometrial pathology distils the current literature to provide a practical text on endometrial pathology. Differential diagnosis is emphasised, and the clinical correlates of pathology are also stressed to make this a clinically useful book.Fully updated and including over 400 colour images, this book provides a valuable resource for the practising pathologist in general and community hospitals as well as in teaching hospitals.