Endometrium

12019/4/ Endometrium - Libre Pathology
Endometrium
From Libre Pathology
The endometrium is typically biopsied because of abnormal bleeding. Endometrial hyperplasia and endometrial
carcinoma are dealt with in separate articles. An overview of gynecologic pathology is in the gynecologic
pathology article.
Contents
1 Indications for endometrial biopsy
1.1 Endometrial thickness on ultrasound
2 Normal microscopic findings
2.1 Glandular telescoping
2.2 Endometrial gland compression artifact
2.2.1 Image
2.2.2 Micro
2.2.3 See also
2.3 Endocervical epithelium versus endometrial epithelium
2.3.1 Table
2.3.2 List
2.3.3 Images
2.4 Metaplasias of the endometrium
3 Tamoxifen effects
4 Inadequate endometrial biopsy
4.1 Sign out
4.1.1 No stroma
4.1.2 Proliferative without definite stroma
4.1.3 Possible endometrium - insufficient
4.1.4 No endometrium
4.1.5 No tissue
5 Overview
5.1 A simple approach
5.1.1 Low power
5.1.2 High power
5.2 Tabular summary
6 Normal endometrium
6.1 Proliferative phase endometrium
6.2 Secretory phase endometrium
6.3 Menstrual endometrium
6.3.1 General
6.3.2 Microscopic
6.3.2.1 Images
6.3.3 Sign out
6.3.3.1 Block letters
6.3.3.2 Consistent with menstrual endometrium
6.3.3.3 Late menses
7 Specific entities/abnormalities
7.1 Adipose tissue on endometrial biopsy
7.1.1 General
https://librepathology.org/w/index.php?title=Endometrium&printable=yes 1/15
7.1.2 Microscopic
7.1.2.1 Images
7.1.3 Sign out
7.2 Arias-Stella reaction
7.3 Endometritis
7.4 Benign endometrial polyp
7.5 Anovulatory endometrium
7.6 Disordered proliferative endometrium
7.7 Endometrium with changes due to exogenous hormones
7.8 Atrophic endometrium
7.9 Ablated endometrium
7.10 Endometrium with squamous morules
7.11 Endometrium with psammoma bodies
7.12 Endometrial hyperplasia
7.13 Endometrial carcinoma
8 See also
9 References
Indications for endometrial biopsy

Abnormal bleeding:
Abnormal uterine bleeding (AUB).

Dysfunctional uterine bleeding, abbreviated DUB, is diagnosed if other causes of bleeding are
excluded.
DUB may get a D&C if they fail medical management.[1]
Post-menopausal bleeding.
Other indications:[2]
Products of conception - dealt with in a separate article.

Dating of endometrium - infertility work-up.
Endometrial thickness on ultrasound
A thin endometrium on ultrasound has a very low risk of malignancy.[3]
Normal microscopic findings

Endometrium - consists of:
1. Epithelium (endometrial glands).

2. Stroma (endometrial stroma).
In endometrial biopsies:
Endocervical glands are commonly seen, as is endocervical mucous.

This is 'cause the gynecologist scrapes some off on the way in or out.
Glandular telescoping
AKA gland-within-a-gland.
AKA gland intussusception.
AKA telescoping.
Considered an artifact of tissue processing, i.e. normal.[4]
Image:
Telescoping (bmjjournals.com) (http://jcp.bmjjournals.com/content/59/8/801/F3.large.jpg).[4]
Endometrial gland compression artifact

AKA compression artifact.
Gland moulding.
Tearing of tissue around the compressed glands - key feature.
Usually at the edge of a tissue fragment.
DDx:
Focal complex endometrial hyperplasia.
Image
Gland compression (bmjjournals.com) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/figure/fig
4/).[4]
Micro
An increased gland density is seen focally, at the edge of one tissue fragment, in association with tearing of the
stroma (compression artifact).
See also
Endometrial gland coiling.
Endocervical epithelium versus endometrial epithelium

Table
Feature Endometrial Endocervical Tubal metaplasia

Cytoplasmic staining usu. hyperchromatic +/-vacuoles clear or light eosinophilic hyperchromatic
Nucleus-to-cytoplasm ratio moderate to high (1:2) low (often 1:3) high (1:1)
Surface features villi
Associated stroma cellular, hyperchromatic inflamed, less cellular variable
List
Endocervical:
Less hyperchromatic.
Nuclei round & small.
Cell borders usually well-defined.
Endometrial:
More hyperchromatic.
Nuclei columnar.
Images
Endocervical and Endocervical and

endometrial epithelium endometrial epithelium
- low mag. (WC) - high mag. (WC)
Metaplasias of the endometrium

The big table of metaplasias - adapted from Nicolae et al.:[5]
Risk of
Metaplasia Subtypes Microscopic Notes Image
malignancy
Morules - nearly always
frequent -
usu. lumped
endometrial
together with
hyperplasia
Ciliary - ciliated cells tubal, unopposed
(complex and
estrogen,
simple),
endometriosis
adenocarcinoma
usu. lumped frequent (complex
ciliated cells, together with only) - endometrial
complex, secretory cell, ciliary, hyperplasia
Tubal
simple intercallary unopposed (complex and
cells estrogen, seen in simple),
endometriosis adenocarcinoma
complex, frequent (complex
Mucinous
simple only)
Squamous - rare
Papillary
syncytial
- rare
change
(surface)
Eosinophilic,
oxyphilic, not known
oncocytic
Clear cell
- not reported
(secretory)
osseous,
cartilaginous,
Stromal
adipose, smooth not reported
metaplasia
muscle, myoid,
sex-cord like
Tamoxifen effects
Endometrial hyperplasia.
Endometrial cancer.
Endometrial polyps.
Atrophy.
Inadequate endometrial biopsy

Endometrial biopsies often have scant tissue.
This is normal in post-menopausal women.

Ideally, the biopsy should have some endometrial stroma.
Without stroma it is not possible to assess the gland-to-stroma ratio.
Sign out
No stroma
ENDOMETRIUM, BIOPSY:
- VERY SCANT STRIPPED NON-PROLIFERATIVE COLUMNAR EPITHELIUM, PROBABLY FROM THE LOWER UTERINE SEGMENT.
- NO DEFINITE ENDOMETRIAL STROMA, SEE COMMENT.
- STRIPPED ENDOCERVICAL EPITHELIUM AND ENODOCERVICAL MUCOSA WITHIN NORMAL LIMITS.
- MUCOUS.
COMMENT:
A re-biopsy should be considered within the clinical context.
- VERY SCANT STRIPPED EPITHELIUM PROBABLY FROM THE LOWER UTERINE SEGMENT.
- NO DEFINITE ENDOMETRIAL STROMA.
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- SMALL FRAGMENTS OF DETACHED BENIGN SQUAMOUS EPITHELIUM.
COMMENT:
A re-biopsy should be considered within the clinical context.
- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM AND DETACHED NON-PROLIFERATIVE ENDOMETRIAL GLANDS.
- ASSESSMENT LIMITED AS VERY SCANT ENDOMETRIAL STROMA IS PRESENT.
- ENDOMETRIUM: STRIPS OF EPITHELIUM, NON-PROLIFERATIVE.
- ENDOCERVIX: SCANT BENIGN EPITHELIUM.
- EXOCERVIX: SCANT BENIGN EPITHELIUM.
- OTHER: TUBAL METAPLASIA.
- STRIPS OF NON-PROLIFERATIVE ENDOMETRIUM.
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
- SCANT BENIGN SQUAMOUS EPITHELIUM.
- TUBAL METAPLASIA.
- STRIPS OF BENIGN ENDOMETRIAL EPITHELIUM/TUBAL METAPLASIA, NON-PROLIFERATIVE.
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
- RARE SQUAMOUS METAPLASTIC CELLS.
Proliferative without definite stroma
- FRAGMENTS OF DETACHED SQUAMOUS EPITHELIUM, ENDOCERVICAL EPITHELIUM AND FOCALLY PROLIFERATIVE ENDOMETRIAL GLANDS.
- ASSESSMENT LIMITED AS NO DEFINITE ENDOMETRIAL STROMA IS PRESENT.
Possible endometrium - insufficient
ENDOMETRIUM, ASPIRATION:
- ONE MINUTE STRIP OF POSSIBLE NONPROLIFERATIVE ENDOMETRIAL EPITHELIUM, INSUFFICIENT
FOR ADEQUATE DIAGNOSTIC ASSESSMENT.
- VERY SCANT BENIGN STRIPPED ENDOCERVICAL EPITHELIUM.
- VERY SCANT METAPLASTIC SQUAMOUS EPITHELIUM.
COMMENT:
Re-biopsy is advised.
- BENIGN STRIPPED ENDOCERVICAL EPITHELIUM AND BENIGN INFLAMED ENDOCERVICAL MUCOSA.
- NO DEFINITE ENDOMETRIUM WITH STROMA, INADEQUATE SPECIMEN.
No endometrium
- SPECIMEN INADEQUATE; NO ENDOMETRIUM IDENTIFIED.
- ONE VERY TINY FRAGMENT OF ENDOCERVICAL MUCOSA WITHOUT APPARENT PATHOLOGY.
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- MICROGLANDULAR HYPERPLASIA AND FOCAL SQUAMOUS METAPLASIA.
- NO DEFINITE ENDOMETRIUM IDENTIFIED, SUGGEST RE-BIOPSY.
No tissue
- NO TISSUE IDENTIFIED ON MICROSCOPY.
Overview
A simple approach
Low power
1. Decide whether you are looking at endometrium.

2. Is the gland-to-stroma ratio normal?
1:3 is normal.
If the gland-to-stroma ratio is increased... think complex endometrial hyperplasia.
If the glands are fused to one another or cribriform... think endometrial carcinoma.
3. Glands round?
Round is normal.
Irregular - may be seen in secretory phase endometrium, menses, disordered proliferative
endometrium (focal), simple endometrial hyperplasia (diffuse).
4. Glands pseudostratified?
Pseudostratified glands are normal in the proliferative phase endometrium, hyperplasias, malignancy.
5. Balls of cells?
Blue - likely menstrual (stromal condensation).
Pink - consider leiomyoma, squamous morules (associated with endometrial hyperplasia, endometrioid
endometrial carcinoma, may be benign).
High power
1. Mitoses present in the glands?

Present in the proliferative phase, hyperplasias, malignancies.
2. Mitoses present in the stroma?
Present in the proliferative phase, hyperplasias, malignancies.
3. Mucous present in the glands?
Present in the secretory phase.
4. Inflammatory cells present?
Some are normal during menses.
Tabular summary
Key feature Additional

Diagnosis DDx Other Image
(low power) features
disordered
proliferative
phase, simple
endometrial
Proliferative round spaced hyperplasia,
mitoses in glands
phase pseudostratified complex normal
and stroma
endometrium glands endometrial
hyperplasia, Proliferative
early secretory endometrium. (WC)
phase
endometrium
endometrial
decidual changes
hyperplasia with
irregular glands (nucleus central,
Secretory secretory
with secretions eosinophilic
phase changes, late normal
or simple glands cytoplasm, well-
endometrium proliferative
with vacuoles defined cell
phase
borders)
endometrium
Secretory phase
endometrium. (WC)
nonproliferative
glands,
disordered
Menstrual stromal stromal/epithelial
proliferative normal Image
endometrium condensation neutrophils,
phase
glandular cell
apoptosis
disordered
proliferative
polypoid shape
Benign fibrous stroma, endometrium DPE and SEH
(epithelium on 3
endometrial muscular blood (DPE), simple do not occur in
sides), +/-gland
polyp vessels endometrial polyps
dilation
hyperplasia Benign endometrial
(SEH) polyp. (WC)
Key feature Additional

Diagnosis DDx Other Image
(low power) features
decidualized
inactive glands secretory phase
Endometrium stroma (nucleus
(round/ovoid endometrium,
with changes central,
glands, simple endometrial variant of
due to eosinophilic
cuboidal hyperplasia with normal
exogenous cytoplasm, well- Endometrium with
epithelium, no secretory
hormones defined cell changes due to
mitoses) changes
borders) exogenous hormones.
(WC)
no nuclear atypia,
serous normal
Atrophic nonproliferative often without
endometrial postmenopausal
endometrium glands appreciable
carcinoma finding
stroma
Inactive endometrium.
(WC)
simple
proliferative
no nuclear atypia, endometrial
Disordered focally dilated & can be thought
+/-evidence of hyperplasia,
proliferative irregular glands of a waffle
shedding (stromal proliferative
endometrium (usu. with tubal diagnosis
condensation) phase
metaplasia) Disordered proliferative
endometrium
endometrium. (WC)
Normal endometrium
Proliferative phase endometrium
Main article: Proliferative phase endometrium
Secretory phase endometrium

Main article: Secretory phase endometrium
Menstrual endometrium
General
Technically part of the proliferative phase or follicular phase.
Microscopic
Features:
Proliferative endometrium (mitoses).[6]

Apoptotic cells common.[7]
Tightly packed cellular balls of stromal cells with nuclear moulding.
Known as "blue balls".
Tightly packed cellular stromal cells known as "stromal condensation".
Inflammation, especially abundant neutrophils.
DDx:
Small cell carcinoma - proliferative activity in the moulded (stromal condensation-like) cells.
Anovulatory endometrium - less neutrophils.
Images
Endometrial stromal
condensation - high
mag. (WC/Nephron)
www:
Menstrual endometrium - several images (gfmer.ch) (http://www.gfmer.ch/selected_images_v2/detail_list.ph

p?cat1=5&cat2=26&cat3=0&cat4=3&stype=n).
Menstrual phase endometrium (stonybrook.edu) (http://www.hsc.stonybrook.edu/gyn-atlas/UT3415B.htm).
Sign out
Endometrium, Biopsy:
- Consistent with menstrual endometrium.
-- Weakly proliferative endometrial glands with apoptosis, fragmented.
-- Abundant balls of condensed non-proliferative endometrial stroma and blood.
Block letters
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM:
-- STRIPPED WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- ABUNDANT NEUTROPHILS AND BLOOD.
- CONSISTENT WITH MENSTRUAL PHASE ENDOMETRIUM:
-- WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
-- BALLS OF CONDENSED ENDOMETRIAL STROMA.
-- BLOOD.
- VERY WEAKLY PROLIFERATIVE ENDOMETRIAL GLANDS WITH NEUTROPHILS AND APOPTOSIS.
- BALLS OF CONDENSED ENDOMETRIAL STROMA AND BLOOD.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
Consistent with menstrual endometrium
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH PSEUDOSTRATIFIED
GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
AND BLOOD).
- CONSISTENT WITH MENSTRUAL ENDOMETRIUM (FRAGMENTED ENDOMETRIUM WITH SIMPLE
GLANDS WITH APOPTOTIC CELLS, ABUNDANT NEUTROPHILS, CONDENSED ENDOMETRIAL STROMA
(FOCAL) AND BLOOD).
Late menses
- ENDOMETRIAL GLANDS WITH APOPTOTIC CELLS, INFILTRATING NEUTROPHILS,
AND GLANDULAR PROLIFERATIVE ACTIVITY.
- BALLS OF CONDENSED ENDOMETRIAL STROMA.
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- NEGATIVE FOR HYPERPLASIA.
COMMENT:
The findings are most in keeping with late menstrual endometrium.
Specific entities/abnormalities
Adipose tissue on endometrial biopsy
AKA fat on endometrial biopsy.
General
Benign.
Raises the possibility of perforation - should prompt a phone call to the clinician.
Microscopic
Features:
Adipose tissue, benign - key finding.

Definite endometrium.
DDx:
Extraneous tissue.
Tissue floater.
Pick-up.
Images
EMB with fat - EMB with fat - EMB with fat - high
intermed. mag. intermed. mag. mag.
Sign out
- BENIGN ADIPOSE TISSUE, SEE COMMENT.
- PROLIFERATIVE PHASE ENDOMETRIUM.
COMMENT:
The presence of adipose tissue raises the possibility of perforation.
The findings were briefly discussed with Dr. Brown on November 6, 2009.
Arias-Stella reaction
Main article: Arias-Stella reaction
Benign atypical endometrial changes associated with chorionic tissue -- may be seen in a completely normal
pregnancy and misdiagnosed as a malignancy.[8]
Endometritis
Main article: Endometritis
Benign endometrial polyp

Main article: Benign endometrial polyp
Anovulatory endometrium
Main article: Anovulatory endometrium
Disordered proliferative endometrium

Abbreviated DPE.
AKA endometrium with disordered proliferative phase.
AKA disordered proliferative phase.
Main article: Disordered proliferative endometrium
Endometrium with changes due to exogenous hormones

Main article: Endometrium with changes due to exogenous hormones
Atrophic endometrium
AKA atrophy of the endometrium.
AKA endometrial atrophy.
Main article: Inactive endometrium
Ablated endometrium
Main article: Ablated endometrium
Endometrium with squamous morules

Main article: Endometrium with squamous morules
Endometrium with psammoma bodies

Main article: Endometrium with psammoma bodies
Endometrial hyperplasia
Main article: Endometrial hyperplasia
Can be thought of as a precursor lesion for endometrial carcinoma.
It comes in two main flavours:
1. Simple.
2. Complex.
Each flavour may or may not have nuclear atypia.
Endometrial carcinoma
Main article: Endometrial carcinoma
Endometrial cancer is the most common gynecologic malignancy (in the USA).[9]
See also
Uterine tumours.
Gynecologic pathology.
Psammoma bodies.
References
spectrum of altered differentiation.". J Clin Pathol 64
1. URL: http://emedicine.medscape.com/article/257007- (2): 97-106. doi:10.1136/jcp.2010.085555 (http://dx.do
treatment. Accessed on: 15 July 2010. i.org/10.1136%2Fjcp.2010.085555). PMID 21126963
2. Mazur, Michael T.; Kurman, Robert J. (2005). (http://www.ncbi.nlm.nih.gov/pubmed/21126963).
Diagnosis of Endometrial Biopsies and Curettings: A 6. Tadrous, Paul.J. Diagnostic Criteria Handbook in
Practical Approach (2nd ed.). Springer. pp. 1. Histopathology: A Surgical Pathology Vade Mecum
ISBN 978-0387986159. (1st ed.). Wiley. pp. 237. ISBN 978-0470519035.
3. Gambacciani, M.; Monteleone, P.; Ciaponi, M.; Sacco, 7. Spencer, SJ.; Cataldo, NA.; Jaffe, RB. (May 1996).
A.; Genazzani, AR. (Aug 2004). "Clinical usefulness of "Apoptosis in the human female reproductive tract.".
endometrial screening by ultrasound in asymptomatic Obstet Gynecol Surv 51 (5): 314-23. PMID 8744416 (h
postmenopausal women.". Maturitas 48 (4): 421-4. ttp://www.ncbi.nlm.nih.gov/pubmed/8744416).
doi:10.1016/j.maturitas.2003.10.006 (http://dx.doi.org/ 8. Arias-Stella, J. (Jan 2002). "The Arias-Stella reaction:
10.1016%2Fj.maturitas.2003.10.006). PMID 15283934 facts and fancies four decades after.". Adv Anat Pathol
(http://www.ncbi.nlm.nih.gov/pubmed/15283934). 9 (1): 12-23. PMID 11756756 (http://www.ncbi.nlm.ni
4. McCluggage, WG. (Aug 2006). "My approach to the h.gov/pubmed/11756756).
interpretation of endometrial biopsies and curettings.". 9. Lu KH (April 2009). "Management of early-stage
J Clin Pathol 59 (8): 801-12. endometrial cancer". Semin. Oncol. 36 (2): 137–44.
doi:10.1136/jcp.2005.029702 (http://dx.doi.org/10.113 doi:10.1053/j.seminoncol.2008.12.005 (http://dx.doi.or
6%2Fjcp.2005.029702). PMID 16873562 (http://www. g/10.1053%2Fj.seminoncol.2008.12.005).
ncbi.nlm.nih.gov/pubmed/16873562). PMID 19332248 (http://www.ncbi.nlm.nih.gov/pubme
5. Nicolae, A.; Preda, O.; Nogales, FF. (Feb 2011). d/19332248).
"Endometrial metaplasias and reactive changes: a
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12019/4/ Endometrium - Libre Pathology

Indications for endometrial biopsy

Abnormal uterine bleeding (AUB).

Products of conception - dealt with in a separate article.

Endometrial thickness on ultrasound

A thin endometrium on ultrasound has a very low risk of malignancy.[3]

Normal microscopic findings

1. Epithelium (endometrial glands).

Endocervical glands are commonly seen, as is endocervical mucous.

Considered an artifact of tissue processing, i.e. normal.[4]

Telescoping (bmjjournals.com) (http://jcp.bmjjournals.com/content/59/8/801/F3.large.jpg).[4]

Endometrial gland compression artifact

Focal complex endometrial hyperplasia.

Endometrial gland coiling.

Endocervical epithelium versus endometrial epithelium

Feature Endometrial Endocervical Tubal metaplasia

Endocervical and Endocervical and

Metaplasias of the endometrium

Morules - nearly always

Inadequate endometrial biopsy

This is normal in post-menopausal women.

Proliferative without definite stroma

Possible endometrium - insufficient

1. Decide whether you are looking at endometrium.

1. Mitoses present in the glands?

Key feature Additional

Key feature Additional

Secretory phase endometrium

Technically part of the proliferative phase or follicular phase.

Proliferative endometrium (mitoses).[6]

Menstrual endometrium - several images (gfmer.ch) (http://www.gfmer.ch/selected_images_v2/detail_list.ph

Consistent with menstrual endometrium

Adipose tissue, benign - key finding.

Benign endometrial polyp

Disordered proliferative endometrium

Main article: Disordered proliferative endometrium

Endometrium with changes due to exogenous hormones

Main article: Inactive endometrium

Endometrium with squamous morules

Endometrium with psammoma bodies

Can be thought of as a precursor lesion for endometrial carcinoma.

It comes in two main flavours:

Each flavour may or may not have nuclear atypia.

Retrieved from "https://librepathology.org/w/index.php?title=Endometrium&oldid=47031"

Categories: Gynecologic pathology Endometrium

This page was last modified on 2 March 2017, at 10:37.

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