Page 747 - Textbook of Pathology, 6th Edition

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Figure 24.9 Sequential physiologic patterns of endometrium.

Oestrogen and Progesterone as it is generally called, is thin and atrophic with inactive
glands and fibrous stroma. However, some of the glands
Oestrogen produces the characteristic changes of may show cystic dilatation. Sometimes, retrogressive CHAPTER 24
proliferative phase at the time of menopause and in young hyperplasia is seen which is characterised by Swiss-cheese
women with anovulatory cycles as occurs in Stein-Leventhal pattern of glands resembling endometrial hyperplasia but
syndrome. The therapeutic addition of progesterone composed of inactive retrogressive lining epithelium. There
produces secretory pattern in an oestrogen-primed is intermingling of cystic and dilated glands with small and
endometrium. Oestrogen-progesterone combination atrophic glands. Postmenopausal endometrium may show
hormonal therapy is employed for control of conception. actual active hyperplasia under the stimulatory influence
The sequential type of oestrogen-progesterone oral of post-menopausal oestrogen originating from the ovary
contraceptives act by producing prolonged oestrogenic or adrenal gland.
effect past the time of ovulation and implantation so that
the secretion is delayed until about 25th day, followed by
progestational effect and shedding. Repeated cyclic DYSFUNCTIONAL UTERINE BLEEDING (DUB) The Female Genital Tract
administration with combination therapy such as after long-
term use of oral contraceptives produces inactive-looking, Dysfunctional uterine bleeding (DUB) may be defined as
small and atrophic endometrial glands, and compact excessive bleeding occurring during or between menstrual
decidua-like stroma. periods without a causative uterine lesion such as tumour,
polyp, infection, hyperplasia, trauma, blood dyscrasia or
Pregnancy pregnancy. DUB occurs most commonly in association with
anovulatory cycles which are most frequent at the two
The implantation of a fertilised ovum results in interruption extremes of menstrual life i.e. either when the ovarian
of the endometrial cycle. The endometrial glands are enlarged function is just beginning (menarche) or when it is waning
with abundant glandular secretions and the stromal cells off (menopause). Anovulation is the result of prolonged and
become more plump, polygonal with increased cytoplasm excessive oestrogenic stimulation without the development
termed decidual reaction. About 25% cases of uterine or of progestational phase. The causes for anovulation at diffe-
extrauterine pregnancy show hyperactive secretory state rent ages are as follows:
called Arias-Stella reaction. It is characterised by 1. In pre-puberty: precocious puberty of hypothalamic,
hyperchromatic, atypical, tall cells lining the glands and the pituitary or ovarian origin.
glandular epithelium may show multilayering and budding 2. In adolescence: anovulatory cycles at the onset of
which may be mistaken for an adenocarcinoma. menstruation.
3. In reproductive age: complications of pregnancy, endo-
Menopause
metrial hyperplasia, carcinoma, polyps, leiomyomas and
The onset of menopause is heralded with hormonal adenomyosis.
transition and consequent varying morphologic changes in 4. At premenopause: anovulatory cycles, irregular shedding,
the endometrium. Most commonly, the senile endometrium, endometrial hyperplasia, carcinoma and polyps.