A 26 year old female presents with a chief complaint of menstrual bleeding 10 days prior to the usual onset of menses. She states that her last menstrual period was heavier than usual. The physician examines her and performs a pregnancy test (which is negative) then concludes that she is probably experiencing dysfunctional bleeding due to anovulation. If an endometrial biopsy were performed, which of the following would be the most likely histologic appearance of this type of endometrium?
The most common cause of dysfunctional uterine bleeding is anovulation. This is caused by excessive and prolonged estrogen effect without the postovulatory progesterone effect. This occurs most often around menarche and menopause, when subtle hormonal imbalances commonly occur. An estrogenic stimulation causes the endometrial glands to proliferate. Persistent proliferation without a progesterone phase will eventually break down and bleed even though there is no secretory change present and the stroma is not menstrual. That is why this is called "anovulation bleed," because it is a non-ovulatory bleed that may seem like normal menstruation. Asynchronous secretory endometrium refers to secretory endometrium that has a mismatch of 2 or more days between the glands and the stroma. For example, the glands may be at day 17 while the stroma shows more maturity, corresponding to day 22. This is a type of dysfunctional ovulatory bleeding and clinically presents with infeility. It is usually due to an inadequate luteal phase because the corpus luteum is not producing enough progesterone even though ovulation has occurred. Decidualized stroma with inactive glands is the common histologic appearance of patients taking oral contraceptives. These patients have asynchronous glands and stroma. The glands are usually not active and the stroma appears to be ready for implantation. This reves to normal with discontinuation of oral contraceptives. Early proliferative endometrium and late secretory endometrium (choice D) are physiologic phases of the normal menstrual cycle. Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 8. Abnormal Uterine Bleeding. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.
Asynchronous secretory endometrium
Decidualized stroma with inactive glands
Early proliferative endometrium
Proliferative endometrium with stromal breakdown