••• Chapter 26^ Benign Disorders of the Upper Genital Tract^265
❍ A 23-year-old woman presents for a primary infertility workup and is found to have a septate uterus. What
treatments can be offered and what are their success rates?
A septate uterus is associated with pregnancy wastage. Only 15% of patients without treatment achieve a term
pregnancy. Most septums can be excised via hysteroscopy. Occasionally, a very large septum may necessitate a Jones
(wedge) metroplasty. Term pregnancy rates of 75% are possible following repair.
❍ A 30-year-old woman presents 6 weeks postpartum from a vaginal delivery with mild uterine tenderness,
heavy bleeding, and an 8-week size, boggy uterus. A serum pregnancy test is negative. What is the most
likely diagnosis?
Failure of the uterus to return to its normal size postpartum is referred to as “subinvolution.” Microscopy of the
placental site reveals retention of trophoblastic cells, enlarged vessels, and necrotic decidua. This may serve as a
nidus for infection as well as cause delayed postpartum bleeding.
❍ What is the incidence of benign endometrial polyps?
The reported incidence of polyps is nearly 25% of all uteri. They frequently present with abnormal uterine
bleeding. This diagnosis should be considered especially when bleeding persists following D+C because the curette
may miss small polyps.
❍ An endometrial biopsy is performed on a 36-year-old anovulatory, fertility patient and shows “tubal
metaplasia.” What does this mean?
Ciliated cells are usually not seen in endometrial glands. The presence of a significant number of ciliated glandular
cells is referred to as tubal metaplasia or ciliated cell change because of the resemblance to epithelium of the
fallopian tube. This is a benign finding and reflects a mild degree of estrogenic stimulation. It may accompany
endometrial hyperplasia.
❍ What is the first histologic sign on an endometrial biopsy that ovulation has occurred?
The first sign of the secretory phase is the appearance of subnuclear intracytoplasmic glycogen vacuoles in the
glandular epithelium. This is soon followed by active secretion into the endometrial cavity with a peak level
reached about 7 days after ovulation—coinciding with the time of blastocyst implantation.
❍ What is the primary histologic feature of the endometrium at the time that implantation should occur?
On days 21 to 22 of a normal cycle the predominant feature is stromal edema. This may be caused by an increased
vascular permeability secondary to greater prostaglandin production.
❍ Which layer of the endometrium is responsible for the greatest increase in height during the menstrual
cycle?
The functionalis layer is primarily responsible for the increased height of the endometrium during the proliferative
phase. After ovulation the height is generally fixed at approximately 6 mm by the growth restraining effects of
progesterone.
❍ What is the risk of progression to malignancy with complex atypical hyperplasia of the endometrium?
Approximately 25% of these cases progress to carcinoma without treatment. Only 2% of endometrial hyperplasia
without atypia progresses this way.