The Postmenopausal Endometrium

McBride, John Malcolm (1953) The Postmenopausal Endometrium. MD thesis, University of Glasgow.

Abstract

An investigation of the endometrial patterns found in normal post-menopausal women was considered a necessary preliminary to a consideration of the problem of functional postmenopausal bleeding. It was found that contrary to general opinion simple atrophy of the endometrium was by no means an invariable finding. An inactive state of the endometrium, however, did occur in 98 per cent, of cases. Those cases which were histologically inactive could be divided into two main groups,namely those of simple atrophy which accounted for approximately two thirds of the total, and the remainder in which cystic dilatation of the glands was a prominent feature. In rather less than half of the cases showing an inactive gland pattern the condition was localised to a simple portion of the cavity of the uterus in the form of an endometrial polyp. None of these patterns had any relationship to the age after the menopause when they were discovered. Complete atrophy of the endometrium had occurred in patients one year after the menopause and the cystic gland pattern occurred from one to 34 years after the cessation of menstruation. Active hyperplasia of the endometrium was found in less than two per cent, of normal postmenopausal women and when it was present the discovery was made in the early years after the menopause. This may indicate that active hyperplasia in these cases represents a persistence of menopausal hyperplasia associated with terminal anovulatory cycles. It was not possible, however, to obtain a history of excessive or irregular menstruation prior to the menopause in patients whose endometrium later showed hyperplasia. In view of the diversity of views on the significance of the senile endometrial polyp of a cystic gland pattern evidence was sought relating to the mode of development of such polyps. The dilated gland pattern has frequently been mistaken for hyperplasia although the histological appearance is one of inactivity. There was no statistical evidence to suggest that there was any relationship between active hyperplasia and senile polyps. It would seem that these polyps are merely a localised form of the diffuse cystic gland pattern which is itself a variety of atrophy of the endometrium. It is significant that a senile endometrial polyp is a normal finding in the endometrium of one post-menopausal women in ten where bleeding has not occurred. The serious view adopted by gynaecologists of the significance of post-menopausal bleeding is supported by the finding of malignant disease of the uterus and cervix in more than a quarter of cases. Where a benign condition was responsible for the bleeding there was a local extra-uterine source such as decubitus ulceration or polypus of the cervix in many cases. Analysis of the endometrial pattern showed approximately the same incidence of variation as was found in normal postmenopausal women. And in particular the incidence of active hyperplasia was not significantly increased. This indicates that the bleeding originated from the obvious gynaecological lesion and could not be attributed to an altered state of the endometrium. In some cases of fibroids of the uterus a possible explanation of the bleeding in the postmenopausal patient was found in the position of the fibroid. In the absence of co-existing endometrial carcinoma or of malignant degeneration in the fibroid itself, a submueous situation of the fibroid was considered to be a factor. This was particularly so when the fibroid had become polypoidal. Where, however, the fibroids were intra-mural it seemed that bleeding was likely to be related to an altered uterine function and the increased incidence of hyperplasia was considered to be of considerable significance. The group of cases of post-menopausal bleeding referred to as "functional" accounted for approximately 25% of the total. The striking feature of this group was the high incidence of endometrial hyperplasia which was more than ten times as frequent as in normal postmenopausal women. An important point in this connection was that hyperplasia in patients with bleeding, in contrast to that found in normal women, was not restricted to the early postmenopausal years. On the contrary active hyperplasia in those patients was found as late as 30 years after the cessation of menstruation. It would seem that hyperplasia associated with bleeding is not the persistence of a menopausal condition but frequently arises de novo in elderly women. In the majority of such cases curettage results in cessation of the bleeding. This may be supplemented by deep X-rays to the ovary. Where haemorrhage recurs after such treatment the most likely cause is the presence of a hitherto unsuspected granulose cell tumour of the ovary, often so small as to be impalpable. Although hyperplasia was of frequent occurrence in post-menopausal patients with bleeding, this symptom was also present in women whose endometrium showed atrophy or an inactive cystic gland pattern.

• Item Type: Thesis (MD)
• Qualification Level: Doctoral
• Keywords: Medicine
• Date of Award: 1953
• Depositing User: Enlighten Team
• Unique ID: glathesis:1953-78945
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 28 Feb 2020 12:09
• Last Modified: 28 Feb 2020 12:09
• URI: https://theses.gla.ac.uk/id/eprint/78945