Endometrium

Endometrium

Uterus and uterine tubes. (Endometrium labeled at center right.)
Details
Identifiers
Latin tunica mucosa uteri
MeSH A05.360.319.679.490
Dorlands
/Elsevier		 Endometrium
TA A09.1.03.027
FMA 17742

Anatomical terminology

The endometrium is the inner mucous membrane of the mammalian uterus.

Structure

Histology

High magnification micrograph of decidualized endometrium due to exogenous progesterone (oral contraceptive pill). H&E stain.
Low magnification micrograph of decidualized endometrium. H&E stain.

The endometrium consists of a single layer of columnar epithelium plus the stroma on which it rests. The stroma is a layer of connective tissue that varies in thickness according to hormonal influences. Simple tubular uterine glands reach from the endometrial surface through to the base of the stroma, which also carries a rich blood supply of spiral arteries. In a woman of reproductive age, two layers of endometrium can be distinguished. These two layers occur only in endometrium lining the cavity of the uterus, not in the lining of the uterine (Fallopian) tubes:[1]

In the absence of progesterone, the arteries supplying blood to the functional layer constrict, so that cells in that layer become ischaemic and die, leading to menstruation.

It is possible to identify the phase of the menstrual cycle by observing histological differences at each phase:

Phase Days Thickness Epithelium
Menstrual phase 1–5 Thin Absent
Proliferative phase 5–14 Intermediate Columnar
Luteal phase 15–27 Thick Columnar. Also visible are helicine branches of uterine artery
Ischemic phase 27–28 Columnar. Also visible are helicine branches of uterine artery

Chorionic tissue can result in marked endometrial changes, known as an Arias-Stella reaction, that have an appearance similar to cancer.[2] Historically, this change was diagnosed as endometrial cancer and it is important only in so far as it should not be misdiagnosed as cancer.

Function

The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a thick, blood vessel-rich, glandular tissue layer. This represents an optimal environment for the implantation of a blastocyst upon its arrival in the uterus. The endometrium is central, echogenic (detectable using ultrasound scanners), and has an average thickness of 6.7 mm.

During pregnancy, the glands and blood vessels in the endometrium further increase in size and number. Vascular spaces fuse and become interconnected, forming the placenta, which supplies oxygen and nutrition to the embryo and fetus.

Cycle

The endometrial lining undergoes cyclic regeneration. Humans and the other great apes display the menstrual cycle, whereas most other mammals are subject to an estrous cycle. In both cases, the endometrium initially proliferates under the influence of estrogen. However, once ovulation occurs, in addition to estrogen, the ovary will also start to produce progesterone. This changes the proliferative pattern of the endometrium to a secretory lining. Eventually, the secretory lining provides a hospitable environment for one or more blastocysts.

If the blastocyst does not implant and provide feedback to the body with human cortico gonadotropin [hCG] and continued feedback through pregnancy with placental progesterone and estrogen, the endometrial lining is either reabsorbed (estrous cycle) or shed (menstrual cycle). In the latter case, the process of shedding involves the breaking down of the lining, the tearing of small connective blood vessels, and the loss of the tissue and blood that had constituted it through the vagina. The entire process occurs over a period of several days. Menstruation may be accompanied by a series of uterine contractions; these help expel the menstrual endometrium.

In case of implantation, however, the endometrial lining is neither absorbed nor shed. Instead, it remains as decidua. The decidua becomes part of the placenta; it provides support and protection for the gestation.

If there is inadequate stimulation of the lining, due to lack of hormones, the endometrium remains thin and inactive. In humans, this will result in amenorrhea, or the absence of a menstrual period. After menopause, the lining is often described as being atrophic. In contrast, endometrium that is chronically exposed to estrogens, but not to progesterone, may become hyperplastic. Long-term use of oral contraceptives with highly potent progestins can also induce endometrial atrophy.[3][4]

In humans, the cycle of building and shedding the endometrial lining lasts an average of 28 days. The endometrium develops at different rates in different mammals. Its formation is sometimes affected by seasons, climate, stress, and other factors. The endometrium itself produces certain hormones at different points along the cycle. This affects other portions of the reproductive system.

Pathology

Thin endometrium may be defined as an endometrial thickness of less than 8 mm. It usually occurs after menopause. Treatments that can improve endometrial thickness include Vitamin E, L-arginine and sildenafil citrate.[5]

Gene expression profiling using cDNA microarray can be used for the diagnosis of endometrial disorders.[6] The European Menopause and Andropause Society (EMAS) released Guidelines with detailed information to assess the endometrium. [7]

An endometrial thickness (EMT) of less than 7 mm decreases the pregnancy rate in in vitro fertilization by an odds ratio of approximately 0.4 compared to an EMT of over 7 mm. However, such low thickness rarely occurs, and any routine use of this parameter is regarded as not justified.[8]

Other clinical uses

Triple-line endometrium measuring 7mm.

Observation of the endometrium by transvaginal ultrasonography is used when administering fertility medication, such as in in vitro fertilization. At the time of embryo transfer, it is favorable to have an endometrium of a thickness of between 7 and 14 mm with a triple-line configuration,[9] which means that the endometrium contains a hyperechoic (usually displayed as light) line in the middle surrounded by two more hypoechoic (darker) lines. A triple-line endometrium reflects the separation of the stratum basalis and functionalis layers, and is also observed in the periovulatory period secondary to rising estradiol levels, and disappears after ovulation.[10]

Additional images

See also

References

  1. ↑ Blue Histology - Female Reproductive System. School of Anatomy and Human Biology - The University of Western Australia http://www.lab.anhb.uwa.edu.au/mb140/CorePages/FemaleRepro/FemaleRepro.htm Accessed 20061228 20:35
  2. ↑ Arias-Stella, J. (Jan 2002). "The Arias-Stella reaction: facts and fancies four decades after.". Adv Anat Pathol 9 (1): 12–23. doi:10.1097/00125480-200201000-00003. PMID 11756756.
  3. ↑ Deligdisch, L. (1993). "Effects of hormone therapy on the endometrium". Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc 6 (1): 94–106. PMID 8426860.
  4. ↑ William's Gynecology, McGraw 2008, Chapter 8, Abnormal Uterine Bleeding
  5. ↑ Takasaki A, Tamura H, Miwa I, Taketani T, Shimamura K, Sugino N (April 2010). "Endometrial growth and uterine blood flow: a pilot study for improving endometrial thickness in the patients with a thin endometrium". Fertil. Steril. 93 (6): 1851–8. doi:10.1016/j.fertnstert.2008.12.062. PMID 19200982.
  6. ↑ Tseng, L.; Chen, I.; Chen, M.; Yan, H.; Wang, C.; Lee, C. (2010). "Genome-based expression profiling as a single standardized microarray platform for the diagnosis of endometrial disorder: an array of 126-gene model". Fertility and Sterility 94 (1): 114–119. doi:10.1016/j.fertnstert.2009.01.130. PMID 19328470.
  7. ↑ Dreisler E, Poulsen LG, Antonsen SL, Ceausu I, Depypere H, Erel CT, Lambrinoudaki I, Pérez-López FR, Simoncini T, Tremollieres F, Rees M, Ulrich LG. (2013). "EMAS clinical guide: Assessment of the endometrium in peri and postmenopausal women". Maturita 75 (2): 181–90. doi:10.1016/j.maturitas.2013.03.011. PMID 23619009.
  8. ↑ Kasius, A.; Smit, J. G.; Torrance, H. L.; Eijkemans, M. J. C.; Mol, B. W.; Opmeer, B. C.; Broekmans, F. J. M. (2014). "Endometrial thickness and pregnancy rates after IVF: a systematic review and meta-analysis". Human Reproduction Update 20 (4): 530–541. doi:10.1093/humupd/dmu011. ISSN 1355-4786.
  9. ↑ Zhao, Jing; Zhang, Qiong; Li, Yanping (2012). "The effect of endometrial thickness and pattern measured by ultrasonography on pregnancy outcomes during IVF-ET cycles". Reproductive Biology and Endocrinology 10 (1): 100. doi:10.1186/1477-7827-10-100. ISSN 1477-7827.
  10. ↑ Baerwald, A. R.; Pierson, R. A. (2004). "Endometrial development in association with ovarian follicular waves during the menstrual cycle". Ultrasound in Obstetrics and Gynecology 24 (4): 453–460. doi:10.1002/uog.1123. ISSN 0960-7692.

External links

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