a histological study of uterus in reproductive and ... · a histological study of uterus in...

17National Journal of Clinical Anatomy

A histological study of uterus in reproductive and postmenopausal women1Malamoni Dutta , 2K L Talukdar1Assistant Professor, 2Professor & Head ,Department of Anatomy, Gauhati Medical College, Guwahati, Assam

Abstract

Background and aims: The "Uterus" or "Womb" is

a part of the female reproductive tract that receives the

fertilized ovum from the oviduct, provides the bed for

implantation and establishes the vascular connections

necessary for sustenance of the embryo throughout its

development. Due to increasing rate of infertility, the

reproductive organs are gaining importance. The aim

of the study is to ascertain that the research work could

be utilized for investigation and guidance for management

of infertility cases. The knowledge of normal histological

architecture of the uterus will be of help to isolate any

pathological changes. Materials and methods: Ten

samples each from reproductive and postmenopausal

women were collected from fresh unembalmed human

cadavers. The slides were prepared using the standard

laboratory procedure. Stress was given on the structure

of endometrium, cervical mucosa and squamocolumnar

junction. Endometrial and cervical mucosal thickness

were measured in both groups. Results: Significant

differences of histological architecture were noted

between the two groups. The average endometrial

thickness as measured by micrometer scale was 4.29

mm and 1.64 mm in reproductive and post-menopausal

women respectively. The average cervical mucosal

thickness was 2.76 mm and 1.55 mm in reproductive

and postmenopausal women respectively. Conclusion:

Knowledge of the normal histological structure of the

uterus is of prime importance to have the basic

knowledge of various pathological entities.

Key words: endometrium, cervical mucosa,

squmocolumnar junction, glandular epithelium,

myometrium

Introduction

The uterus is subjected to a wide range of normalvariations in both its anatomy and physiology. It developsfrom fused paramesonephric ducts of both sides1.Thecyclic histological changes in the adult humanendometrium has been described by Noyes et al2. Themenstrual cycle starts usually between 12-15 years ofage and continues until about 45-503. The primaryfunctions of the endometrium are preparation forimplantation of a fertilized ovum, participation inimplantation and formation of the maternal portion ofplacenta4.

Neoplasia of the female genital tract, both benign aswell as malignant is a very common pathological entityin gynaecological practice. The squamo-columnarjunction of cervix is the most usual site of epithelialabnormalities that may progress to malignancy of cervix.Endometrial cancer is the most common gynecologicalcancer in developed countries and second most commonin developing countries5. It is a cancer of postmenopausalwomen; worldwide 91% of cases occur in women aged50 years and older6. Cervical cancer is the commonestmalignancy among women in India7. The aims of thepresent study are to study and compare the histologicalarchitecture of the uterus in reproductive andpostmenopausal age groups.

Materials and methods

The present study was conducted in the departmentof Anatomy, Gauhati Medical College, Guwahati. Afterobtaining ethical clearance, the uteri of both age groupswere collected from autopsies done in the departmentof Forensic Medicine, Gauhati Medical College,Guwahati. Specimens were collected from autopsiesdone within 6 hours following death and without obviouspathological changes and decomposition. Uteri with

Original article

Vol. - 4 (1) Pg. 17- 25 (2015)


product of conceptus, abnormal uterine anatomy,pathology of the pelvis were excluded from the study.

From the different dissected parts of the body andcervix, approximately 3-5 mm size pieces were takenand fixed in 10% formalin and labelled separately. Tissueswere kept in 10% formalin for 24-48 hours. The fixedtissues were processed for embedding in paraffin andsectioned at 5 µm thickness in a 'Rotary microtome'.Sections of tissues were stained by routine Haematoxylinand Eosin according to standard method of Carleton8.

Different layers of uterus, epithelial lining andglandular structures were observed under both low andhigh power objective. Endometrial thickness of uterinebody and mucosal thickness of cervix were measuredwith the help of a 'Spencer ocular' lens and objectivemicrometer scale. One division of the ocular micrometerscale was equivalent to 5µm at 400 magnification.

Calculation of the micrometer scale

2 divisions of ocular micrometer coincide with 1division of objective micrometer. Therefore, 1 divisionof ocular scale=1/2 division of objective micrometerscale.

As one division of objective micrometer scalemeasures 0.01mm, hence 1/2 division = 1/2 x 0.01 =0.005 mm = 5µm (since 10-3 mm = 1µm)

Therefore, 1 division of ocular micrometer scale= 0.005mm

Statistical Analysis

The data on endometrial thickness (mm) and cervicalmucosal thickness (mm) were analyzed by standardstatistical methods9. The data were analyzed to calculatethe mean and't' test was applied to find out the significantdifference between mean values.

Results

In the present study uteri were grouped into two asfollows :

Group A: Reproductive (14 years to 49 years)Group B: Postmenopausal (50 years and above)Micro anatomical features of human uterus were

observed as follows:

Endometrium

In reproductive age group the endometrium ormucosal lining of the uterus was found to be composed

of simple columnar epithelium and a layer of connective

tissue i.e. the endometrial stroma or lamina propria.

The epithelium consisted of non-ciliated, secretory

columnar cells. The glands were tubular running

perpendicular to the luminal surface and penetrated up

to the myometrial layer.

In postmenopausal age group the endometrium was

found to be consisting of only the stratum basalis. The

glandular epithelial cells were cuboidal or low columnar

with no mitotic figures. The secretory activity was absent

in glandular epithelial cells.During reproductive age the endometrium was

variable in thickness measuring between 1.5 mm to 6.2mm at different stages of menstrual cycle. In post-menopausal age the endometrium was thin and atrophic.The average endometrial thickness as measured bymicrometer scale was 4.29 mm and 1.64 mm inreproductive and post-menopausal age grouprespectively (Table 1). The inter-group variation ofendometrial thickness has been shown with the help ofbar diagram (Fig 1).

Since calculated value of 't' is greater than 1% tablevalue of 't' for 18 d.f., it is highly significant. Thereforeendometr ial thickness in reproductive andpostmenopausal women differs significantly.

Myometrium

In both the age groups the main bulk of uterus wasfound to be consisting of smooth muscle i.e. myometrium,which was composed of interlacing bundles of long andslender fibers arranged in ill-defined layers. All themuscle layers were seen intermingled with each other inboth the age groups. The thickness of the myometriumwas more in reproductive age than that ofpostmenopausal age. The myometrium inpostmenopausal age was thin and atrophic.

Histological study on uterus - Malamoni &Talukdar

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Table 1 : Comparison of endometrial thickness (mm) of uterus in reproductive and postmenopausal age group

No of Specimen

Reproductive Age (Group A)

Post menopausal Age (Group B)

Age in Years Endometrial Thickness

Age in Years Endometrial Thickness

1

2

3

4

5

6

7

8

9

10

15(NP)

17(NP)

22(NP)

25(NP)

27

32

35

38

40

42

3.1

1.5

3.4

4.1

4.3

6.2

5.7

5.3

4.5

4.8

52

55

58

60

62

65

68

72

75

80

2.3

1.9

1.8

1.5

1.7

1.6

1.5

1.5

1.4

1.2

Mean 29.4x 64.1y

NP = NulliparousCalculated value of 't' = 5.95327 ; d.f.=18 ; Table value of 't' at 1% level of significance = 2.88;

p - value = 1.240365E-05

No of Specimen

Reproductive Age (Group A)

Post menopausal Age (Group B)

Age in Years

Mucosal Thickness

Age in Years Mucosal

Thickness 1

2

3

4

5

6

7

8

9

10

15(NP)

17(NP)

22(NP)

25(NP)

27

32

35

38

40

42

2.8

3.0

2.9

2.6

2.7

2.5

2.8

3.0

2.7

2.6

52

55

58

60

62

65

68

72

75

80

2.2

1.8

1.75

1.5

1.6

1.5

1.4

1.4

1.3

1.1

Mean 76.2x 55.1y

Table 2 : Comparison of cervical mucosal thickness (mm) in reproductive and postmenopausal age group

NP=NulliparousCalculated value of't'=10.09698 ; d.f.=18 ; Table value of't' at 1% level of significance = 2.88;

p – value = 7.69668


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Cervical mucosa

The epithelial lining of the cervix in the upper part ofthe cervical canal was seen to be simple columnarepithelium. The cells were tall in the reproductive groupwith light stained cytoplasm and basally placed nuclei.In the lower part of the canal the epithelium was stratifiedsquamous epithelium of non-keratinized variety.

The squamocolumnar junction was abrupt in most ofthe tissues. In the upper part of the canal there werepatchy areas of cilia which were maximum in thereproductive age group.

The stroma was found to contain the cervical glandswhich opened into the luminal surface of the epithelium.The proportion of the glands was more in the reproductivegroup than that of post menopausal group. The glandswere lined by non-ciliated simple columnar epithelium.

The mucosal thickness as measured by micrometerscale was found to be thicker in reproductive age group.The average thickness of the cervical mucosa was 2.76mm and 1.55 mm in reproductive and postmenopausalage group respectively (Table 2). Inter-group variationof cervical mucosal thickness has been shown with thehelp of bar diagram (Fig 2).

Since calculated value of't' is greater than 1% tablevalue of 't' for 18 d.f., it is highly significant. Thereforecervical mucosal thickness in reproductive andpostmenopausal group differs significantly.

Cervical musculature

The muscular layer was found to consist of smoothmuscle along with dense connective tissue containingboth collagen and elastic fibers. It was noticed thatproportion of muscle was more in reproductive agegroup than that of postmenopausal group. Inpostmenopausal group the elastic and collagen fibreswere replaced by fibrous tissue.

DiscussionThis study has revealed several points of interest

having marked importance in practical life with the hope

that it will help in the investigation and management ofvarious pathological conditions related to the uterus.

In reproductive age group the endometrium was seento be lined by a simple columnar epithelium (Fig.3).Thisfinding is analogous with that of Dawn10, Cunninghamet al11 and Gartner and Hiatt12. Just after menstruationthe epithelium was found to be cuboidal and later becamecolumnar. Similar observation was made by Wilson etal13, Jones14, Novak and Woodruff15, Clayton et al16,Tindall17 and Healy et al18. In the early part of menstrualcycle the endometrial glands were simple straight tubeslined by columnar epithelium with large oval nuclei (Fig.3).But later on the glands became curved or tortuous(Fig.5,6). Similar observations were noted by Clayton etal16, Fox and Buckley19, and Healy et al18. Subnucleolarvacuolation was also noticed in the endometrial glands(Fig.6). This was also noted by authors like Passmoreand Robson20, Rao and Roy Choudhury21, Padubidri andDaftary22. This vacuolation is considered as thepresumptive evidence of ovulation.

In contrast to reproductive endometrium thepostmenopausal endometrium was found to be thin andatrophic and was composed of stratum basalis only(Fig.4). This finding corroborates with that of Massani23,Rao and Roy Choudhury21 and Young et al24. Theendometrial glands were sparse and inactive, which wasalso reported by Tindall17 and Young et al24. Theglandular epithelium in the postmenopausal age groupconsisted of low columnar or cuboidal epithelium withno mitotic figure (Fig.7). This finding was similar tofindings of Massani23, Fox and Buckley19, Young et al24.

In the present study endometrial thickness was foundto be variable in reproductive age group depending ondifferent phases of the menstrual cycle (Table 1). Similarobservation was made by other authors (Table 3).

The average thickness of the postmenopausalendometrium was found to be 1.64 mm (Table 1). Thiscorroborates with the findings of Padubidri andDaftary22, who mentioned that at menopause theendometrium is only 1-3 mm in thickness.


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The difference in endometrial thickness might bedue to the fact that the endometrium is very refractoryto the hormones i.e. oestrogen and progesteronesecreted by ovary. Hence the endometrial thickness inreproductive age group suggests high level of oestrogenin the plasma whereas atrophic endometrium in post-menopausal group indicates low oestrogen level inplasma. This observation was also made by severalauthors- Fox and Buckley19, Cunningham et al11 andPadubidri and Daftary22.

In both the age groups the myometrium was found tobe composed of interlacing bundles of long and slenderfibres arranged in ill defined layers (Fig.8,9). Theoutermost and innermost layers were thin and consistedof chiefly longitudinal and obliquely dispersed fibres. Thisfinding was also supported by Bloom and Fawcett4,Gartner and Hiatt12 and Healy et al18.

The thickness of myometrium was more inreproductive age. In postmenopausal age themyometrium was thin, fibrous and atrophic (Fig.9). Thisobservation was supported by Rao and RoyChoudhury21,Young et al24. These atrophic changescould possibly be due to atrophy of the muscle fibresand increase in fibrous connective tissue due to absenceof oestrogen in the postmenopausal age.

It was observed in the present study that the mucosalthickness in the upper part of cervical canal was 2.76mm and 1.55 mm in reproductive and postmenopausalage respectively. It could be due to increase in numberof glands present in reproductive age. The mucosalthickness matches with the findings of Bloom andFawcett4 and Bannister and Dyson26.

The epithelial lining of the cervix in the upper part ofthe canal i.e. endocervix was found to be simple columnartype. Similar observation was made by Anderson andGenadry27, Dawn10, Impey28,Young et al24 and Gartnerand Hiatt12. In the upper part of the canal there werepatchy areas of cilia which were maximum in thereproductive group. This was also observed by Fluhmannand Dickmann29, Ham and Cormack30 and Moghissi31.These ciliae probably help in the transport of spermtowards the body the uterus.

In the lower part of the canal i.e. the ectocervix, theepithelium was found to be nonkeratinized stratifiedsquamous type (Fig.10). This is akin to the findings ofAnderson and Genadry27,Young et al24, Gartner andHiatt12 and Healy et al18. In the present study, it wasobserved that after menopause, the stratified squamousepithelium was atrophic and thin (Fig.11). Fox andBuckley19 have stated that after menopause the depth

Table 3 : Endometrial thickness of uterus (Reproductive age) noted by differentauthors and present study


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Novak and Woodruff (1979)15 1-2mm to 3-8mmRao and Roy Choudhury (1984)21 2mm to 5-6mmTindall (1994)17 1-5mmDawn (2004)10 1-10mmCunningham et al (2005)11 0.5-5mmYoung et al (2006)24 1-5mmHealy et al (2008)18 1-2mm to 6mmRoss and Pawlina (2011)25 1- 6mmPresent study 1.5-6.2mm (mean = 4.29mm)

Authors Endometrial Thickness (mm)


Fig 1: Bar Diagram showing inter-group variation of en-dometrial thickness of Uterus

2.76

1.55

0

0.5

1

1.5

2

2.5

3

Muc

osal

thic

knes

s in

mm

ReproductivePostmenopausal

Fig 2: Bar diagram showing inter-group variation of mucosalthickness of cervix

4.29

1.64

00.5

11.5

22.5

33.5

44.5

Endo

met

rial t

hick

ness

in m

m

ReproductivePostmenopausal

Fig.3: Photomicrograph showing endometrium ofreproductive uterus under low power magnification (100X)

Fig.4: Photomicrograph showing endometrium and a part ofmyometrium of postmenopausal uterus under low power

magnification 100X)

Fig. 5: Photomicrograph showing tubular and tortuousglands in uterus of reproductive age (100X magnification)

Fig. 6: Photomicrograph showing subnuclear Vacuolation(arrow) in the endometrial glands of reproductive uterus

(400X magnification)

Fig. 7: Photomicrograph showing endometrial glands linedby low columnar or cuboidal epithelium in postmenopausal

uterus (400X magnification)

Fig. 8: Photomicrograph showing myometrium and a part ofthe endometrium (stratum basalis) in reproductive uterus

(100X magnification)


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Fig. 9: Photomicrograph showing myometrium with bloodvessels and a part of the endometrium in postmenopausal

uterus (100X magnification)

Fig. 10: Photomicrograph of reproductive cervix showingepithelium and underlying stroma (400X magnification)

Fig. 11: Photomicrograph showing postmenopausal cervixwith atrophic, thin squamous epithelium and fibrosis of

cervical musculature (400X magnification)

Fig. 12: Photomicrograph of reproductive cervix showingbranched tubular glands in stroma (100X magnification)

Fig. 13: Photomicrograph of reproductive cervix showingsquamocolumnar junction (arrow) (100X magnification)

and maturity of cervical squamous epithelium becomesshallow and maturation is arrested. The atrophic mucosais particularly susceptible to infection.

The squamocolumnar junction-which is an abruptchange of epithelium from columnar to squamous typewas found to be situated at or near the external os(Fig.13). This is supported by similar findings of Tindall17

and Young et al24. This abrupt change is due to theeffect of oestrogen which has been experimentallyproved on mouse by Graham32. The site ofsquamocolumnar junction was found to be variable.After menopause it was found at a higher level i.e.within the endocervical canal. Similar observation wasalso made by Ostergard33 and Anderson et al27.


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The stroma was found to contain the tubular branchedcervical glands (Fig.12) which were lined by nonciliatedsecretory columnar epithelium. Similar findings werenoted by Bannister et al26, Dawn10, Gartner and Hiatt12

and Healy et al18. The proportion of the glands wasmore in reproductive group than in the postmenopausalgroup which was supported by Tindall17.

In the present study the muscle layer of the cervixwas found to be composed of smooth muscle along withdense connective tissue- both collagen and elastic fibres.This finding was similar to that of Bannister and Dyson26

and Healy et al18.The muscle fibres were found to bemore abundant in reproductive group than that ofpostmenopausal group. In the postmenopausal age theelastic and collagen tissues were replaced by fibroustissue (Fig.11). This observation was akin to that ofBlaikely34.

Conclusion

The present study has highlighted the majorhistological changes of uterus in reproductive andpostmenopausal women. Endometrium is the 'mirror' ofthe ovarian cycle because it responds in a consistantmanner to the fluctuating concentration of gonadotrophinand ovarian hormones. Hence there is a wide scope foruterus to be studied with advanced techniques forinvestigation and management of infertility cases.Uterineneoplasia (both benign and malignant) and cervicalpathology especially carcinoma are common clinicalentities in present era. The knowledge of normalhistological structure as well as changes in different agegroups may aid in the early diagnosis and treatment ofany disease of this part of female reproductive tract.

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Address for communication:Dr. Malamoni Dutta

Assistant Professor of Anatomy,Gauhati Medical College

Guwahati - 781 032. Assam.Mobile : 09864110077

E-mail ID :[email protected]


Vol. - 4 (1) Pg. 17- 25 (2015)

a histological study of uterus in reproductive and ... · a histological study of uterus in...

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