Art of hysteroscopy hysteroscopy

Endometrial Vascular Dystrophy

INTRODUCTION

Hamou describes Endometrial Vascular Dystrophy in his Atlas (1), as well as other authors in the literature (2, 3) It is described as a vascular alteration in which the vessels are very tortuous and dilated, assuring that in some cases are thrombosed (2).

They usually describe it in the secretory phase of the cycle or in women under treatment with progestogens (3). Paoletti even puts it in relation to the disease of Rendu- Osler-Weber, genetic disorder of angiogenesis (3). Paoletti describes the follow-up of one of his cases in the next cycle in the proliferative phase and finds complete regression of the lesions (3).

Labastida describes in his book changes in the appearance of the lesion according to the evolution, that is to say that there are more obvious cases than others

RESULTS

We have found a total of 8 cases diagnoses as Endometrial Vascular Dystrophy.

All the patients were in women of reproductive age with normal cycles. Four of the cases were associated with the presence of an endometrial polyp, which in no case presented the alterations of the vessels of the rest of the endometrium.

In the hysteroscopy of all our cases, we found tubular, dilated, tortuous formations filled with a brownish content. The blood vessels were of normal thickness. The intensity of the lesion was different in the different cases, as well as the extension, as described in his book Labastida (2). In some, the lesion existed only in the uterine fundus and cornual zones, dilated tortuous formations with a brown content and in some fine superficial vessels of normal characteristics could be distinguished. In other cases, the lesion was diffuse throughout the cavity (Figure 1). In some cases there were small pockets of hemorrhage and

in others none. All the cases, like those described in the literature, were performed during the secretory phase of the menstrual cycle. None were on hormonal treatment.

A characteristic of all the cases, although with different intensity, was the debris of small remains throughout the cavity, which made a cloudy hysteroscopy and secretions of the same brown color as those contained in the supposed dilated vessels. In one case according to the hysteroscopic examination, the ejection of a brown fluid of the same color as those retained in the vessels was visualized. This can be seen in the mounted video of all cases.

The surprise was when analyzing the biopsy specimen realizing that they are not vascular alterations, but secretory glands (hence their tortuosity) filled with retained blood giving its brown color.

The problem is that, if the glands are as shown in figure 2, how does the blood get inside the gland? There are no vessel ruptures, nor stromal hemorrhages. The uterine cavity is filled with secretions similar to those present in the glands, color dark brown, as if they were expelling into the cavity.

We performed different stains in addition to the hematoxylin eosin, to show that there were red blood cells inside the lumen of the glands. Using PAS stain we found, as expected, the glands in the secretory phase filled with positive PAS material and the normal basal membranes, since it stained mucopolysaccharides.

Using Alcian Blue technique, which stains neutral mucopolysaccharides, acids and red blood cells, revealed intraglandular red blood cells.

Selectively, we determined glycophorin A (5) by immunohistochemical technique. Glycophorin A is a sialoglycoprotein present in the membrane of human red blood cells and their precursors, being the most common of the different types of glycophorin. We found, that it is not present within all the endometrial glands, and is also present in the endometrial vessels between normal glands.

DISCUSSION

In the literature, we did not find any histological description of the so called “vascular dystrophy”. We only see photos of hysteroscopies in which all the authors coincide in their description, being an image very easy to identify.

What we do not share, is that it is blood vessels or even thrombosis inside of them. We believe that it is evident, with the photos that we present, that it is not blood vessels, but glands in the secretory phase (this is described by all the authors).

They are filled with mucopolysaccharide PAS positive and with the specific staining of red blood cells (glycophoria A) it is shown present inside the glands. What we are not able to understand, is how these red cells get inside the glands?

Blood vessels are normal, there is no hemorrhagic areas seen in the stroma, neither in hysteroscopy nor in histology. The glands are also normal, with a normal basement membrane.

CONCLUSIONS

The so-called “endometrial vascular dystrophy”, it seems to us, does not exist. The image described are in fact secretory glands, filled with a secretion and blood.

We fail to understand how blood reaches inside the glands, but it is confirmed that there are red blood cells inside the glands (Fig. 3) This phenomenon can be normal part of the menstrual cycle. Paoletti describes the spontaneous disappearance of this phenomenon in the following cycle.

There are women who refer a few days before starting bleeding with a thick brown discharge, very similar to the one seen in the hysteroscopy. We recommend to continue to study this phenomenon in patients describing the presence of premenstrual dark brown discharge.

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