Hysterectomies are often performed for symptomatic conditions without malignancy, including uterine prolapse, urinary incontinence, pelvic pain, leiomyomas (a.k.a. fibroids), and adenomyosis/endometriosis. There may or may not be accompanying fallopian tubes and ovaries.
Distinguish the anterior from the posterior surface. There are two methods:
The serosa (a.k.a. peritoneal reflection) extends lower on the posterior surface than on the anterior surface.
The fallopian tubes insert anterior to the point of attachment of the round ligament
Weigh the specimen. Measure the uterus in 3 dimensions: fundus to cervix, anterior to posterior, and cornu to cornu. Obtain measurements before opening the uterus, since the myometrium will bulge outward after sectioning.
Describe the overall shape of the uterus (pyriform = pear-shaped, globular, multinodular, deformed).
Describe each component of the uterus, before or after opening and sectioning, as appropriate:
Ectocervix: dimensions of surface and os; color, laceration, ulcer, hemorrhage, mass, cyst.
Endocervix: length of canal from squamocolumnar junction to uterine corpus; color, mucosal texture, polyp.
Serosa: color, smooth vs. rough, adhesions, nodularity.
Myometrium: average thickness; color, hemorrhage, mass (describe, give diameter of smallest and largest, location). Leiomyomas (fibroids) are extremely common in hysterectomy specimens. They are usually tan-white-gray, well-circumscribed nodules with bulging cut surfaces, often with areas of ischemic degeneration which are softer and darker than the surrounding tissue and which may be mistaken for true necrosis (a potential sign of malignancy). Make several cuts through each to look for areas which appear “different” (e.g. fleshy, hemorrhagic, necrotic). It is best to avoid making the diagnosis of “leiomyoma” or “fibroid” in a gross description; instead, use “nodule” or “mass”. Adenomyosis may appear as a spongy, hemorrhagic focus in the myometrium and can sometimes result in significant mural thickening or even a mass-like lesion.
Endometrium: dimensions of cavity; average thickness; color, polyp (measurements and location).
If the uterus is received intact, it should be opened by cutting through the lateral walls, beginning at the cervix. Continue the cuts through to the top of the fundus, but leave the two halves attached by a small amount of myometrium and serosa. Serially section (“breadloaf”) each half of the corpus at 0.5 cm intervals transversely, keeping the sections joined by a small amount of serosa. Section the cervix in the opposite plane. Process the fallopian tubes and ovaries as described in their respective sections.
If the uterine cervix is received detached from the corpus, handle each part similarly to what is described above.
Cervix: two sections (one anterior and one posterior; alternatively, some choose to submit left and right sides in the hope of identifying microscopic mesonephric remnants), with squamocolumnar junction and lesions included. Entirely submit polyps and masses which do not resemble leiomyomas.
Corpus: two transmural sections (i.e. endometrium, myometrium, and serosa). Sections can be divided in half if necessary to fit in a cassette. Additional sections of lesions.
Leiomyomas: No more than five cassettes total, emphasizing areas which look “different” (see guideline). If five or fewer leiomyomas, submit one section per leiomyoma.
Endometrial polyps: Submit entirely, sectioned perpendicular to the wall, so as to include the stalk and underlying myometrium.
Received without fixative/in formalin, labeled _____ and “ _____ “ is an unopened/a previously opened ____ (distorted, symmetrically enlarged, pyriform) uterus with attached (right, left, bilateral) adnexae weighing __in toto. The uterus measures __ cm anterior to posterior, __ cm cornu to cornu, and __ cm fundus to cervix. The serosa is ___ (smooth, nodular, covered by adhesions). The ectocervix has a surface diameter of __ x __ cm and a __ cm slit-like/patulous/stenotic os. The ectocervical mucosa is _____ (color, lesions). The __ cm long x __ cm wide endocervical canal is covered with _____ mucosa. The endometrial cavity is _____ (shape), __ cm long x __ cm wide, and covered with _____ (color) endometrium of __ cm thickness. There is no/a __ x __ x __ cm polyp in _____ (location). There are _____ (number vs. multiple) _____ (subserosal/intramural/submucosal) nodules ranging __ to __ cm with _____ (color, whorled, trabecular, firm, bulging) cut surfaces with/without _____ (central degeneration, hemorrhage, necrosis). There is a spongy, hemorrhagic focus in the anterior/posterior myometrium, __ cm in greatest dimension. The uninvolved myometrium is __ cm in thickness. (SeeSalpingectomyandOophorectomy for dictation templates for fallopian tube and ovary.) Representative sections are submitted as follows: