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[MudPhud20XX]

A 46 yr old woman has had irregular menses for 6 months. Pelvic examination is normal, an abdominal ultrasound reveals no mass lesions, and the uterus appears normal in size. An endometrial biopsy is performed and on microscopic examination shows a proliferative pattern. Which of the following is the most likely diagnosis?

A. Adenomyosis
B. Anovulatory cycles
C. Asherman syndrome
D. Ectopci pregnancy
E. Gonorrheal infection

So after POE, I had to choose B (answer is B), but the expression "proliferative pattern" made me hesitant to do so. Why would you get "proliferative pattern" from anovluatory cycles? I was sort of looiking for an answer that had to do with some kind of hyperplasia. Many thanks in advance.

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[SBR249]

A typical menstrual cycle is composed of four stages 1) menstruation 2) proliferative phase (estrogen dominant) 3) ovulation (LH surge) 4) secretory phase (progesterone dominant).

The fact that you see a proliferative pattern in the context of irregular menses means you have prolonged periods of being stuck in the proliferative phase (estrogen stimulation) without progression through ovulation and then the secretory phase and menstruation. Only when the endometrial layer is too overgrown to support further growth do you get menstruation as the tissue dies and sloughs off and this occurs not due to withdrawal of progesterone's maintenance effects like with normal menstruation but due to tissue outgrowing their blood supply with the underlying tissue remaining in proliferative phase under estrogen stimulation. This prolonged proliferative phase also means there's no ovulation because normal progression of the menstrual cycle is disrupted. Anovulatory cycles are commonly seen in women going through menopause which fits the context.

You should go back and review your reproductive physiology again as the "proliferative pattern" is a buzzword for an important concept.