Click here to view next page of this article

Endometrial Hyperplasia

The hallmark symptom of endometrial hyperplasia is abnormal bleeding. We have to keep in mind what our differential diagnosis is in terms or reproductive tract disease, don’t forget that complications of pregnancy whether it’s a missed abortion or an ectopic pregnancy, or chronic placental polyp can present with abnormal bleeding, various benign pelvic lesions as you see here, malignancy of the cervix or endometrium, rarely higher up in the pelvis, and then premalignancy endometrial hyperplasia. Rarely, you may need to consider systemic diseases, coagulopathy would be more common in adolescence, and only in cases of severe dysfunctional uterine bleeding do we do a coagulation profile on adolescence which would be PT, PTT, platelets and bleeding time.

Most of the time, the risk factors for endometrial hyperplasia come from unopposed estrogen for a chronic long period of time. So first off, let’s review what estrogen and progesterone do in terms of effects on the endometrium and the various phases of the cycle or when we administer hormones in other phases such as during a postmenopausal hormone replacement therapy.

With endometrial hyperplasia, 18 to 32% on unopposed estrogen will go on to develop hyperplasia and 10% of those that have adenomatous hyperplasia will actually undergo a progression to frank carcinoma. What happens when we have hyperplasia , you have histologic changes in the glandular epithelium, you are going to have cellular proliferation, in terms of greater numbers of mitosis, cell layers and stratification, glandular crowding.

When to biopsy - in general, I would prefer that you over biopsy or biopsy on a more liberal basis than on a less liberal basis, office biopsy for the most part is a noninvasive procedure. So first of all, when to biopsy based on symptoms, patient comes in saying her periods have changed, as the normal menstrual cycle is defined, you should biopsy whenever she crosses the limits of those normal definitions, so that would be, whenever her menstrual flow lasts more than seven days, whenever the interval less than 21 days or when she complains of bleeding.

The PCO patient type as it says here, we already said what she looks like, you can walk Michigan Avenue after this lecture session is over today, and I want you to pick out five ladies that you would biopsy if you could get them into a room and it shouldn’t take you more than a block and a half.

When not to biopsy - I can only think of one time not to biopsy, and that’s if you haven’t ruled out pregnancy yet. It’s very embarrassing to make the diagnosis of an ectopic pregnancy based on an endometrial biopsy, even if it’s somebody that’s been infertile for 20 years, or says she’s not that sexually active, rule out pregnancy if you have any doubt whatsoever. In the older text books, you might see, we only biopsy after the age of 35, no longer true, there is no minimum age limit. Endometrial carcinoma has been reported in teenagers.

I try to always do these things on a practical basis, if you encounter cervical stenosis when you are trying to do your biopsy, you put in the Pipelle and you know 2 or 3 cm are going and you hit the obstruction, don’t quit there, there are several little maneuvers that you can do to get past cervical stenosis, I call it cervical stenosis.

If she has failed to respond to hormonal treatment, you do the repeat biopsy after the six weeks or eight weeks of Megace and you still have endometrial hyperplasia present, the text book answer is that at this point she needs a hysteroscopy with a directed biopsy, D&C to rule out misdiagnosis, i.e., unsuspected or undiagnosed atypia or carcinoma in situ. A possible exception may be a patient that is a very poor surgical risk, again, remember the patient type, she is 350 pounds, do you really want to put her to sleep.

Tamoxifen comes up every now and then, In think it’s really more of what In call a package insert risk or something that the breast oncologist feels compelled to warn the patient about which is fine, I’m all for having an informed patient, but it’s really not as serious of a risk as some of the patient’s interpret it to be. So we can reassure that incidents vary, depending on which series you look at, most of the time when we hysteroscope these patient’s.

Endometrial ablation. This is becoming like the new toy on the market, now that it’s gone from Yag laser to these nice little hot air balloons or hot liquid balloons that we put inside, don’t be like the carpenter’s apprentice, that once he gets his new hammer, everything looks like a nail, and they start thinking they can treat everything with endometrial ablation. It is not a treatment for endometrial hyperplasia.

Prevention. It would be interesting if we could find a way to lower the rates of endometrial hyperplasia by given those ladies that we consider to be at risk oral contraceptives regardless of whether or not they are sexually active and/or need birth control, and that’s because for years, even though this is not package labeling.