Endometrial hyperplasia overview: Difference between revisions
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==Overview== | ==Overview== | ||
[[Endometrial hyperplasia]] is a [[condition]] of excessive [[proliferation]] of the [[endometrial]] [[Cells (biology)|cells]] (inner lining of the [[uterus]]) associated with an increased [[gland]] to [[stroma]] [[ratio]]. The majority of cases of [[endometrial]] [[hyperplasia]] result from high [[concentrations]] of [[estrogen]] combined with insufficient [[concentration]] of the [[progesterone]]-like [[hormone]]s which [[Normal|normally]] counteract the [[Proliferation|proliferative]] effects of [[estrogen]] on the [[endometrial]] [[tissue]].<ref name="wj">Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia Accessed on March 7, 2016.</ref> [[Anovulation]] results in the prolonged release of [[estrogen]] and the relative lack of [[progesterone]] resulting in excessive stimulation of the [[endometrium]]. Unopposed [[estrogen]] stimulation may be either from an [[endogenous]] or [[exogenous]] source.<ref name="pmid24678678">{{cite journal| author=Owings RA, Quick CM| title=Endometrial intraepithelial neoplasia. | journal=Arch Pathol Lab Med | year= 2014 | volume= 138 | issue= 4 | pages= 484-91 | pmid=24678678 | doi=10.5858/arpa.2012-0709-RA | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24678678 }} </ref><ref name="wj">Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia Accessed on March 7, 2016.</ref> [[Endometrial hyperplasia]] may be broadly [[Classification|classified]] based on [[histology]] into simple and complex types. [[Endometrial hyperplasia]] may also be [[Classification|classified]] based on the presence or absence of [[cellular]] [[atypia]] ([[hyperplasia]] with [[cellular]] [[atypia]] and [[hyperplasia]] without [[cellular]] [[atypia]]).<ref name="qq">Scully RE. Histological typing of female genital tract tumours. Springer; 1994.</ref><ref name="wp">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.</ref><ref name="pmid12130438">{{cite journal| author=Jorizzo JR, Chen MY, Martin D, Dyer RB, Weber TM| title=Spectrum of endometrial hyperplasia and its mimics on saline hysterosonography. | journal=AJR Am J Roentgenol | year= 2002 | volume= 179 | issue= 2 | pages= 385-9 | pmid=12130438 | doi=10.2214/ajr.179.2.1790385 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12130438 }} </ref> [[Endometrial hyperplasia]] must be [[Differentiate|differentiated]] from [[conditions]] that have similar [[ultrasound]] appearances such as [[normal]] thickening during the [[secretory phase]], [[sessile]] [[endometrial polyp]], [[submucosal]] [[uterine]] [[fibroid]]s, [[endometrial cancer]], adherent intrauterine [[blood clot]],and [[pregnancy]].<ref name="wp">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.</ref><ref name="pmid8184058">{{cite journal| author=Hulka CA, Hall DA, McCarthy K, Simeone JF| title=Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography. | journal=Radiology | year= 1994 | volume= 191 | issue= 3 | pages= 755-8 | pmid=8184058 | doi=10.1148/radiology.191.3.8184058 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8184058 }} </ref><ref name="ol">Abnormally thickened endometrium: differential diagnosis. Radiopedia. http://radiopaedia.org/articles/abnormally-thickened-endometrium-differential-diagnosis Accessed on March 3, 2016.</ref> [[Women]] of all [[age]] groups may [[Development|develop]] [[endometrial hyperplasia]].<ref name="lk">Endometrial Hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 9, 2016</ref> However, [[endometrial hyperplasia]] is more common in [[postmenopausal]] [[women]]. The majority of cases of [[endometrial hyperplasia]], except complex [[Atypia|atypical]] [[hyperplasia]] resolve spontaneously with time.<ref name="pmid9255033">{{cite journal| author=Terakawa N, Kigawa J, Taketani Y, Yoshikawa H, Yajima A, Noda K et al.| title=The behavior of endometrial hyperplasia: a prospective study. Endometrial Hyperplasia Study Group. | journal=J Obstet Gynaecol Res | year= 1997 | volume= 23 | issue= 3 | pages= 223-30 | pmid=9255033 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9255033 }} </ref> If left untreated, 30% of [[patients]] with [[Atypia|atypical]] [[hyperplasia]] may progress to [[Development|develop]] [[endometrial carcinoma]].<ref name="pmid19285814">{{cite journal| author=Lacey JV, Chia VM| title=Endometrial hyperplasia and the risk of progression to carcinoma. | journal=Maturitas | year= 2009 | volume= 63 | issue= 1 | pages= 39-44 | pmid=19285814 | doi=10.1016/j.maturitas.2009.02.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19285814 }} </ref> [[Malignant]] [[transformation]] into [[endometrial cancer]] is the most common [[Complication (medicine)|complication]] of [[Endometrial hyperplasia|endometrial hyperpasia]].<ref name="rc">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 16, 2016</ref> [[Prognosis]] is generally good with treatment. [[Pelvic]] [[ultrasound]] on days 5 to 10 of [[menstrual cycle]] reduce the variability in [[endometrial]] thickness and may be helpful in the [[diagnosis]] of [[endometrial hyperplasia]]. On [[pelvic]] [[ultrasound]], [[endometrial hyperplasia]] is characterized by a [[homogeneous]] increase in the [[endometrial]] thickness in the majority of [[patients]]. However, [[endometrial hyperplasia]] may also cause asymmetric or focal thickening with surface irregularity which should raise a suspicion for [[malignancy]].<ref name="qw">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 10, 2016.</ref> [[Progesterone]] [[therapy]] is the preferred [[drug]] for the treatment of [[benign]] [[hyperplasia]]. The management of [[endometrial hyperplasia]] depends upon the desire for future childbearing.<ref name="pmid25797956">{{cite journal| author=Emons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO)| title=New WHO Classification of Endometrial Hyperplasias. | journal=Geburtshilfe Frauenheilkd | year= 2015 | volume= 75 | issue= 2 | pages= 135-136 | pmid=25797956 | doi=10.1055/s-0034-1396256 | pmc=PMC4361167 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25797956 }} </ref> Total [[hysterectomy]] is curative for [[Atypia|atypical]] [[endometrial hyperplasia]] or [[endometrial]] intraepithelial [[neoplasia]].<ref name="pmid23090535">{{cite journal| author=Trimble CL, Method M, Leitao M, Lu K, Ioffe O, Hampton M et al.| title=Management of endometrial precancers. | journal=Obstet Gynecol | year= 2012 | volume= 120 | issue= 5 | pages= 1160-75 | pmid=23090535 | doi=http://10.1097/AOG.0b013e31826bb121 | pmc=PMC3800154 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23090535 }} </ref> | |||
== | |||
==Classification== | ==Classification== | ||
[[Endometrial hyperplasia]] may be broadly [[Classification|classified]] based on [[histology]] into simple and complex types. [[Endometrial hyperplasia]] may also be [[Classification|classified]] based on the presence or absence of [[cellular]] [[atypia]] ([[hyperplasia]] with [[cellular]] [[atypia]] and [[hyperplasia]] without [[cellular]] [[atypia]]).<ref name="qq">Scully RE. Histological typing of female genital tract tumours. Springer; 1994.</ref><ref name="wp">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.</ref><ref name="pmid12130438">{{cite journal| author=Jorizzo JR, Chen MY, Martin D, Dyer RB, Weber TM| title=Spectrum of endometrial hyperplasia and its mimics on saline hysterosonography. | journal=AJR Am J Roentgenol | year= 2002 | volume= 179 | issue= 2 | pages= 385-9 | pmid=12130438 | doi=10.2214/ajr.179.2.1790385 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12130438 }} </ref> | |||
==Pathophysiology== | ==Pathophysiology== | ||
[[Endometrial hyperplasia]] is a [[condition]] of excessive [[proliferation]] of the [[endometrial]] [[cells]] (inner lining of the [[uterus]]) associated with an increased [[gland]] to [[stroma]] [[ratio]]. The majority of cases of [[endometrial hyperplasia]] [[result]] from high [[concentrations]] of [[estrogen]] combined with insufficient [[concentration]] of the [[progesterone]]-like [[hormone]]s which normally counteract the [[Proliferation|proliferative]] effects of [[estrogen]] on the [[endometrial]] [[tissue]].<ref name="wj">Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia Accessed on March 7, 2016.</ref> [[Anovulation]] results in the prolonged release of [[estrogen]] and the relative lack of [[progesterone]] resulting in excessive stimulation of the [[endometrium]]. Unopposed [[Estrogen|oestrogen]] stimulation may be either from an [[endogenous]] or [[exogenous]] source.<ref name="wj">Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia Accessed on March 7, 2016.</ref><ref name="pmid24678678">{{cite journal| author=Owings RA, Quick CM| title=Endometrial intraepithelial neoplasia. | journal=Arch Pathol Lab Med | year= 2014 | volume= 138 | issue= 4 | pages= 484-91 | pmid=24678678 | doi=10.5858/arpa.2012-0709-RA | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24678678 }} </ref> | |||
==Causes== | ==Causes== | ||
[[Endometrial hyperplasia]] is caused by high levels of [[estrogen]]s, combined with insufficient levels of the [[progesterone]]-like [[Hormone|hormones]] which ordinarily counteract [[estrogen]]'s [[Proliferation|proliferative]] effects on this [[tissue]].<ref name="qw">Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia#Diagnosis Accessed on March 16, 2016</ref> | |||
==Differentiating Endometrial Hyperplasia from other Diseases== | ==Differentiating Endometrial Hyperplasia from other Diseases== | ||
[[Endometrial hyperplasia]] must be [[Differentiate|differentiated]] from [[conditions]] that have similar [[ultrasound]] [[Appearance|appearances]] such as [[normal]] thickening during the [[secretory phase]], [[sessile]] [[endometrial polyp]], [[submucosal]] [[uterine]] [[fibroid]]s, [[endometrial cancer]], adherent intrauterine [[blood clot]], and [[pregnancy]].<ref name="wp">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.</ref><ref name="pmid8184058">{{cite journal| author=Hulka CA, Hall DA, McCarthy K, Simeone JF| title=Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography. | journal=Radiology | year= 1994 | volume= 191 | issue= 3 | pages= 755-8 | pmid=8184058 | doi=10.1148/radiology.191.3.8184058 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8184058 }} </ref><ref name="ol">Abnormally thickened endometrium: differential diagnosis. Radiopedia. http://radiopaedia.org/articles/abnormally-thickened-endometrium-differential-diagnosis Accessed on March 3, 2016.</ref> | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
[[Women]] of all [[age]] groups may [[Development|develop]] [[endometrial hyperplasia]].<ref name="lk">Endometrial Hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 9, 2016</ref> However, [[endometrial hyperplasia]] is more common in [[postmenopausal]] [[women]]. | |||
==Risk Factors== | ==Risk Factors== | ||
Common [[risk factors]] in the [[development]] of [[endometrial hyperplasia]] include [[age]]>35 [[Year|years]], white [[race]], [[nulliparity]], late [[menopause]], early [[menarche]], [[tamoxifen]] [[therapy]], [[obesity]], [[Lynch syndrome]], history of [[diabetes]], [[gallbladder]] disease, or [[thyroid]] [[disease]], and family history of [[ovarian]], [[colon]], or [[uterine]] [[cancers]].<ref name="df">Endometrial Hyperplasia. The American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Endometrial-Hyperplasia. Accessedon March 3, 2016.</ref> | |||
==Screening== | ==Screening== | ||
Routine [[screening]] for [[endometrial hyperplasia]] or [[endometrial carcinoma]] is not recommended. | |||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
The majority of cases of [[endometrial hyperplasia]], except complex [[Atypia|atypical]] [[hyperplasia]] resolve spontaneously with time.<ref name="pmid9255033">{{cite journal| author=Terakawa N, Kigawa J, Taketani Y, Yoshikawa H, Yajima A, Noda K et al.| title=The behavior of endometrial hyperplasia: a prospective study. Endometrial Hyperplasia Study Group. | journal=J Obstet Gynaecol Res | year= 1997 | volume= 23 | issue= 3 | pages= 223-30 | pmid=9255033 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9255033 }} </ref> If left untreated, 30% of [[patients]] with [[Atypia|atypical]] [[hyperplasia]] may progress to [[Development|develop]] [[endometrial carcinoma]].<ref name="pmid19285814">{{cite journal| author=Lacey JV, Chia VM| title=Endometrial hyperplasia and the risk of progression to carcinoma. | journal=Maturitas | year= 2009 | volume= 63 | issue= 1 | pages= 39-44 | pmid=19285814 | doi=10.1016/j.maturitas.2009.02.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19285814 }} </ref> [[Malignant]] [[transformation]] into [[endometrial cancer]] is the most common [[complication]] of [[Endometrial hyperplasia|endometrial hyperpasia]].<ref name="rc">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 16, 2016</ref> [[Prognosis]] is generally good with treatment. | |||
==Diagnosis== | ==Diagnosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
A positive history of irregular [[menstrual cycle]]s ([[PCOD]]) may be present.<ref name="qw">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 10, 2016.</ref> A detailed [[drug]] history may be helpful in the [[Assessment and Plan|assessment]] of possible [[risk factors]] for [[endometrial hyperplasia]]. A history of inappropriate [[hormone replacement therapy]] in [[Postmenopausal|post menopausal]] [[women]] and history of [[tamoxifen]] use in [[breast cancer]] [[patients]] may be present.<ref name="pmid25797956">{{cite journal| author=Emons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO)| title=New WHO Classification of Endometrial Hyperplasias. | journal=Geburtshilfe Frauenheilkd | year= 2015 | volume= 75 | issue= 2 | pages= 135-136 | pmid=25797956 | doi=10.1055/s-0034-1396256 | pmc=PMC4361167 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25797956 }} </ref><ref name="pmid19393600">{{cite journal| author=Reed SD, Newton KM, Clinton WL, Epplein M, Garcia R, Allison K et al.| title=Incidence of endometrial hyperplasia. | journal=Am J Obstet Gynecol | year= 2009 | volume= 200 | issue= 6 | pages= 678.e1-6 | pmid=19393600 | doi=10.1016/j.ajog.2009.02.032 | pmc=PMC2692753 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19393600 }} </ref><ref name="mn">Tamoxifen associated endometrial changes. Radiopedia. http://radiopaedia.org/articles/tamoxifen-associated-endometrial-changes Accessed on March 10, 2016</ref> | |||
===Physical Examination=== | ===Physical Examination=== | ||
Patients with endometrial hyperplasia usually appear well. Physical examination of patients with endometrial hyperplasia is usually not remarkable for any physical findings. | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Routine laboratory tests are usually normal among patients with endometrial hyperplasia. Some patients with endometrial hyperplasia may have abnormal [[complete blood count]], which is usually suggestive of [[anemia]] from prolonged vaginal bleeding.<ref name="pmid18021979">{{cite journal| author=Bobrowska K, Pietrzak B, Jabiry-Zieniewicz Z, Cyganek A, Kaminski P, Wielgos M et al.| title=Operative treatment of endometrial hyperplasia in kidney graft recipients: report of seven cases. | journal=Transplant Proc | year= 2007 | volume= 39 | issue= 9 | pages= 2756-8 | pmid=18021979 | doi=10.1016/j.transproceed.2007.09.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18021979 }} </ref> | |||
===CT=== | ===CT=== | ||
There are no CT findings associated with endometrial hyperplasia. | |||
===MRI=== | ===MRI=== | ||
There are no MRI findings associated with endometrial hyperplasia. | |||
===Ultrasound=== | ===Ultrasound=== | ||
Pelvic ultrasound on days 5 to 10 of [[menstrual cycle]] reduce the variability in endometrial thickness and may be helpful in the diagnosis of endometrial hyperplasia. On pelvic [[ultrasound]], endometrial hyperplasia is characterized by a homogeneous increase in the endometrial thickness in the majority of patients. However, endometrial hyperplasia may also cause asymmetric or focal thickening with surface irregularity which should raise a suspicion for [[malignancy]].<ref name="qw">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 10, 2016.</ref> | |||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
There are no other imaging findings associated with endometrial hyperplasia. | |||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
[[Hysteroscopy]] may be helpful in the direct visualization of [[precancerous]] lesions.<ref name="pmid23090535">{{cite journal| author=Trimble CL, Method M, Leitao M, Lu K, Ioffe O, Hampton M et al.| title=Management of endometrial precancers. | journal=Obstet Gynecol | year= 2012 | volume= 120 | issue= 5 | pages= 1160-75 | pmid=23090535 | doi=http://10.1097/AOG.0b013e31826bb121 | pmc=PMC3800154 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23090535 }} </ref> Diagnosis of endometrial hyperplasia is usually performed through [[curettage]] of the uterine cavity to obtain endometrial tissue for histopathologic analysis.<ref name="pmid18021979">{{cite journal| author=Bobrowska K, Pietrzak B, Jabiry-Zieniewicz Z, Cyganek A, Kaminski P, Wielgos M et al.| title=Operative treatment of endometrial hyperplasia in kidney graft recipients: report of seven cases. | journal=Transplant Proc | year= 2007 | volume= 39 | issue= 9 | pages= 2756-8 | pmid=18021979 | doi=10.1016/j.transproceed.2007.09.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18021979 }} </ref> | |||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
[[Progesterone]] therapy is the preferred drug for the treatment of [[benign]] hyperplasia. The management of endometrial hyperplasia depends upon the desire for future childbearing.<ref name="pmid25797956">{{cite journal| author=Emons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO)| title=New WHO Classification of Endometrial Hyperplasias. | journal=Geburtshilfe Frauenheilkd | year= 2015 | volume= 75 | issue= 2 | pages= 135-136 | pmid=25797956 | doi=10.1055/s-0034-1396256 | pmc=PMC4361167 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25797956 }} </ref> | |||
===Surgery=== | ===Surgery=== | ||
Total [[hysterectomy]] is curative for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia.<ref name="pmid23090535">{{cite journal| author=Trimble CL, Method M, Leitao M, Lu K, Ioffe O, Hampton M et al.| title=Management of endometrial precancers. | journal=Obstet Gynecol | year= 2012 | volume= 120 | issue= 5 | pages= 1160-75 | pmid=23090535 | doi=http://10.1097/AOG.0b013e31826bb121 | pmc=PMC3800154 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23090535 }} </ref> | |||
==References== | ==References== | ||
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Latest revision as of 03:54, 15 May 2019
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Endometrial hyperplasia Microchapters |
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Endometrial hyperplasia overview On the Web |
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American Roentgen Ray Society Images of Endometrial hyperplasia overview |
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Risk calculators and risk factors for Endometrial hyperplasia overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Swathi Venkatesan, M.B.B.S.[2]
Overview
Endometrial hyperplasia is a condition of excessive proliferation of the endometrial cells (inner lining of the uterus) associated with an increased gland to stroma ratio. The majority of cases of endometrial hyperplasia result from high concentrations of estrogen combined with insufficient concentration of the progesterone-like hormones which normally counteract the proliferative effects of estrogen on the endometrial tissue.[1] Anovulation results in the prolonged release of estrogen and the relative lack of progesterone resulting in excessive stimulation of the endometrium. Unopposed estrogen stimulation may be either from an endogenous or exogenous source.[2][1] Endometrial hyperplasia may be broadly classified based on histology into simple and complex types. Endometrial hyperplasia may also be classified based on the presence or absence of cellular atypia (hyperplasia with cellular atypia and hyperplasia without cellular atypia).[3][4][5] Endometrial hyperplasia must be differentiated from conditions that have similar ultrasound appearances such as normal thickening during the secretory phase, sessile endometrial polyp, submucosal uterine fibroids, endometrial cancer, adherent intrauterine blood clot,and pregnancy.[4][6][7] Women of all age groups may develop endometrial hyperplasia.[8] However, endometrial hyperplasia is more common in postmenopausal women. The majority of cases of endometrial hyperplasia, except complex atypical hyperplasia resolve spontaneously with time.[9] If left untreated, 30% of patients with atypical hyperplasia may progress to develop endometrial carcinoma.[10] Malignant transformation into endometrial cancer is the most common complication of endometrial hyperpasia.[11] Prognosis is generally good with treatment. Pelvic ultrasound on days 5 to 10 of menstrual cycle reduce the variability in endometrial thickness and may be helpful in the diagnosis of endometrial hyperplasia. On pelvic ultrasound, endometrial hyperplasia is characterized by a homogeneous increase in the endometrial thickness in the majority of patients. However, endometrial hyperplasia may also cause asymmetric or focal thickening with surface irregularity which should raise a suspicion for malignancy.[12] Progesterone therapy is the preferred drug for the treatment of benign hyperplasia. The management of endometrial hyperplasia depends upon the desire for future childbearing.[13] Total hysterectomy is curative for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia.[14]
Classification
Endometrial hyperplasia may be broadly classified based on histology into simple and complex types. Endometrial hyperplasia may also be classified based on the presence or absence of cellular atypia (hyperplasia with cellular atypia and hyperplasia without cellular atypia).[3][4][5]
Pathophysiology
Endometrial hyperplasia is a condition of excessive proliferation of the endometrial cells (inner lining of the uterus) associated with an increased gland to stroma ratio. The majority of cases of endometrial hyperplasia result from high concentrations of estrogen combined with insufficient concentration of the progesterone-like hormones which normally counteract the proliferative effects of estrogen on the endometrial tissue.[1] Anovulation results in the prolonged release of estrogen and the relative lack of progesterone resulting in excessive stimulation of the endometrium. Unopposed oestrogen stimulation may be either from an endogenous or exogenous source.[1][2]
Causes
Endometrial hyperplasia is caused by high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily counteract estrogen's proliferative effects on this tissue.[12]
Differentiating Endometrial Hyperplasia from other Diseases
Endometrial hyperplasia must be differentiated from conditions that have similar ultrasound appearances such as normal thickening during the secretory phase, sessile endometrial polyp, submucosal uterine fibroids, endometrial cancer, adherent intrauterine blood clot, and pregnancy.[4][6][7]
Epidemiology and Demographics
Women of all age groups may develop endometrial hyperplasia.[8] However, endometrial hyperplasia is more common in postmenopausal women.
Risk Factors
Common risk factors in the development of endometrial hyperplasia include age>35 years, white race, nulliparity, late menopause, early menarche, tamoxifen therapy, obesity, Lynch syndrome, history of diabetes, gallbladder disease, or thyroid disease, and family history of ovarian, colon, or uterine cancers.[15]
Screening
Routine screening for endometrial hyperplasia or endometrial carcinoma is not recommended.
Natural History, Complications and Prognosis
The majority of cases of endometrial hyperplasia, except complex atypical hyperplasia resolve spontaneously with time.[9] If left untreated, 30% of patients with atypical hyperplasia may progress to develop endometrial carcinoma.[10] Malignant transformation into endometrial cancer is the most common complication of endometrial hyperpasia.[11] Prognosis is generally good with treatment.
Diagnosis
History and Symptoms
A positive history of irregular menstrual cycles (PCOD) may be present.[12] A detailed drug history may be helpful in the assessment of possible risk factors for endometrial hyperplasia. A history of inappropriate hormone replacement therapy in post menopausal women and history of tamoxifen use in breast cancer patients may be present.[13][16][17]
Physical Examination
Patients with endometrial hyperplasia usually appear well. Physical examination of patients with endometrial hyperplasia is usually not remarkable for any physical findings.
Laboratory Findings
Routine laboratory tests are usually normal among patients with endometrial hyperplasia. Some patients with endometrial hyperplasia may have abnormal complete blood count, which is usually suggestive of anemia from prolonged vaginal bleeding.[18]
CT
There are no CT findings associated with endometrial hyperplasia.
MRI
There are no MRI findings associated with endometrial hyperplasia.
Ultrasound
Pelvic ultrasound on days 5 to 10 of menstrual cycle reduce the variability in endometrial thickness and may be helpful in the diagnosis of endometrial hyperplasia. On pelvic ultrasound, endometrial hyperplasia is characterized by a homogeneous increase in the endometrial thickness in the majority of patients. However, endometrial hyperplasia may also cause asymmetric or focal thickening with surface irregularity which should raise a suspicion for malignancy.[12]
Other Imaging Findings
There are no other imaging findings associated with endometrial hyperplasia.
Other Diagnostic Studies
Hysteroscopy may be helpful in the direct visualization of precancerous lesions.[14] Diagnosis of endometrial hyperplasia is usually performed through curettage of the uterine cavity to obtain endometrial tissue for histopathologic analysis.[18]
Treatment
Medical Therapy
Progesterone therapy is the preferred drug for the treatment of benign hyperplasia. The management of endometrial hyperplasia depends upon the desire for future childbearing.[13]
Surgery
Total hysterectomy is curative for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia.[14]
References
- ↑ 1.0 1.1 1.2 1.3 Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia Accessed on March 7, 2016.
- ↑ 2.0 2.1 Owings RA, Quick CM (2014). "Endometrial intraepithelial neoplasia". Arch Pathol Lab Med. 138 (4): 484–91. doi:10.5858/arpa.2012-0709-RA. PMID 24678678.
- ↑ 3.0 3.1 Scully RE. Histological typing of female genital tract tumours. Springer; 1994.
- ↑ 4.0 4.1 4.2 4.3 Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.
- ↑ 5.0 5.1 Jorizzo JR, Chen MY, Martin D, Dyer RB, Weber TM (2002). "Spectrum of endometrial hyperplasia and its mimics on saline hysterosonography". AJR Am J Roentgenol. 179 (2): 385–9. doi:10.2214/ajr.179.2.1790385. PMID 12130438.
- ↑ 6.0 6.1 Hulka CA, Hall DA, McCarthy K, Simeone JF (1994). "Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography". Radiology. 191 (3): 755–8. doi:10.1148/radiology.191.3.8184058. PMID 8184058.
- ↑ 7.0 7.1 Abnormally thickened endometrium: differential diagnosis. Radiopedia. http://radiopaedia.org/articles/abnormally-thickened-endometrium-differential-diagnosis Accessed on March 3, 2016.
- ↑ 8.0 8.1 Endometrial Hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 9, 2016
- ↑ 9.0 9.1 Terakawa N, Kigawa J, Taketani Y, Yoshikawa H, Yajima A, Noda K; et al. (1997). "The behavior of endometrial hyperplasia: a prospective study. Endometrial Hyperplasia Study Group". J Obstet Gynaecol Res. 23 (3): 223–30. PMID 9255033.
- ↑ 10.0 10.1 Lacey JV, Chia VM (2009). "Endometrial hyperplasia and the risk of progression to carcinoma". Maturitas. 63 (1): 39–44. doi:10.1016/j.maturitas.2009.02.005. PMID 19285814.
- ↑ 11.0 11.1 Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 16, 2016
- ↑ 12.0 12.1 12.2 12.3 Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 10, 2016.
- ↑ 13.0 13.1 13.2 Emons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO) (2015). "New WHO Classification of Endometrial Hyperplasias". Geburtshilfe Frauenheilkd. 75 (2): 135–136. doi:10.1055/s-0034-1396256. PMC 4361167. PMID 25797956.
- ↑ 14.0 14.1 14.2 Trimble CL, Method M, Leitao M, Lu K, Ioffe O, Hampton M; et al. (2012). "Management of endometrial precancers". Obstet Gynecol. 120 (5): 1160–75. doi:http://10.1097/AOG.0b013e31826bb121 Check
|doi=value (help). PMC 3800154. PMID 23090535. - ↑ Endometrial Hyperplasia. The American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Endometrial-Hyperplasia. Accessedon March 3, 2016.
- ↑ Reed SD, Newton KM, Clinton WL, Epplein M, Garcia R, Allison K; et al. (2009). "Incidence of endometrial hyperplasia". Am J Obstet Gynecol. 200 (6): 678.e1–6. doi:10.1016/j.ajog.2009.02.032. PMC 2692753. PMID 19393600.
- ↑ Tamoxifen associated endometrial changes. Radiopedia. http://radiopaedia.org/articles/tamoxifen-associated-endometrial-changes Accessed on March 10, 2016
- ↑ 18.0 18.1 Bobrowska K, Pietrzak B, Jabiry-Zieniewicz Z, Cyganek A, Kaminski P, Wielgos M; et al. (2007). "Operative treatment of endometrial hyperplasia in kidney graft recipients: report of seven cases". Transplant Proc. 39 (9): 2756–8. doi:10.1016/j.transproceed.2007.09.023. PMID 18021979.