Endometrial hyperplasia overview: Difference between revisions
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==Classification== | ==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).<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 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 oestrogen 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> | |||
==Causes== | ==Causes== | ||
Endometrial hyperplasia is caused by high levels of [[estrogen]]s, combined with insufficient levels of the [[progesterone]]-like hormones which ordinarily counteract [[estrogen]]'s 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 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="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=wp>Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.</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 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 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 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 atypical hyperplasia may progress to 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 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 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.<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== | ||
Revision as of 19:16, 17 March 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus. Most cases of endometrial hyperplasia result from high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily counteract estrogen's proliferative effects on this tissue. This may occur in a number of settings, including polycystic ovary syndrome and certain formulations of estrogen replacement therapy. Endometrial hyperplasia is a significant risk factor for the development of endometrial cancer so careful monitoring and treatment of women with this disorder is essential.
Historical Perspective
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).[1][2][3]
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.[4] 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.[5][4]
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.[6]
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.[7][2][8]
Epidemiology and Demographics
Women of all age groups may develop endometrial hyperplasia.[9]. 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.[10]
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.[11] If left untreated, 30% of patients with atypical hyperplasia may progress to develop endometrial carcinoma.[12] Malignant transformation into endometrial cancer is the most common complication of endometrial hyperpasia.[13] Prognosis is generally good with treatment.
Diagnosis
History and Symptoms
A positive history of irregular menstrual cycles (PCOD) may be present.[6] 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.[14][15][16]
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.[17]
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.[6]
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.[18] Diagnosis of endometrial hyperplasia is usually performed through curettage of the uterine cavity to obtain endometrial tissue for histopathologic analysis.[17]
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.[14]
Surgery
Total hysterectomy is curative for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia.[18]
References
- ↑ Scully RE. Histological typing of female genital tract tumours. Springer; 1994.
- ↑ 2.0 2.1 Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.
- ↑ 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.
- ↑ 4.0 4.1 Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia Accessed on March 7, 2016.
- ↑ 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.
- ↑ 6.0 6.1 6.2 Endometrial hyperplasia. Wikipedia. https://en.wikipedia.org/wiki/Endometrial_hyperplasia#Diagnosis Accessed on March 16, 2016
- ↑ 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.
- ↑ Abnormally thickened endometrium: differential diagnosis. Radiopedia. http://radiopaedia.org/articles/abnormally-thickened-endometrium-differential-diagnosis Accessed on March 3, 2016.
- ↑ Endometrial Hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 9, 2016
- ↑ Endometrial Hyperplasia. The American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Endometrial-Hyperplasia. Accessedon March 3, 2016.
- ↑ 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.
- ↑ 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.
- ↑ Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 16, 2016
- ↑ 14.0 14.1 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.
- ↑ 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
- ↑ 17.0 17.1 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.
- ↑ 18.0 18.1 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.