Endometrial hyperplasia

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Endometrial hyperplasia
Simple endometrial hyperplasia - low mag.jpg
Micrograph showing simple endometrial hyperplasia, where the gland-to-stroma ratio is preserved but the glands have an irregular shape and/or are dilated. Endometrial biopsy. H&E stain.
Specialty Gynaecology   OOjs UI icon edit-ltr-progressive.svg

Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus.

Contents

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 obesity, polycystic ovary syndrome, estrogen producing tumours (e.g. granulosa cell tumour) and certain formulations of estrogen replacement therapy.

Endometrial hyperplasia with atypia is a significant risk factor for the development or even co-existence of endometrial cancer, so careful monitoring and treatment of women with this disorder is essential.

Classification

Histopathology of complex hyperplasia without atypia: Cystically dilated endometrial glands lined by a single layer of columnar epithelium. Histopathology of complex hyperplasia without atypia.jpg
Histopathology of complex hyperplasia without atypia: Cystically dilated endometrial glands lined by a single layer of columnar epithelium.
Histopathology of complex hyperplasia with atypia: Closely packed endometrial glands with sparse intervening stroma and stratification of the lining epithelium. Epithelial cells show cytological atypia with high nucleocytoplasmic ratio, irregular clumping of nuclear chromatin, and mitotic figures. Histopathology of complex hyperplasia with atypia.jpg
Histopathology of complex hyperplasia with atypia: Closely packed endometrial glands with sparse intervening stroma and stratification of the lining epithelium. Epithelial cells show cytological atypia with high nucleocytoplasmic ratio, irregular clumping of nuclear chromatin, and mitotic figures.

Like other hyperplastic disorders, endometrial hyperplasia initially represents a physiological response of endometrial tissue to the growth-promoting actions of estrogen. However, the gland-forming cells of a hyperplastic endometrium may also undergo changes over time which predispose them to cancerous transformation. Several histopathology subtypes of endometrial hyperplasia are recognisable to the pathologist, with different therapeutic and prognostic implications. [3]

The most commonly used classification system for endometrial hyperplasia is the World Health Organization (WHO) system, which previously had four categories: simple hyperplasia without atypia, complex hyperplasia without atypia, simple atypical hyperplasia and complex atypical hyperplasia. [4] In 2014, the WHO updated the classification system and removed the distinction between simple or complex hyperplasia, instead only on presence or absence of atypia. [5]

Diagnosis

Diagnosis of endometrial hyperplasia can be made by endometrial biopsy, which is done in the office setting or through curettage of the uterine cavity to obtain endometrial tissue for histopathologic analysis. A workup for endometrial disease may be prompted by abnormal uterine bleeding, or the presence of atypical glandular cells on a pap smear. [7]

Prognosis

Many studies have shown that endometrial hyperplasia can progress to cancer, particularly when there are atypical cells. Nevertheless, such studies has typically dealt with atypical hyperplasia. A review of 65 articles on estimated risk of progression to cancer concludes that none of those studies reported estimates specifically for non-atypical hyperplasia patients. Further it states the need for population based studies including both non-atypical and atypical hyperplasia to accurately estimate the risk of progression to cancer. [8]

If untreated with hysterectomy, endometrial hyperplasia progresses to adenocarcinoma within 20 years in:

The rates are more favorable in cases with simple rather than complex hyperplasia, [10] but as mentioned above this terminology was phased out of the WHO classification in 2014.

In patients with samples showing atypia, carcinoma is already present in over 40% of cases. [11] [12] Given this, the aforementioned 28% atypia progression rate may be an underestimate, and the true number may closer to the 42.5% part of the study's remarkably wide confidence interval.

Treatment

Treatment of endometrial hyperplasia is individualized, and may include hormonal therapy, such as cyclic or continuous progestin therapy, or hysterectomy. [7]

See also

Related Research Articles

Endometrium Inner mucous membrane of the mammalian uterus

The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional layer thickens and then is shed during menstruation in humans and some other mammals, including apes, Old World monkeys, some species of bat, the elephant shrew and the Cairo spiny mouse. In most other mammals, the endometrium is reabsorbed in the estrous cycle. During pregnancy, the glands and blood vessels in the endometrium further increase in size and number. Vascular spaces fuse and become interconnected, forming the placenta, which supplies oxygen and nutrition to the embryo and fetus. The speculated presence of an endometrial microbiota has been argued against.

Uterine cancer Medical condition

Uterine cancer, also known as womb cancer, includes two types of cancer that develop from the tissues of the uterus. Endometrial cancer forms from the lining of the uterus, and uterine sarcoma forms from the muscles or support tissue of the uterus. Endometrial cancer accounts for approximately 90% of all uterine cancers in the United States. Symptoms of endometrial cancer include changes in vaginal bleeding or pain in the pelvis. Symptoms of uterine sarcoma include unusual vaginal bleeding or a mass in the vagina.

Endometrial cancer Uterine cancer that is located in tissues lining the uterus

Endometrial cancer is a cancer that arises from the endometrium. It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain. Endometrial cancer occurs most commonly after menopause.

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Hyperplasia Increase in the amount of organic tissue that results from cell proliferation

Hyperplasia, or hypergenesis, is an enlargement of an organ or tissue caused by an increase in the amount of organic tissue that results from cell proliferation. It may lead to the gross enlargement of an organ, and the term is sometimes confused with benign neoplasia or benign tumor.

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Adenomyosis Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Endometrial polyp Medical condition

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

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Endometrial intraepithelial neoplasia (EIN) is a premalignant lesion of the uterine lining that predisposes to endometrioid endometrial adenocarcinoma. It is composed of a collection of abnormal endometrial cells, arising from the glands that line the uterus, which have a tendency over time to progress to the most common form of uterine cancer—endometrial adenocarcinoma, endometrioid type.

Fibrocystic breast changes Medical condition

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Sebaceous carcinoma Medical condition

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Arias-Stella reaction

Arias-Stella reaction, also Arias-Stella phenomenon, is a benign change in the endometrium associated with the presence of chorionic tissue.

Vaginal adenosis is a benign abnormality in the vagina, commonly thought to be caused by intrauterine and neonatal exposure of diethylstilbestrol and other progestogens and nonsteroidal estrogens, however it has also been observed in otherwise healthy women and has been considered at times idiopathic or congenital. Postpubertal lesions have also been observed to grow de novo. It has a rather common incidence, of about 10% of adult women.

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References

  1. Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India". Indian Journal of Medical and Paediatric Oncology. 30 (4): 131–135. doi:10.4103/0971-5851.65335. ISSN   0971-5851. PMC   2930300 . PMID   20838554.
    - Figure- available via license: Creative Commons Attribution 2.0 Generic
  2. Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India". Indian Journal of Medical and Paediatric Oncology. 30 (4): 131–135. doi:10.4103/0971-5851.65335. ISSN   0971-5851. PMC   2930300 . PMID   20838554.
    - Figure- available via license: Creative Commons Attribution 2.0 Generic
  3. Cote, Richard; Suster, Saul; Weiss, Lawrence; et al., eds. (2002). Modern Surgical Pathology (2 Volume Set). London: W B Saunders. ISBN   0-7216-7253-1.[ page needed ]
  4. Skov, B. G.; Broholm, H; Engel, U; Franzmann, M. B.; Nielsen, A. L.; Lauritzen, A. F.; Skov, T (1997). "Comparison of the reproducibility of the WHO classifications of 1975 and 1994 of endometrial hyperplasia". International Journal of Gynecological Pathology. 16 (1): 33–7. doi:10.1097/00004347-199701000-00006. PMID   8986530. S2CID   26446736.
  5. Emons, G.; Beckmann, M. W.; Schmidt, D.; Mallmann, P. (February 2015). "New WHO Classification of Endometrial Hyperplasias". Geburtshilfe und Frauenheilkunde. 75 (2): 135–136. doi:10.1055/s-0034-1396256. ISSN   0016-5751. PMC   4361167 . PMID   25797956.
  6. 1 2 Kurman, Robert J.; Kaminski, Paul F.; Norris, Henry J. (1985). "The behavior of endometrial hyperplasia. A long-term study of "untreated" hyperplasia in 170 patients". Cancer. 56 (2): 403–12. doi: 10.1002/1097-0142(19850715)56:2<403::AID-CNCR2820560233>3.0.CO;2-X . PMID   4005805.
  7. 1 2 Howard A Zacur; Robert L Giuntoli, II; Marcus Jurema. "Endometrial Hyperplasia" . UpToDate Online. Retrieved 2007-05-26.
  8. Doherty, Michelle T.; Sanni, Omolara B.; Coleman, Helen G.; Cardwell, Chris R.; McCluggage, W. Glenn; Quinn, Declan; Wylie, James; McMenamin, Úna C. (2020). "Concurrent and future risk of endometrial cancer in women with endometrial hyperplasia: A systematic review and meta-analysis". PLOS ONE. 15 (4): e0232231. Bibcode:2020PLoSO..1532231D. doi: 10.1371/journal.pone.0232231 . PMC   7188276 . PMID   32343732.
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