Endometrial Hyperplasia

S.Laxiny,Medical Student,

FHCS,EUSL.

Endometrial Hyperplasia

• Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium-Endometrial glands & surrounding tissue(Stroma).

• Endometrial hyperplasia is a non-cancerous condition.

• May involve part or all of the endometrium.

• Hyperplasia usually develops in the presence of continuous estrogen stimulation unopposed by progesterone.

• The female hormones—estrogen and progesterone—control the changes in the uterine lining.

• Estrogen builds up the uterine lining. • Progesterone maintains and controls this growth. • Estrogen without enough progesterone may cause the

lining of the uterus to thicken.

Pathogenesis

Risks for developing Endometrial Hyperplasia

• Estrogen replacement therapy -Take estrogen without progesterone to replace the estrogen their body is no longer making and to relieve symptoms of menopause

• Polycystic ovary syndrome- women are anovulatory and have unopposed estrogen effect.

• Estrogen producing tumours (e.g. granulosa cell tumour).• Irregular Menstrul Periods-Skip menstrual periods or have no

periods at all –continuous unopposed estrogen activity.• Perimenopause period• Overweight • Diabetes Mellitus

Classification of endometrial hyperplasia

• Simple hyperplasia (cystic without atypia) • Complex hyperplasia (adenomatous without atypia)• Atypical simple hyperplasia (cystic with atypia)• Atypical complex hyperplasia (adenomatous with

atypia)

Simple Endometrial Hyperlasia

Simple or Cystic Hyperplasia

Proliferation of glands and stroma.

Glands vary in size, some are cystic.

The epithelial cells are active with stratification and mitoses

Complex Endometrial Hyperlasia

a very complex gland pattern

abnormally shaped glands, in- and out-pouching.

Glands are crowded with very little endometrial stroma,

Atypical Endometrial Hyperplasia

Increased gland density

Nuclear atypia - hyperchromatic, enlarged epithelial cells with an increased nuclear to cytoplasmic ratio.

Resembles well differentiated carcinoma.

Atypical Endometrial Hyperplasia

On high power view the nuclear atypia can be seen:

Nuclei are of variable size, shape and chromatin distribution; prominent nucleoli.

Symptoms of Endometrial Hyperplasia

• Vaginal discharge• Abdominal pain• Bleeding between menstrual periods• Heavy or prolonged menstrual periods

Progression of Endometrial Hyperplasia

Type of Hyperplasia

Total Cases (n=170)

Years of Follow up (mean=13.4)

# Progressed to Cancer

% Progressed to Cancer

%Persistent

Hyperplasia

% Spont. Regression

Simple 93 15.2 1 1% 19% 80%Complex 29 13.5 1 3% 17% 80%Atypical,

simple13 11.4 1 8% 23% 69%

Atypical, complex

35 11.4 10 29% 14% 57%

Hyperplasia without atypia rarely progresses to endometrial cancer, Hyperplasia with atypia is a precancerous condition that may progress to overt malignancy.

Investigations

•Vaginal ultrasound•Endometrial biopsy•Dilation and curettage (D&C)•Hysteroscopy

Vaginal ultrasound

Focal Simple Hyperplasia

Atypical Hyperplasia

Treatment

• In most cases, endometrial hyperplasia can be treated with medication that is a form of the hormone progesterone.

• Taking progesterone will cause the lining to shed and prevent it from building up again. It often will cause vaginal bleeding.

Treatment for endometrial hyperplasia without Atypia

• In hyperplasia without atypia, cyclical progestin therapy is the recommended choice in women not seeking contraception.

• 10 mg medroxyprogesterone acetate for 10 to 14 days a month for 3 to 6 months.

• If they have a normal biopsy and are asymptomatic, discontinue therapy. • If the hyperplasia is persistent, then continuous-dose progestin therapy is instituted with 20

mg/day for 3 to 6 months• In women desiring contraception, OCP can be used or an injectable depot preparation of

medroxyprogesterone acetate ( Depo-Provera ) can be administered in the normal dose used for contraception - 150 mg every 12 weeks.

Commonly Used Progesterone- Only Agents

Generic Name Common Trade Names Common Dosage• Progesterone Crinone;Progestasert; • Prometrium 200 mg PO• Medroxyprogesterone Provera 10-20 mg PO Acetate Depo-Provera 150 mg IM

• Megestrol acetate Megace 40-320 mg PO

• Levonorgestrel Mirena IUS 1 intrauterine every 5 years

Treatment for Atypical endometrial hyperplasia

• Ideal management is hysterectomy• If hysterectomy is not a viable option for young

patient & patient is a very poor surgical candidate), • high-dose continuous progestin therapy can be used.

Typically, 20 mg of medroxyprogesterone acetate daily.

• Another option is 40 to 160 mg megestrol acetate daily for 6 months.

• biopsies every 6 months because of the high risk of recurrence.

Protecting Against EndometrialHyperplasia

• Take estrogen with progesterone after menopause, • Women who don't have regular periods-Take oral

contraceptives contain estrogen along with a form of progesterone.

• If you are overweight, losing weight may help.

Thank You