Endometrial Hyperplasia: An Over-Diagnosed Condition in Perimenopausal Women

by Magnolia on August 9, 2013

Post image for Endometrial Hyperplasia: An Over-Diagnosed Condition in Perimenopausal Women

Today’s post is a guest post by Dr. Roger Reichert, a leading expert in endometrial hyperplasia.  Endometrial hyperplasia is a medical term for the abnormal thickening of the lining of the uterus which causes heavy, irregular bleeding. This condition is commonly diagnosed in perimenopausal women, and has certainly been a popular topic here at The Perimenopause Blog.  

I know the post is highly technical in some places, and perhaps a little difficult for some of you to understand, but, it is a very important topic, and well worth the effort to read.  If you need any clarification, please do not hesitate to ask.  Dr. Reichert’s bio is at the end of the post, along with links to his website as well. 

Most patients with endometrial hyperplasia are in the perimenopausal age group and are diagnosed after their gynecologist has obtained an endometrial sample because the patient has complained of abnormal uterine bleeding.

Prior to endometrial sampling, the patient may have had an ultrasound that showed a thickened endometrium. Endometrial hyperplasia is a benign condition in which the glands of the endometrium have proliferated to an extent where they are noticeably more crowded than the glands found in the normal proliferative endometrium (too many glands, not enough stroma).

These hyperplastic glands often display abnormal sizes and shapes due to cystic dilatation, branching, and budding. The lower end of the spectrum of endometrial hyperplasia is due to the effects of unopposed estrogen, whereas superimposed genetic abnormalities are also thought to be present in its more atypical forms.

During the evaluation of a hyperplastic endometrium, the pathologist determines whether or not cytologic (nuclear) atypia is present within the cells lining the hyperplastic glands and whether the architecture of the glands is simple or complex.

In the most widely used classification of endometrial hyperplasia, these determinations result in four possible diagnoses:

  • simple hyperplasia without atypia
  • complex hyperplasia without atypia
  • simple hyperplasia with atypia
  • complex hyperplasia with atypia.

Clinical management decisions are driven by whether or not the proliferation is considered atypical.  Hyperplasia without atypia is managed conservatively as a self-limited process, whereas atypical hyperplasia is considered precancerous and is usually treated with hysterectomy (in women who wish to preserve their uterus, progestin therapy is another option).

If a patient’s pathology report indicates a diagnosis of endometrial intraepithelial neoplasia (EIN), then her pathologist is using a less popular classification system. Management of EIN is similar to that of atypical hyperplasia.

Due to sampling and/or interpretative issues, roughly 40% of uteri removed shortly after a diagnosis of complex atypical hyperplasia are found to contain endometrial cancer, which in these cases is usually low grade and associated with an excellent prognosis.

Patients and their gynecologists tend to accept the diagnosis of endometrial hyperplasia as provided to them by the pathologist, as if categorizing abnormal endometrial proliferations were a straightforward exercise. In fact, classification of endometrial hyperplasia is often difficult and subjective, and it is best done by pathologists with many years of experience in this area.

When mistakes are made, it is usually overcalling rather than undercalling endometrial hyperplasia, since the pathologist’s tendency is to not miss a lesion that might potentially harm a patient.

Mimics of endometrial hyperplasia include (a) glandular dissociation, coiling, and telescoping artifacts, (b) endometrial polyps, (c) late secretory endometrium, (d) basalis endometrium, (e) cystic atrophy, and (f) endometrial metaplasia, but the most common problem is overdiagnosing disordered proliferative endometrium as hyperplasia.

Disordered proliferative endometrium is a normal and expected finding in women with irregular uterine bleeding as they transition to menopause. Misinterpreting this physiologic process as endometrial hyperplasia can result in unnecessary patient anxiety, needless consultations with gynecologic oncologists, hormonal treatment, and even hysterectomy (hormonal treatment may be appropriate to manage uterine bleeding, but is misguided if the intent is to treat a precancerous lesion).

As an example of the widespread nature of this problem, a recent article (Am J Clin Pathol 2012; 138:524-534) reported that out of 22 cases of complex atypical hyperplasia diagnosed at two respected university hospitals, 4 (18%) were reinterpreted as disordered proliferative endometrium upon reexamination by pathologists with expertise in gynecologic pathology.

A diagnosis with an even higher likelihood of being reinterpreted as a less serious process upon expert review is simple atypical hyperplasia. Clearly, one of the most effective means of “curing” many patients with endometrial hyperplasia, and the first one patients should try, is obtaining an expert second opinion on their pathology slides.

********************

RAR Blog Photo (298x300) (199x200)Dr. Roger Reichert is an experienced, well-known gynecologic pathologist who did his pathology training at Stanford University, where he also obtained his B.S., M.D., and Ph.D. degrees.

Dr. Reichert has written a critically acclaimed book entitled Diagnostic Gynecologic and Obstetric Pathology: An Atlas and Text, which was published by Lippincott Williams & Wilkins in 2012. Through his website, reichertpathology.com, Dr. Reichert provides expert second opinions on gynecologic pathology slides sent to him at the request of patients.

No TweetBacks yet. (Be the first to Tweet this post)

{ 15 comments… read them below or add one }

Dawn August 14, 2013 at 11:53 am

Good info. Thank you for sharing!

Reply

Sue August 14, 2013 at 12:29 pm

Goodness, sounds awfully complicated

Reply

sandra August 14, 2013 at 1:03 pm

I think I have this. This article is very technical and difficult to follow. But it’s good info.

Reply

jackie lemmink August 14, 2013 at 10:58 pm

Interesting…

Reply

Elizabeth December 11, 2013 at 2:07 pm

Very well written and informative article.Thank you.

Reply

Amy April 7, 2014 at 7:35 pm

That’s all fine and dandy. But what if you’re 22 and diagnosed? ie not peri menopausal.

Reply

Roger Reichert, MD PhD June 24, 2014 at 7:37 pm

Hi Amy,

If you’re 22 and diagnosed with endometrial hyperplasia, the most likely possibilities are that you have polycystic ovary syndrome or that you have been overdiagnosed.

Reply

Kelly August 24, 2014 at 11:59 am

Thank you for writting this article. It is great to know there is hope if one receives this diagnosis.

I was diagnosed with complex hyperplasia without atypia in March. My doc has been pushing for a hysterectomy and is nonstop with the “this will turn into cancer” talk. I tried IUD therapy for 7 weeks which was a nightmare and it was discontinued resulting in 2 months without any therapy. I am just beginning oral Prometrium therapy and I am very concerned about the side affects. I am stressed out, scared, worried and very anxious about my condition. I am just beginning the process of finding someone for a 2nd opinion. Your article has brought me hope. Thank you.

Reply

Shabana August 26, 2014 at 1:09 pm

Well at least some of my queries got resolved and I know that my gyneac is on the right track. I was especially worried for my health after a recent D n C.

Reply

Barb September 25, 2014 at 7:38 pm

I was just diagnosed with complex hyper w/atypical cells and my dr immediately started the hysterectomy discussion. If this is caused by too much estrogen, as he explained to me, why isnt the first course of action giving progesterone to balance the hormones out? I hate this ‘cut it out’ mentality and Im shocked by the number of women who keep telling me that getting a hysterectomy is ‘no big deal’. Its a very big deal to me.

Reply

Marcia October 1, 2014 at 3:26 am

I was diagnosed this summer with Grade 1 complex hyperplasia with atypia, and was immediately referred to a gynecologic oncologist. The doctor I saw recommended surgery, but a robotic surgery that he didn’t do, so he referred me to his colleague. I really didn’t like the idea of surgery; but when I consulted with the second doctor, he actually suggested we treat it with progesterone therapy instead; as he’s had success with other patients, even one with a cancer diagnosis. I was first started on oral megestrol tablets, 40mg twice a day; then returned a couple weeks later where they inserted a Mirena IUD. It’s been about a month and a half, and I’m ok; although I recently started having breakthrough bleeding. (I figure the stuff’s gotta go somewhere…yuck) I don’t think I was overdiagnosed, an I’m hopeful that the hormone therapy works for me, since I really don’t like the idea of a hysterectomy.

Reply

Keisha October 3, 2014 at 12:39 pm

40yr old Black female:

This is very helpful. It seems to not be a big topic online, as it took forever to find this site.
I was 38 when my Dr told me that I had to have my uterus shaved because the lining was too thick. I have no idea if I was atypical or not. I allowed them to do the procedure and I was woke and it was so painful I cried. It put me in the mind of an abortion (which I have never had, but heard about). Now I’m 40 and they are telling me that it has thickened again. I refuse to go through that again so I started taking Evening Primrose Oil once a day(I have recently been told to take three a day) before the start of my menses. It helps with the heavy bleeding, mood swings and feeling of anger but during my last menses I think I only took it one day . On my second dayI passed a clot the size of a half dollar. So I did some research and heard about Red Rasberry Tea. I am about to come on soon so I have been drinking the tea (I bought at a local health store and it taste way better than what you buy at the store already prepared) and started taking the Primrose oil as I expect my visitor next week. I will keep you posted on my results for this month.
My question would be is there any other natural therapies for this condition? I read on the dangers of hormone replacement and I’d rather pass.
Thank you in advance.

Reply

Roger Reichert, MD PhD October 21, 2014 at 6:44 pm

Please see my related post on the overuse of hysterectomy for endometrial hyperplasia on kevinmd.com. Here’s the link:
http://www.kevinmd.com/blog/2014/10/hysterectomy-many-endometrial-hyperplasias-often-overkill.html

Reply

Erika October 26, 2014 at 1:14 pm

I had breakthrough bleeding on and off for a year. A sonogram reveled a 4.5 x4.5×1.5 cm polyp which was removed in July. My pathology report read:
Polypoid fragments of hyperplastic endometrium
negative for cytologic atypia or malignancy
I’m 68 and my doctor put me on 5 mg Medroxyprogesterone taken every day because she says that endometrial hyperplasia is a precancerous condition. I’m cranky, bloated, breaking out and don’t like how this medication makes me feel.
Since the report states it was negative for atypia I wonder if it is really necessary for me to take progesterone. I would be extremely grateful for your opinion.

Thank you in advance.

Reply

Roger Reichert, MD PhD October 30, 2014 at 9:41 pm

Hi Erika,
Only some forms of endometrial hyperplasia are precancerous. The type typically found in endometrial polyps is not, and should not even be labeled hyperplasia (see the link from my 10/21/14 comment). It would be interesting to know if your gynecologist sampled non-polypoid endometrium at the time of the polypectomy, and what that showed. If (a) that was normal or showed only simple hyperplasia without atypia, (b) your path report is accurate, and (c) you are not currently having any abnormal bleeding, then you could make a case with your gynecologist to discontinue the progesterone.

Reply

Leave a Comment

Previous post:

Next post: