Endometrial Hyperplasia: An Over-Diagnosed Condition in Perimenopausal Women

by Magnolia on August 9, 2013

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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.

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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.

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{ 24 comments… read them below or add one }

Mimsey April 3, 2015 at 7:03 pm

3 April 2015

Hello.
Einstein for E=mc2
Ford for cars
and Dr. Reichert for ALL MATTERS relating to gynecologic pathology!
He is stellar.
He:
1. provided with me a more accurate and specific diagnosis than the general pathologist.
2. gave me EXTREMELY IMPORTANT questions, regarding my condition, to ask my doctors that I would not have been to get by just reading the net.
3. gave me UNLIMITED time, concern and information in the countless e-mails we exchanged with each other.
4. spent 37 minutes with me in a phone consultation =answering my questions, reaffirming the treatment I need and explaining in detail the 2-pg. slide analysis that he faxed to me.
I will say that this type of personalized care and time investment is what you would see in a parent or a spouse.
Thank you Dr. Reichert for all that you did for me.
Mimsey

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Kerrie May 16, 2015 at 10:51 pm

Hello Magnolia
Thanks for inviting Dr Reichert onto your blog as a guest.

His article was quite informative.

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Sujatha Nayar August 19, 2015 at 11:18 am

Hello Magnolia,

Thank you so much for starting this blog and inviting Dr Reichert. It feels a little comforting that the medical lingo in most reports which scare us, can be easily understood through Doctor’s explanation. Also, when i read about other women’s problems, i feel am not alone and if they are taking it in their stride, so can i. I respect and salute all my dear lady friends who have shared in this blog and wish all of you well.

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Lisa August 19, 2015 at 1:14 pm

Dr. Reichert is an absolute godsend. As Mimsy stated, he will spend as much time as necessary clearly explaining the science behind your pathology report in a way that is easy to understand by any layperson. While he did not disagree with my original pathology report, he thoroughly disagreed that it implied a hysterectomy was necessary. I appreciate the fact that he took the time to thoughtfully analyze my results and correlate them with my clinical history. He completely confounded both my PCP as well as my GYN with his detailed explanation as to why a hysterectomy was not necessary in my case. They still maintained that the “safest” option was to have a radical hysterectomy, but when I asked them on what basis they were disagreeing with Dr. Reichert’s conclusions and recommendation they were unable to articulate their position from a scientific perspective. Often, doctors simply lack the time, inclination, or depth of knowledge (i.e., a specialty in gynecologic pathology) to thoughtfully analyze each individual case and therefore default to the “safest” recommendation, which also happens to be the one that protects them the most from potential future lawsuits (and also pays the bills). I am so grateful to have found Dr. Reichert and can not thank him enough for the amount of time he invested in researching and analyzing my case, as well as providing a refreshingly unbiased perspective and recommendation.

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Anne September 4, 2015 at 1:03 am

Hi Dr Roger,

I am 28yrs old. No childeren.
5 months ago I had a hysterocopy, D&C, removal of polyps and partial cysectomy on my left ovary as I had contstant healvy bleeading for 1 year and I am wanting to conceive.
From the biopsy I was diagnosed with complex hyperplasia without atypia. My Dr reccommended that seeing as I am wanting to conceive is to have the IUD inserted for 2-3 and regular D&C’s and smears to monitor and for me to lose at least 20kg. This is all instead of hormone therapy and hsyterectomy.

What I would like to know is- What are the chances of it progressing into cancer and are there any known alternative therapies that have aided in this condition.

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Roger Reichert, MD PhD September 14, 2015 at 8:35 am

Hi Anne,

Sorry, but my expertise is in diagnosis rather than treatment. Since I haven’t reviewed your slides, I can’t be sure that your diagnosis is correct. If you and your physician prefer to assume that it is, then your physician is in a better position to assess your risk and to recommend the proper course of action.

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Kirsteen September 24, 2015 at 4:58 pm

Hi Dr Roger

I haven’t had a period or any bleeding for 6 months now. My blood tests showed that I have an FSH level of 83. A CT scan for gastrointestinal problems has now shown a “thickening of the wall of the uterus”. Is this a normal peri menopausal symptom? I also have tenderness lower middle abdomen and sciatica. Is any of this related? I have no hot flushes, headaches etc. what do I now ask doctors to do?

Thank you

Kirsteen

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Roger Reichert, MD PhD September 29, 2015 at 7:17 pm

Hi Kirsteen,

You might have adenomyosis, which would explain your thickened uterine wall and some of your symptoms. I recommend that you learn about adenomyosis online, and then ask your doctors about it.

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Kelley G October 30, 2015 at 4:49 pm

Dr. Reichert is an extremely kind person and I am extremely thankful to have access to his texts and articles.

Thank you for your research and for making information readily available to women.

Kelley

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jose November 2, 2015 at 6:10 am

Hi thank U for your extraordinary post. I have a doubt. I am 50 yrs and got my period yesterday after 6 months. On my first day of period(usually little flow)I took an ultrasound and it turned out that my endometrium is 14mm thick. Is it normal or do I have hyperplasia?

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Roger Reichert, MD PhD November 5, 2015 at 11:46 am

You should discuss your symptoms and ultrasound findings with your gynecologist to determine whether or not an endometrial biopsy is indicated. Although the diagnosis of hyperplasia can be suspected from clinical and radiologic findings, it can only be confirmed and subtyped by examining a tissue sample.

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Tiffany November 8, 2015 at 3:13 am

Hi,
I am a 37 year old woman trying to conceive. I was recently diagnosed with disordered proliferative endometrium following a uterine biopsy done for 2 weeks of spotting after stopping birth control 4 months prior. I experienced 4 months of having a period every 3 weeks prior to the biopsy, and was told that i had a uterine lining of 2 mm, then 2.5 in the following week. My most recent period occured 4 weeks after my last period, and is very painful and heavy, with many clots. Any ideas, suggestions.

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Roger Reichert, MD PhD November 10, 2015 at 3:23 am

Hi Tiffany,

Your issues are out of my area of expertise, which is gynecologic pathology. From your thin endometrial lining and your diagnosis of disordered proliferative endometrium, it sounds like you don’t have to worry about endometrial hyperplasia. Please discuss your situation with your gynecologist. I wish you the best of luck.

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Julie VanOrshoven November 11, 2015 at 2:00 am

I am 56 years old. No irregular periods, no heavy periods, no bad paps. Last period 4 years ago no PMB. Then diagnosed with hypothyroid and problems regulating right now. Then elevated fasting glucose of 115 and 6.3%A1C. I have gained 50 pounds since hypothyroid diagnosis at 280 pounds and 5-8″ tall. I had an unusually high episode of glucose topping out at 300 for over 1/2 hour then back down – normal by morning. I immediately went from 10 min on treadmill per day at 1.5 mph with 2500 calorie a day to strict no carb, 45 minutes on treadmill at time at 2.5 mph at 5-8% incline. Within 7 days felt like I was ovulating and felt great. Then 7th day – light spotting (first time ever) – I did no lose eyedropper full of blood over 5 day period with light brown spotting – very light. Then it stopped on 5th day and has not returned for 5 weeks. Mentioned it to my doctor, they insisted on a transvaginal probe and ultrasound. completed that yesterday. No tumors present; 10MM endometrial hyperplasia diagnosed; with 1 polyp. The pathologist mentioned that he could not determine size or atypia of polyp or lesion so recommended and endometrial biopsy, which I am having tomorrow. My doctor say checking for cancer cells in the thickened lining and removing and examining polyp. She says at this point in worst case scenario it would bee 100% curable. I assume that is because it is most likely pre-cancer rather than cancer. I am not familiar at all with the doctor doing the biopsy. Should I insist on a second opinion or go on with the biopsy tomorrow. Should I be very very worried about my life. I have a 10 years old child.

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Roger Reichert, MD PhD November 11, 2015 at 10:44 pm

Hi Julie,

Given your ultrasound findings and clinical history, I think that it is reasonable to do an endometrial biopsy. The odds are very high that it is nothing serious, so try not to worry. If the results lead you down a path that you don’t want to go, then you should get a second opinion on your pathology slides before proceeding with treatment.

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Cristina L December 25, 2015 at 6:10 am

Hello,

After my second c-section about 15 months ago, I have been having heavy bleeding with clots the first few days and my periods would last from 7-10 days….the last few days would be brown discharge. I just turned 35 years old and I have always had moderate to heavy periods that have been irregular since I was younger. For the past 8 months or so though I have had mid cycle discharge that is mucousy/sticky dark brown and brown. This usually starts a few days after my period has eneded and right around the time I was supposed to be ovulating (my cycles are mostly irregular). I usually have pain on one side when I am ovulating so I can feel it. Before this pregnancy, during my mid cycle I would get clear mucous discharge but now it looks like it has old blood in it. I did a transvaginal ultrasound in July and everything came back normal. I just had a endometrial biopsy done and the diagnosis was “disordered proliferative endometrium showing focal gland crowding bordering on endometrial hyperplasia. No atypical hyperlasia or malignancy identified. Clinical impression: menorrhagia.” My doctor just responded with its normal and to consider an ablation procedure. From looking online, this does not sound like its normal. Is cancer something I need to worry about in the future and is there anything I can do or take to prevent hyperplasia completely since it says bordering?? Your opinion would be greatly appreciated! Thank you so much!

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Roger Reichert, MD PhD December 29, 2015 at 3:41 pm

Hi Cristina,

If the diagnosis of your endometrial biopsy is correct, I agree that it is pretty close to normal and I would not be too concerned about it. If you would like me to provide you with a second opinion on your slides, please contact me through my website. Please note that the biopsy diagnosis does not explain the brown discharge, which is indicative of bleeding/shedding with a delay before passage (“old blood”).

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Laura Feher December 28, 2015 at 10:44 am

Taking time to inform via internet empowers me to adjust to results of my recent biopsy. Grateful for scholarly article.

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Laura Feher December 28, 2015 at 10:54 am

Thank you for caring. Adore comment field and your compassion.

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Bonnie B March 5, 2016 at 2:56 pm

I am post menopausal. I went to the ob last week with a bladder infection. An ultrasound was done along with the vaginal probe. At that time they noticed my lining had gone from 4.2 in 2014 to 5.7 currently. I have no bleeding or pain. My question is, could a tilted uterus show a thickening at any point. I am going for a biopsy next week and I’m quite nervous about it. I am sure I’m fine but I want to be prepared if the results show something. I am glad I read your article as I had already decided that a second opinion would be necessary if the results show anything serious. Any info you can give me on my question above would be much appreciated. Thank you!

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Roger Reichert, MD PhD March 7, 2016 at 5:31 pm

Hi Bonnie,

Although I am a pathologist rather than an OB/GYN or a radiologist, my understanding is that an ultrasound measurement of < 11 mm in an asymptomatic postmenopausal woman should not prompt an endometrial biopsy. If you were having vaginal bleeding, then an endometrial thickness of > 5 mm would prompt a biopsy. Search the internet for a 2004 paper entitled “How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding,” which shows that women in your situation have an estimated risk of having endometrial cancer of 0.002% (1 in 50,000!). This risk is way too low to subject yourself to the time, expense, stress, and potential complications of this procedure.

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Courtney April 18, 2016 at 8:07 pm

Hello,
I had a uterine biopsy and the pathology indicates Disordered proliferative pattern with focal simple hyperplasia without atypia. After doing some research and also reading your article I’m concerned that they may be jumping the gun by treating me with medroxyprogesterone. From what I have been learning the term “pre-cancerous” goes with the word atypia. My Gyn called my results pre-cancerous, which is why she wants me to treat it and follow it up with a biopsy in 3 months.
I have a muscle condition that causes a lot of pain and see that one of the side effects of the medicine is pain. Also, I’ve tried taking progestin in the past and it has made me feel horrible; lots of water retention, weight gain and feelings of hopelessness and anger.
Can you shed any light on my question of whether this does actually need treated? I feel like my doctor is mixing language with me. I know the tendency is to over-treat possible cancerous activity but I don’t share the same sentiment.
Thank you in advance!

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Roger Reichert, MD PhD April 21, 2016 at 1:45 pm

Hi Courtney,

Assuming that your diagnosis is correct, you are absolutely right to question the treatment and follow-up recommendations of your gynecologist. Virtually every woman who transitions to menopause will have an endometrium that at one point or another will show a disordered proliferative pattern with occasional foci that could be interpreted as simple hyperplasia without atypia, and I hope that gynecologists aren’t recommending that every woman in this situation be treated with progesterone and subjected to follow-up biopsies. Just as gynecologists tend to overtreat, pathologists tend to overcall, so the end result is unnecessary treatment and possible complications/side effects from that treatment. As I state in my article, hormonal treatment may be appropriate to manage excessive uterine bleeding, but it is misguided if the intent is to treat a precancerous lesion.

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Roger Reichert, MD PhD April 21, 2016 at 1:56 pm

Just to clarify the last sentence of my previous post, I do not think that women who share your diagnosis need to be treated with hormones unless the intent is to manage abnormal uterine bleeding; in patients with hyperplastic lesions that are more significant than yours, hormonal treatment is an appropriate option to consider.

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