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.

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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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{ 37 comments… read them below or add one }

Dawn August 14, 2013 at 11:53 am

Good info. Thank you for sharing!

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Kim Thirkill December 15, 2014 at 3:28 am

I was diagnosed with a mild simple hyperplasia of the endometrial glands but no atypia and a benign endocervical polyp. I am 57 years old and my period stopped at age 47 with no more bleeding. I was put on the pill for 6 months of which I then had periods again and when I went back to the doctors everything was clear and I have had no more medication. I still see the doctor every 6 months which is now for 3 years and everything is now okay, do I still need to see the doctor? Can it still re-occur as I am going private and it obviously costs me each time?

Many thanks
Kim

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Roger Reichert, MD PhD December 18, 2014 at 4:41 pm

Hi Kim,

If your pathologic diagnosis is correct and you are asymptomatic, then I would recommend that you revert back to routine clinical follow-up.

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Sue August 14, 2013 at 12:29 pm

Goodness, sounds awfully complicated

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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.

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jackie lemmink August 14, 2013 at 10:58 pm

Interesting…

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Elizabeth December 11, 2013 at 2:07 pm

Very well written and informative article.Thank you.

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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.

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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.

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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.

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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.

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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.

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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.

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Karen November 15, 2014 at 12:47 am

Marcia,
I was diagnosed this week with complex hyperplasia with atypia. My gynecologist says I have to have a hysterectomy plus removal of ovaries by the end of the year. I am very unhappy and hoping to find someone that says it is reasonable to try treating this with progesterone. Would you mind telling me where you live and who the gynecologic oncologist is that is treating you with progesterone? It seems that so often people assume the only reason to avoid hysterectomy is if one still wants children, but I am 48 and I just REALLY do not want these organs removed unless they really have to be to prevent this from becoming cancer. Thanks!

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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.

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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

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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.

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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.

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KM November 18, 2014 at 2:18 am

On October 31, 2104 I went to the doctor for abnormal uterine bleeding. I had also passed a very large clot. I am 56 and don’t think I’ve gone through menopause yet although for the past 12 years my periods have been irregular. Early on I went to the gynecologist and was told that I was probably starting in to pre-menopause. He said some women progress through menopause within a short period of time and some it takes years. I wasn’t concerned as he indicated I had nothing to be concerned about. As the years went on I just figured I was one of those ones that would take years. I would have periodic bouts of no menstrual cycle for a few months at a time.

At this doctor visit on October 31st a transvaginal ultrasound was performed and a diagnosis was made of: Uterus: 7.7 x 4.2 x 4.9 cm: Markedly thickened masslike, isoechoic to the muscle, endometrium, versus mass, measuring 3.7 x 2.2 by 2.7 cm in dimension with increased blood flow. Right ovary 1.3 x 1.8 x 1.5 cm and left ovary 1.6 x 0.8 x 1.9 cm. Both ovaries unremarkable. No adnexal mass.

I was then scheduled for an endometrial biopsy on November 6th. Results for that biopsy read: Complex Endometrial Hyperplasia Atypia.

Gross Description: The specimen consists of mucoid hemorrhagic material 2.7 x 2.7 x 0.2 cm in aggregate.

Microscopic Examination: Histologic sections of all blocks are examined by light microscopy. These findings together with the gross examination support the pathologic diagnosis.

I have now been referred to a genealogical oncologist with a recommendation for hysterectomy as soon as possible.

My question is: I want to avoid any surgery I don’t absolutely have to have. With this diagnosis is it reasonable to take a conservative approach and try diet/nutrition, lifestyle change and perhaps progesterone treatment before taking such a radical step as a hysterectomy? It’s not that I am young enough to be concerned about preserving fertility I am just opposed to traumatizing the body with any unnecessary surgery.

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KM November 18, 2014 at 2:22 am

I might also add that I had a pap test done the same day as the endometrial biopsy and it came back normal.

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Magnolia November 18, 2014 at 7:10 am

Hello KM,

I have referred your question to Dr. Reichert, the physician who wrote this post. He should answer your question shortly.

Magnolia

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Roger Reichert November 18, 2014 at 9:01 am

Hi KM,

Your ultrasound report suggests that you have an endometrial polyp or other type of polypoid lesion, a sample of which has been interpreted as complex atypical hyperplasia (CAH). The problem is that the reproducibility of the diagnosis of CAH is poor. In a 2006 Gynecologic Oncology Group study, an expert panel of gynecologic pathologists agreed with the community-hospital based diagnosis of CAH in only 38% of the cases. 25% of the cases were downgraded to either hyperplasia without atypia or a variant of normal endometrium, and 29% of cases were upgraded to cancer. So without getting your diagnosis of CAH confirmed by a gynecologic pathologist, you really don’t know what you’re being treated for (unfortunately, even experts don’t agree with each other in some difficult cases). If you do in fact have CAH, then most women in your age group would opt for hysterectomy. Progestagen therapy is another option, but is successful in only 40-70% of cases. An endometrial biopsy would be done after six months of treatment, and if atypical hyperplasia persisted or well-differentiated carcinoma developed, then hysterectomy would be recommended at that time.

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DD November 19, 2014 at 9:46 pm

Hello Dr. Reichert let me start off by saying I am a 48 yr. old female

My question comes after having a robotic laporscopic vanginal hysterectomy on Oct. 16 of 2014 which included the removal of the uterus , cervix, ovaries and tubes. Additional info to be made is I had been in post menopause before having the surgery; it had been approx. 14 months or so since I had a menstrul cycle. I would also like to make note that I was not on hrt nor had I been on any birth control since forever. Further info to be noted is I had Pap smear 2 weeks prior to my surgery which came back normal,. The reason for the surgery was because of groin/pelvic pain, occuring cycsts, and a 2nd degree prolapsed uterus. I recently received my pathology report which lead me to search for answers to my questions. From the info I’ve gathered on MG hyperplasia their types are not easly diagnosised. My final pathology diagnosis report as stated:
*Leiomyomata measuring up to 1.2 cm,
*Proliferative pattern endometrium with adenomyosis,
*Chronic cervicitis with microgladular hyperplasia,
*Bilateral ovaries with age related changes and bilateral benign Fallopian tubes.
The problem I have with this report is the lack of its “classification” pertaining to the MG hyperplasia. According to the info I’ve gathered there may be a possibility I may of been under or over diagnosed in light of: my age, not being on any hrt for menopause or on any birth control for sometime. Should I have any concern regarding the MG Hyperplasia diagnosis? With this being said do I need to be concerned with any of the other above findings in correlation with the MG Hyperplasia or otherwise. It is important I should know any concerns with the above findings seeing I may be considering hrt. I would also like to know am I at risk from any of these MG hypersplasia cells being left behind turning into cancer from my vaginal hysterectomy ? If so, is an annual Pap smear enough or should I include an annual ultrasound too?

Thank you so much for the info in your post,

DD

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Roger Reichert, MD PhD November 27, 2014 at 11:43 am

Hi DD,

I do not see any reason for you to be concerned about the findings in your pathology report. The problem is that you are confusing endometrial hyperplasia, which should be subclassfied since some forms are associated with an increased risk of endometrial cancer, and microglandular hyperplasia, which is a common incidental finding that involves the endocervical canal (the tissue between the endometrium and the cervix). Microglandular hyperplasia is totally benign, is typically not subclassified, and is not associated with an increased risk of development of either endometrial or endocervical cancer.

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DD November 19, 2014 at 10:20 pm

P.S. Was it correct as to how the Pathologist gave the diagnosis of the MG Hypersplasia or should it of been followed up with Simple or Complex with or without Atypia or is the above stated pathology report stand for Simple without Atypia unless it’s stated otherwise? If the diagnosis should be followed with additional info, I will definitely be giving the Pathology Dept. a call. What worries me more will their diagnosis of MG Hypersplasia with classification even correct in the first place.

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Eydee November 23, 2014 at 8:40 pm

Would having endometrial cells show up on a pap and endometrial hyperplasia increase my risks? (I’m 43 and I know I’m in perimenopause.) My doctor wants me to have a biopsy, but I think it’s overkill. Thanks in advance for your thoughts!

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Roger Reichert, MD PhD November 27, 2014 at 11:57 am

I’m a little confused about your question. I’m assuming that benign-appearing endometrial cells were found on your Pap smear, and you’re wondering whether that increases your chances of having endometrial hyperplasia or cancer. The presence of benign-appearing endometrial cells is a common finding in Pap smears in premenopausal women, especially during the first 10 days of the menstrual cycle. If your Pap smear was taken during this interval, and you are otherwise asymptomatic, then the chances of you having significant endometrial pathology are close to zero. In your age group, the same holds true even if these cells were found out of phase with your menstrual cycle. However, the situation is different with post-menopausal women, since this finding is associated with significant endometrial pathology is about 10% of these cases, which is high enough to recommend endometrial biopsy for these older women.

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Eydee December 6, 2014 at 5:37 pm

Thank you for your response. I apologize for not being more specific. I have a follow up with my doctor this week and hope to get more details. I assume the endometrial cells (must be!) benign because she only told me that there were endometrial cells present, but shouldn’t be. She then referred me for an ultrasound which showed I had a thickened endometrial lining (16mm). I had a follow up ultrasound 6 mths later that showed only 12mm. She now has recommended a biopsy. I feel like I’m nearing the end of perimenopause simply based on my body and what I have experienced with my cycle the past 7-8 years (night sweats, etc). I am a chicken! Don’t really want to have a biopsy!

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Trish November 26, 2014 at 12:42 pm

First thank you for such a wonderful article. I am 56 years young and I have been regular (yearly) with my pap tests since I was 19, I have 3 children, non smoker, not over weight and I have no other health issues. Three years ago I had a d & c and cone biopsy due to spotting, Everything came back just fine.

Went to doctors a few months ago to check on a cyst I had. It did clear up, however I was sent to a gyn as my lining was thick. I had a biospy and pap test performed at this time.

It came back complex hyperplasia with no cancer or pre cancer showing. The gyn said right away that I need to have a total hysterectomy..everything is going to be taken. I was in shock that he said this was my option as if I waited, odds are it will go into cancer. Now after reading this article I am wondering if this is perhaps something that can be treated with a less aggressive procedure?

My question is this…what at the odds of this going into cancer and if it did is this a slow growing cancer? Is it smart for me to wait and try some other procedure or would that just be putting off a eventual hysterectomy?

Totally confused here. :(

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Roger Reichert, MD PhD November 30, 2014 at 7:35 pm

Hi Trish,

One of the main points of my post is that the diagnosis of endometrial hyperplasia is difficult and subjective. In my opinion, if a hysterectomy is at stake, then this diagnosis should either be made initially by a pathologist who specializes in gynecologic pathology or confirmed by a gynecologic pathologist via a second opinion. A diagnosis of complex hyperplasia could actually represent anything from disordered proliferative endometrium (a normal finding in perimenopausal women) to well-differentiated endometrial cancer. If you’d like to explore the possibility of having me review your slides, please contact me via my website (reichertpathology.com).

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Trish December 3, 2014 at 10:04 am

Thank you so much for taking the time to answer my inquiry. As I read in your article, endometrial hyperplasia is a common finding in women entering into menopause. Since mine did not show any cancer or pre cancer, why is he saying I need a hysterectomy before trying something less invasive first. Right away he said that this will probably turn to cancer. Is it possible that this complex hyperplasia might clear up on its own or with medication? How often does this condition revert back to normal.

Also how do I send you my slides?

Thanks again,
Trish

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Roger Reichert, MD PhD December 5, 2014 at 11:03 am

Hi Trish,

Your gynecologist may be recommending hysterectomy based on the worst possible case scenario, knowing that at least some cases diagnosed as complex hyperplasia can actually represent complex atypical hyperplasia or well-differentiated endometrial cancer. If you would like, email me at reichertpath@aol.com and we can continue this conversation.

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Trish November 26, 2014 at 4:18 pm

One more note…I have not gone into menopause yet…but I think I am entering it. My periods have changed and are not as long and are irregular.

Thanks again for reading my post. :)

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Sue Norris November 28, 2014 at 4:12 pm

I’m 56 and was recently diagnosed with complex hyperplasia with aytpia (Endometrial Intraepithelial Neoplsia). The gynecologist is sending me to a gynecological oncologist for a hysterectomy. I was spotting daily for 3 months and the ultrasound showed a thick lining of 9 mm. I haven’t had any spotting since the D and C. I have no other symptoms except normal menopause hot flashes.

I’m starting to wonder if I really need a hysterectomy. What are the risks of doing nothing?

The pathologist’s report also states that it was reviewed in interdepartmental peer review. Is it still worth the cost to get a 2nd opinion on the samples?

Thank you.

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Roger Reichert, MD PhD November 30, 2014 at 8:01 pm

Hi Trish,

Please read my replies to KM on 11/18/14 and Trish on 11/30/14 on similar topics. If you indeed have complex atypical hyperplasia, then hysterectomy is generally the best option for women in your age group.

You bring up an interesting topic in intradepartmental peer review (I think that you meant “intra” rather than “inter”). Intradepartmental consultations are to be encouraged, and definitely improve the likelihood that the patient will receive the correct diagnosis. However, a problem with intradepartmental consultations is that over time the pathologists within the group tend to become part of the same “tribe.” In addition to the tendency to think and diagnose alike, the group members may not know what they don’t know, and a junior/nonpartner pathologist may feel pressure not to question the diagnosis of a senior/partner pathologist.

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Brein November 29, 2014 at 10:46 am

hello, I recently had a CT for some issues I was having for bladder problems, results were normal except a cyst on my ovary that suggested follow up with my GYN. My GYN so happens to be a nurse midwife who practices women’s health. When the follow up ultra sound was done the cyst had disappeared however my endometrium was 1.5 cm thick. At this time I was only on day 9-10 of my cycle and felt this was too thick. My nurse midwife suggested repeat ultra sound the following month right after my period. The follow up ultra sound was done on day 8 of my cycle and still 1.5 cm thick. I am 37 yrs old normal weight and otherwise in good health and practically had to beg for an endometrial biopsy because the midwife didn’t seem worried. She reluctantly did the biopsy and the results came back disorderd proliferative endometrium no hyperplasia or carcinoma. I am extremely stressed about this result however the midwife is not and is not suggesting any follow up. Is this diagnosis something to be worried about? I have no symptoms, my periods are regular, about 7 days long and cycles average 30-32 days. I have been sick with worry! Also, I have factor five Leiden and cannot take hormones. Any advise will be greatly appreciated!

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Roger Reichert, MD PhD December 5, 2014 at 11:35 am

Hi Brein,

Considering your young age, lack of symptoms, and near-normal endometrial biopsy results, I would not recommend any further endometrial sampling or specific follow-up at this time. I would recommend that you make sure that your ultrasounds were read by a radiologist with experience in interpreting these studies, since the fact that you are asymptomatic with regular periods does not fit with an endometrium that is 1.5 cm thick during the first half of your cycle.

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