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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{ 87 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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Wati December 26, 2014 at 11:21 pm

Dr. Roger Reichert,

In April 2014 I was diagnosed with “Simple Hyperplasia Without Atypia”, after a curettage (after 9 months of irregular and very heavy periods). I was then prescribed to take Cyclo-Progynova (2mg estradiol valerat and 0.5 mg norgestrel). Now is the 10th month of my Cyclo-Progynova treatment.

I also have Fybro Cystic Desease in my breasts (started several years ago), and after 3 months under Cyclo-Progynova, I consulted my Oncologyst. He said the FCD do not get worse and he said it is all right to continue the Cyclo-Progynova treatment given by my Gynaecologist.

After 9 months of treatment, my Ginaecologist found that I have uterine myoma (22.3 mm x 10.4 mm, 27.3 mm x 17.1 mm, 7.5 mm x 25.0 mm x 20.00 mm), but told me to continue the treatment for the next 6 months.

My skin condition is getting worse while taking Cyclo-Progynova (my face is red and I got bad acne).

I am really concerned about taking this hormone replacement therapy because of the side effects. I would like to know your opinion and suggestion (whether it is really necessary for me to get HRT treatment for my Simple Hyperplasia Without Atypia).

Look forward to your reply. Thank you.

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Roger Reichert, MD PhD January 3, 2015 at 10:57 am

As a gynecologic pathologist, I specialize in the diagnosis rather than the treatment of disorders of the female genital tract. Your question relates to treatment and is out of my range of expertise. That said, I can tell you that many cases diagnosed as simple hyperplasia without atypia would be interpreted by me as disordered proliferative endometrium. In my opinion, neither of these disorders needs to be treated unless it is being done so to relieve symptoms of abnormal uterine bleeding. If I were you, as long as you are not currently having any abnormal uterine bleeding, I would discontinue the hormonal therapy and continue to see your gynecologist at periodic intervals.

Please note that I am confused by your gynecologist’s choice of cyclo-progynova for your treatment. This is a combined estrogen and progesterone regimen. Estrogen feeds endometrial hyperplasia while progesterone counteracts it, which is why at least in the US when hormonal therapy is given for endometrial hyperplasia it is with a purely progestational agent.

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Wati December 26, 2014 at 11:24 pm

Dr. Roger Reichert,

I forgot to tell you that I am 49 years old, and before August 2013 I had been having regular periods.

Thanks.

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Jayne b December 27, 2014 at 12:16 pm

I’m 56 and my monthly periods stopped about 18 months ago ,up until then I was having irregular but heavy periods for the previous couple of years . I’ve had episodes over the last year and previously when I feel a lot of ‘dragging’ similar to pre menstral cramps without actually having a period , these episodes have come and gone in a cycular fashion ,I felt that I was still having hormonal surges ? Then in may this year I was diagnosed with breast cancer and three months ago was started on tamoxifen. I had a ultrasound scan of my uterus about 14 months ago and no problems seen except for a couple of fibroids. I went for one on tues as a result of having this dragging again which I might add had stopped again before I went for the scan and I’ve had no bleeding or spotting at all . The radiographer said that she could see my endometrium had thickened and would report it and they may refer me on , as you can imagine I’m beside myself worrying as I’ve had enough for this year!!! Could this be down to the transition from probably perimenopause to post menopause , I need some reassurance!! The bank holiday is here and my results are pending!!

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Roger Reichert, MD PhD January 3, 2015 at 11:11 pm

Hi Jayne,

Tamoxifen is commonly used in the treatment of breast cancer, and exerts its antiestrogenic effect via estrogen receptor blockade. In the endometrium, binding of tamoxifen to estrogen receptors mimics the effect of estrogen to some degree. This puts patients such as yourself at an increased risk for the development of endometrial polyps, endometrial hyperplasia, and cancer. This is why your endometrial lining is being monitored via ultrasound. If your endometrium is thick enough to recommend endometrial sampling, then I would follow that advice to make sure that it is nothing serious.

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Jayne b December 28, 2014 at 4:28 am

Many thanks for your advice

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LydiaM December 31, 2014 at 7:27 pm

Dear Dr. Reichert,

I am 50 years old and have been treated by my OB/GYN for the last year and 1/2 for a fibroid he told me was present. He has done a vaginal ultrasound every six months. In November he told me he could not see anything on his ultrasound machine and scheduled me for an ultrasound with a better machine. After this test he let me know that I do not have a fibroid and the radiologist came back with this being a normal ultrasound, however together with the thickness of my endometrial lining, (10mm), and my irregular periods, (50 days no period, some spotting off and on, also some nausea and back pain) he recommended an endometrial biopsy. I was supposed to do it in his office, but the pain was more then I could bare, now he would like to do it under anesthesia. I have not gone back yet though and am scheduled for a 2nd opinion with another doctor on 1/2/15. I’m just wondering what you think of this? Most of my girlfriends who have gone through menopause indicated that this sounds like normal perimenopause and they wouldn’t have even gone to the doctor for this. When I asked my doctor why I need the biopsy he tells me that I could have endometriosis or andomyosis, or an endometrial cancer, but I thought cancers came with excessive bleeding and I’m barely bleeding at all. I’ve lost confidence in my doctor and am very confused. Any light you can shed on this would be helpful.

Sincerely,
Lydia M.

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Roger Reichert, MD PhD January 3, 2015 at 11:28 pm

Hi Lydia,

My area of expertise is in pathologic diagnosis of gynecologic abnormalities, and your question relates more to proper evaluation and when to perform an endometrial biopsy. I would defer to the opinion of your gynecologists in your case. If they both recommend endometrial biopsy, then I would get a biopsy. If the gynecologist who provided you with a second opinion is comfortable following you without a biopsy, then personally I would go that route.

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carolyn January 5, 2015 at 4:17 pm

I am 67 years old & have recently been diagnosed with complex endometrial hyperplasia without atypia by having a D&C. My symtoms were a slight bleeding from the uterus. I need to decide to either be treated with medicine or to go ahead & have a hysterectomy. I have not received guidance from my doctor as to which would be the best, he is leaving it up to me. I don’t want to have surgery but I also don’t want to end up having to have surgery later down the road in my 70 or 80s if this condition should return with atypia. I also do not want to lose my ovaries. What would you advise. I did have hyperplasia in my 40s & was treated with meds (i do not recall what kind) I went through menopause around age 51 or 52. I also had breast cancer at age 56 stage 0, which was over 10 years ago. (the cancer was sensitive to estrogen) Thank you for any input you may have.

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Roger Reichert, MD PhD January 5, 2015 at 9:40 pm

Hi Carolyn,

As has been the trend recently, your question relates to the treatment rather than to the diagnosis of endometrial hyperplasia. What I do is to provide a second opinion on the pathologic diagnosis of endometrial hyperplasia. Since it is not uncommon for my opinion to differ from the original diagnosis, it would be pointless for me to speculate on what the preferred treatment should be when I may well end up differing with the diagnosis upon which the treatment choices are based. On cases that I have reviewed personally, I am more willing to discuss the therapeutic options. Best of luck as you develop your treatment plan.

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Maria January 23, 2015 at 6:09 am

Dear professor,
I am from Romania and I am 44 years of age. I found your site and I really appreciate your work. I have to tell you that your article here, is responding to all my questions about disorder proliferative endometrial and about hyperplasia.
Let me tell you shortly about my problem : after two months of missing periods, my doc. gave me progestin ( duphaston) for 10 days ( 15-25 menstrual days) for one month, My period came soon after finishing the pills, but was very abundant and I was hospitalized urgently . A Dilatation and Curettage was performed in order to stop bleeding. The result of biopsy resulting of this curettage was “simple glandular endometrial hyperplasia with atypical cells”. I go to discuss with the pathologist who gave this diagnostic and he said that the number of atypical cell is very small and is not even middle or severe hyperplasia, just a simple hyperplasia but he saw a few atypical cells and he must tell me abut them in order to not have a sub- treatment. He said that he would gave me treatment with progestin if he could, and that is not a severe problem.
In alternative, the doc. who performed the curettage (and who had no discussion with the pathologist, which here is a current practice in hospitals), said that I have to remove my uterus because the risk of cancer in the future.( I also have a good Pap test, with negative for malignity or for other non- malign lesion.)
Since I received this diagnostic, I read all I found about endometrial disease. (I am also researcher, not in medical area, and I have a professional determination to study a problem and to not accept a single opinion or a single direction).
This is why, I really have doubt about the diagnostic because I know the interpretative nature of this disease, because I know that is need a lot of experience to diagnose a atypical simple hyperplasia, because simple hyperplasia with atypia is rare, because I had no bleedings between periods, because my periods are rhythmic, and I suspect a premenopausal period.
After the month with D&C, a second period came also very abundant and heavy but I passed in good condition (without D&C or hospital).
I read that hyperplasia came if a person have hiper- estrogenism and less progesterone , but my investigations said that I have no problem with estrogen or progesterone and all the hormonal value are normal ( LH, prolactina,TSH, etc).
I am fat (90 kg and 1, 65 m), I always was, but I have not hiperestrogenism , or polycystic ovaries. I have 3 mioms and polyfibromatos uterus since I was young and I had never get pregnant. (I adopted a boy)
I am asking your opinion about the investigation I have to do, or pills I have to take, and about accuracy of the diagnostic that I just received. What is your opinion about accuracy of a biopsy taken in condition of excessive bleeding (a bleeding who comes after 2 months of missing periods) and after 10 days (20 pills in total) of progestin.
Sorry because I wrote too much…
If I could come to see you for a opinion or investigations, I do it, but unfortunately is such a long distance between our countries and economic situation is poor.

I am very grateful for your answer, in advance dear Professor.
Best wishes and a lot of respect from Maria (Romania).

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Roger Reichert, MD PhD January 28, 2015 at 10:08 pm

Hi Maria,

Assuming that your pathologic diagnosis is correct, I would recommend that you ask your gynecologist to continue to treat you with a progestin and follow you. If he /she is not willing to do this, then I recommend that you find another gynecologist who will. The odds are very low that this is anything significant, and in my opinion a hysterectomy at this point would be overkill.

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Deborah Lachowsky January 26, 2015 at 8:32 pm

Dr. Reichert,
I recently had a endometrium biopsy. The reason for it was that I had 2 small drops of blood one day on the first week of December. I went to my gneocologists partner since she was busy and he said I shoujd first have a ultra sound which I did. It said I had two fibroid tumors and some mini ones. They have never bothered me. The ultrasound showed that endometrium is normal at 8mm.my left ovary was removed due to endometriosis in my 20s. I am now 62. The ultrasound also said there is no free fluid. So, since my endometrium was thick, he said I should have a biopsy. The biopsy was done in his office a week later. The gross description says, received in formalin in one part, designated EMB, consists of tan and mucous soft tissue, (2 cm in aggregate) filtered and all in 1. The microscopic diagnosis , It reads scanty polypoid fragments of endometrium with complex Hyperplasia, negative for cytology can atypia or malignancy. Comment, these may represent some fragments of polyp. Histologic features diagnostic of atypia are not identified. Given that material is scanty, if clinical concern, consider additional sampling. When I went back to my gneocologist , she was freaking out about the results. She said it was pre cancer cells and I shoujd get a Dnc when they scrape the whole endometrium lining. I’m suppose to get my gall bladder out and she said this is more important, the results of the biopsy and she wants me to see a Specialist who is also a cancer doctor. She said maybe he coujd do a Dnc the same time when I get my gall bladder out with another doctor since they are both with the same hospital. She even mentioned I shoujd probably have a hysterectomy depending on what the specialist wanted to do. What is the treatment for my diagnosis, is it usually hysterectomy? I was wondering if it could be more of a polyp or scar tissue from my surgery if endometriosis years ago? I was just curious about your opinion since I saw this blog on line. Thanks so much, Debbie Lachowsky

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Roger Reichert, MD PhD January 28, 2015 at 10:17 pm

Hi Debbie,

Please read my comment to Carolyn from Jan. 5, as it applies to your situation as well. Complex hyperplasia without atypia is a very subjective diagnosis. I have seen cases diagnosed as such that I would diagnose as disordered proliferative endometrium, for which I would recommend follow-up and perhaps progestin therapy, and other cases that I would diagnose as complex atypical hyperplasia for which I would recommend hysterectomy in a woman of your age. Given the small amount of tissue on which this diagnosis was based, I agree that a D&C would likely provide useful additional information.

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Debbie Lachowsky March 2, 2015 at 7:27 pm

Dr. Reichert, I finally had hysteroscopy done and a D&C early February and here is the results on there operative procedure documents. It says, The endometrial cavity was explored and a 1 cm endometrial polyp was found and originated from the posterior aspect of the fundus of the uterus. No other gross tumor was noted. Both ostium were noted to be normal. The endocervical canal was grossly normal. With the biopsy forceps , the endometrial polyp was removed and sent to pathology. Next, an endometrial curetting was performed in standard fashion. Excellent hemostasis was noted. Then the results from the pathology report came back and here’s what it said: Specimen A, is labelled as “endometrial polyp” The specimen consists of multiple pink-tan , irregular tissues admixed with blood and mucus having aggregate dimensions of 1.5 x0.7 x 0,2 cm. Specimen B is labeled as “endometrial curettings ” The specimen consists of multiple pink tan , irregular tissues admixed with blood and mucous having aggravate dimensions of 1.7 x 1. 2 x 0.2 cm. Here is the microscopic diagnosis – {A Endometrial biopsy polyp : Polypoid fragment of endometrium with complex hyperplasia without atypia (B) Endometrium Curettage: Complex Hyperplasia without atypia. The doctors nurse called and said he wants to put me on provera for 3 months and then another biopsy in 3 months. I have not seen him yet but am concerned about side effects of the medicine and if it really is necessary for regression of hyperplasia. I have been reading that some people have regression without the medicine and ofcourse a small percentage that can advance to atypia or cancer. Can these hormone drugs cause breast cancer? Anyway, do you still think both specimens are more then likely what they say it is, hyperplasia without Atypia?

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Roger Reichert, MD PhD March 5, 2015 at 2:36 pm

Hi Debbie,

My original comment from Jan 28th still applies. If you would like me to help you decide on whether or not to take provera, then I would have to review the slides and make my own diagnosis. If you want to go this route, you can contact me through my website, reichertpathology.com.

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Carol January 30, 2015 at 5:51 am

I am 48 years old and believe I am in perimenopause. I have had somewhat irregular periods over the last 2 years, night sweats etc. I had one episode about 1 1/2 years ago of a period that lasted for one month but since then relatively normal periods, albeit sometimes heavy for a short duration. Sometimes I have small clots. Then, more recently I had no period for 8 weeks followed by a period I am now experiencing that has lasted for 10 days or so, so far with many clots, some large. I thought this was simply because perhaps I missed a period, so this one is extra long…..I ran to the doctor (I live overseas so this is a new gyno who does speak some english) She did a trans vag ultrasound and immediately told me my ultrasound looks abnormal, she saw 2 polyps and wanted me to schedule an urgent hysteroscopy, polypectomy and curettage. There were no other options given. She said that my endometrium is 10mm and “wavy” in areas. She put me on tranexam pills to stop the bleeding. In her report she diagnoses glandular hyperplasia. I spoke to my US doctor after this appointment and he thought it was not urgent and that this could simply be as I thought due to the missed period and perhaps I should just get another exam in a month or so unless the bleeding continues or gets worse. I will be back in the US in July/15. Am I wrong to wait that long to do a hysteroscopy? Is it urgent that I get this diagnosed by hysteroscopy?

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Roger Reichert, MD PhD January 30, 2015 at 3:18 pm

Hi Carol,

Situations such as yours are rarely urgent, and can generally wait to be diagnosed until you are back in the US unless your symptoms warrant treatment sooner. Sometimes the stalk of an endometrial polyp twists (compromising its blood supply) or its surface is traumatized. If either of these things is happening in your case, then you may continue to have episodes of abnormal uterine bleeding until your polyps are removed. Also, realize that your overseas gynecologist is using the term “glandular hyperplasia” very loosely, since there is not yet any tissue sample upon which to base this diagnosis.

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Tabitha February 2, 2015 at 4:44 pm

I am 33 and have been struggling with infertility. After a recent hysteroscopy and d&c and polypectomy I was diagnosed with simple Hyperplasia. My doctor says she doesn’t have much experience with women in childbearing age or still wanting children. She suggests I go on Megace for 1 month and progesterone for 5 months then do another d&c to see if it is still there. I would really like to get an opinion from someone a little more familiar with Hyperplasia.

Thanks so much

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Roger Reichert, MD PhD February 6, 2015 at 9:51 am

Hi Tabitha,

I can’t give you an opinion on your treatment without reviewing your slides. I interpret many cases diagnosed as simple hyperplasia as disordered proliferative endometrium, which does not need to be treated with progesterone or anything else unless it is to relieve symptoms of abnormal uterine bleeding. In your case, if your “simple hyperplasia” is located within an endometrial polyp, then it is really of no concern (ordinary endometrial polyps routinely have foci of what would be considered simple hyperplasia if found outside of the confines of a polyp). Please see my article at kevinmd.com entitled “Why hysterectomy for many endometrial hyperplasias is often overkill” for more information on this topic. If you would like me to review your slides, with the real possibility that I can help to spare you from 6 months of progesterone treatment and a follow-up D&C, then please contact me through my website (reichertpathology.com).

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Tabitha February 2, 2015 at 4:51 pm

One more note…..I am regular height and weight, not overweight.

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Kathy February 3, 2015 at 9:07 am

My Mom had thickening of the endometrium lining at age 72…they thought she had signs of cancer..they ended up doing a hysterectomy on her and then determined there was in fact no cancer. I am now facing at age 58 a procedure due to my endrometrium lining at level 11.. I am scheduled for a biopsy to determine what’s developing now myself. I started menopause at age 51 and recently showed some slight spotting. My concern is can this be left alone if no signs of cancer are obvious …I am extremely conservative with surgeries and only if there absolutely necessary..

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Roger Reichert, MD PhD February 6, 2015 at 10:02 am

Hi Kathy,

Given your recent history of spotting and thickened endometrium, I recommend that you follow your doctor’s advice and undergo an endometrial biopsy. The results of your biopsy will largely determine your subsequent treatment options. If you get back a diagnosis that causes your doctor to recommend hysterectomy, then you should consider getting a second opinion on your pathology slides from me or another experienced gynecologic pathologist.

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diana February 10, 2015 at 12:32 am

Hello Doc..
My mother had endometrial thickening and she is 54. 6 months ago she undergone an endometrial biopsy and the result shows it is proliferative endometrium.Now she bleeds again.sir what is proliferative endometrium.Is it an indication of cancer

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Roger Reichert, MD PhD February 10, 2015 at 10:22 pm

Hi Diana,

Proliferative endometrium is a normal pattern. Your mother is probably just having off and on again uterine bleeding as she transitions to menopause. If her gynecologist thinks that something is out of the ordinary, he/she may recommend another endometrial sampling.

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diana February 11, 2015 at 3:22 am

Sir..I had one more doubt.yesterday mom visited the doc.she says everything is normal.But she prefers ca 125 test.Sir what is ca 125 test ?

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Roger Reichert, MD PhD February 11, 2015 at 11:05 am

Hi Diana,

Let’s please keep the comments and questions related to endometrial issues. An internet search of “ca125 test” will turn up plenty of information to answer your question.

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WB February 16, 2015 at 12:42 pm

Dr. Reichert gave me a non-biased, expert opinion on my case which was initially diagnosed as “complex endometrial hyperplasia with atypia and papillary metaplasia.” I am 49, in great health and was advised to have a hysterectomy. Dr. Reichert reviewed the slides and was able to explain why the initial diagnosis was incorrect. What was actually present was “simple hyperplasia without atypia with superimposed metaplastic changes”. Dr. Reichert is professional, highly intelligent and an expert in this field. He is not under pressure to read through a given number of slides a day, which allows him the opportunity to really examine what is presented.

I’m very savvy and skeptical about products and services offered on the web, and did my due diligence to make sure that Dr. Reichert is, indeed, who he says he is. He’s forwarded his report to the original pathology lab and has communicated with them his request for them to amend the report based on his findings. I’m forever grateful to him and to this blog for helping me and other women out there make INFORMED choices about our health.

We must take our health in to our own hands because our health care machine/system (not the doctors necessarily) is broken. The docs are often victims of the machine too, and they deal with it by banding together in groups, or leaving it all together by not accepting insurance. This leaves so much of middle and low income America in an awful quandary.

Patients are consumers and, as such, we have the right to be educated consumers of the health care services we receive. We must also be equally skeptical and savvy in navigating fad “natural” alternatives as well without expert guidance. Let us demand that Naturopathic doctors be covered by the healthcare machine. Please continue to seek out unbiased second opinions from from pathologists like Dr. Reichert if you find yourself stuck in the “machine” as I did.

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Magnolia February 16, 2015 at 9:31 pm

WB,

Thank you very much for sharing your experience. I’m really glad you were able to find some help through this blog and Dr. Reichert. I also agree that we have to take responsibility for our health into our own hands.

Magnolia

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Gail Osburn February 23, 2015 at 5:02 am

Ihave had a vaginal ultrasound which showed a endometriam of 9mm.I have had no bleeding or any other symptoms. My Dr has referred me to a gyn but I cannot get in until end of April which leaves me a couple of months to worry. What would be the chances of this being cancer rather then endometrial hyperplasia .I am 56 and post menapausal Ibhavevalso been taking Remifemin for aprox 2 years for hot flushes could this have caused the thickening I have now stopped taking it

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Roger Reichert, MD PhD March 3, 2015 at 12:01 am

Hi Gail,

Given that you are asymptomatic and your endometrium is only minimally thickened, the chances that you have a significant endometrial lesion are low, and the odds of having full-fledged cancer are close to zero. Try not to worry between now and the time of your endometrial sampling. As a pathologist, I have no experience with Remifemin, and cannot comment on its possible benefits and side effects.

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Sylvia Cabot March 3, 2015 at 4:59 pm

Hi Dr Reichert,
I’m 35 years old and I was diagnosed with endometrial hyperplasia with atapia in October 2014 after I was sent to hospital for severe blood loss. I was bleeding for about a month and became Anemic. I was placed on Megace 80mg 2x a day, bleeding subsided. I had an ultrasound and hysteroscopy in December 2014 when I got my results in January I was told that Megace did not work at all and things looked worse. I was then advised to get a hysteroscopy and was doubled on the Megace. I am now taking 160mg 2x a day and have days of severe cramping and bleeding.
The hysteroscopy and ultrasound findings state: “Focal Complex Endometrial Hyperplasia with Atypia, endometrial curettings”
Uterus sz: 6.7cm Trans x 5.9 cm AP x 10.5 cm long
Position: Anteverted
Endometrium: Abnormal, Bilayer thickness=20 mm thickened, heterogeneous appearing endometrial cavity with areas of hypo and hyper echogenicity, no discrete vascularity.

As mentioned before I am 35 and have a 16 yr old son, we were planning for another child right before this news hit. I’m trying to rule out every option to heal rather then a hysterectomy. I am unsure of the severity of my condition since every time I have appointments at the Dr I see different doctors and get different opinions. Any advice, comment, reply would be very appreciated! Thank you for taking the time to read… God Bless!

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Roger Reichert, MD PhD March 5, 2015 at 2:26 pm

Hi Sylvia,

Given that you are only 35 and want to have another child, I would give every opportunity for the Megace treatment to work. If Megace or some other progestational agent hasn’t controlled your bleeding and resolved your hyperplasia within a year of beginning treatment, then it would be time to more seriously consider hysterectomy.

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Karen Johnston March 11, 2015 at 2:27 pm

Dear Dr. Reichert,
I’m 49 yrs old. I have been have abnormal bleeding, heavy, longer than 10 days, spotting between with water discharge. In Dec. had a t/v ultra sound with findings of diffusely enlarged heterogeneous uterus, 1.3 cm hypoechoic area in left side of uterus (possible small fibroid). Abnormal heterogenous thickened appearance of endometrium at fundus 1.7 cm with a small amount of internal vascularity. Possible etiologies include, polyp, hyperplasia and neoplasm.
Dr did a endometrail biopsy in his office and finding are:
Gross description: Specimen consists of fragments of tissue intermixed with mucus. Diagnosis: Relatively scant frangments of proliferative endometrium showing hemorrhage and stromal and glandular breakdown, negative for hyperplasia or neoplasia.
I’m wondering what should my next course of action? Was this a good simple? Should I have my dr do a d/c?

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Roger Reichert, MD PhD March 11, 2015 at 10:50 pm

Hi Karen,

The ultrasound findings suggest that you may have adenomyosis and an incidental fibroid within the wall of the uterus, and a polypoid lesion protruding into the endometrial cavity. The odds of this polypoid lesion being anything bad are low, but I do not think that the endometrial biopsy sampled it. I recommend that you consult with your gynecologist and decide together as to whether or not you should undergo a D & C. If you are the type of person who can’t sleep at night wondering what is going on, then you can let your doctor know that you would like to have a D & C. On the other hand, if you can live with a small risk and are worried about the inconvenience, expense, and possible complications of having a D & C, then you can advocate for watchful waiting. It is worth noting that your symptoms are most likely due to adenomyosis rather than due to the polypoid lesion.

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Michelle Boyd March 12, 2015 at 11:26 pm

Dr. Reichert,
I am a 49 year old female, 5’4″, 125 lbs., exercise daily and eat organic Paleo as much as possible. In September 2014 my gynecologist performed an ultrasound due to a history of endometrial polyps since 2006. ( I have had three D & C proceedures since 2006, all for polyps and all with benign biposies.) The ultrasound in September 2014 showed a thickened endometrium of 15.5 mm and my doctor immediately recommended a partial hysterectomy, which I refused. I go to a Nurse Practitioner for natural progesterone and asked could my prescription be tweaked to thin out the lining. He agreed, but first did an endometrial biopsy which I was told showed a proliferated endometrium with changes indicative of anovulatory cycles. I do not have the formal report. My NP increased the progesterone therapy from 25 mg. on days 14-28 to an every day dose of 35 mg., sustained release. Today I went in for a follow-up ultrasound that showed an endometrium of 16.52 mm and the doctor immediately wanted to schedule a hysterectomy or a D & C with an ablation with the reasoning that thickened lining could be cancer. I noticed your comments on February 10, 2015 that indicate “Proliferative endometrium is a normal pattern” and that abnormal bleeding could be the result of transitioning into menopause. I have agreed do a D & C before anything more invasive. I have had bleeding changes since 2006, mostly abnormal spotting (which is now very normal for me) on about day 10-12 of my cycle. If a proliferative endometrium is normal for a woman of my age, why is the doctor adamant about a hysterectomy without first doing a D&C/biopsy to see if it’s necessary? I feel as though I’m being pressured into doing something that isn’t necessary and at the same time, I feel he is the doctor with the knowledge and I should follow his recommendations. The hysteroscopy and D&C is scheduled for next Wednesday, March 17th. What is involved in getting you to view my biopsy from that procedure?
Thank you for your input.
Michelle

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Roger Reichert, MD PhD March 14, 2015 at 11:08 am

Hi Michelle,

You are asking the right questions and doing the right thing. Uteri should not be removed just because of a thickened endometrium found on ultrasound. First of all, understand that the ultrasound measurement measures the thickness of both sides of the endometrium across the uterine cavity, so a 16 mm thick endometrium by ultrasound implies that the endometrial lining is 8 mm thick on each side. Second, the endometrium becomes thickened due to the progesterone treatment for a period of time before it is shed, so if an ultrasound is done during this time interval the endometrium will be thickened. Third, ultrasounds taken during the secretory phase from premenopausal women can have reported endometrial thicknesses of up to about 16 mm. Fourth, in postmenopausal women, cystic atrophy (a totally benign process) can result in an ultrasound appearance of a thickened endometrium. Bottom line, you should have a pathologic diagnosis of atypical hyperplasia or worse before consenting to have your uterus removed, unless your symptoms (abnormal uterine bleeding, pelvic pain) are intolerable and you just want to be rid of your uterus. If you want me to provide you with a second opinion on the slides from your D & C, you can contact me via my website at reichertpathology.com.

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Michelle Boyd March 14, 2015 at 9:28 pm

Dr. Reichert,
I have tried to contact you via the website and the messages are being returned to me as undeliverable. Suggestions?

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Roger Reichert, MD PhD March 15, 2015 at 11:52 am

I tested my contact links, and they work for me. Anyway, try typing in my email address directly. It’s reichertpath@aol.com.

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Emma March 17, 2015 at 1:02 pm

Dear Dr. Reichert,
I’m a 35 year-old female, with no children, non-smoker, not overweight. The only health issues I have are irregular periods (cycles average 33-40 days) and fibrocystic breasts. Last year I had a conventional pap smear done (on day 11 of my cycle) which came back abnormal: class 3, with atypical glandular cells of undetermined significance (AGC-NOS). The gynecologist said I had 2 options: either to repeat the test after 2 months or to have a histological tissue examination done (fractional D&C with endocervical and endometrial biopsy).

I decided to repeat the test after 6 weeks at a clinic that specializes in cervical pathology, where they used ThinPrep technology. This second pap test, which was liquid based, came back normal: they identified superficial and intermediate Malpighian cells without nuclear abnormalities, normal endocervical cylinder cells; it was negative for intraepithelial lesion or malignancy. Three months later I came back to the first clinic to talk to the doctor, who told me that I should have another pap test at his (private) clinic, just to make sure there’s nothing wrong with me. This third pap smear, also conventional, came back abnormal: atypical endocervical glandular cells (not AGC-NOS this time).

As I was very scared, I let him do the procedure, which was under general anesthetic, on the 25th day of the menstrual cycle. Here is the pathologist’s report:
Surgical Piece: endocervical curettage specimen, endometrial curettage specimen
Macroscopic Examination: endocervical sampling and endometrial sampling processed and examined entirely
Microscopic Examination: curettage specimen consisting of endometrium fragments under progesterone stimulus, with areas of glandular crowding and lateral budding, epithelial stratification and papillary projections into the lumen.
Pathologic Diagnosis: Endometrial hyperplasia without atypia (no idea if it’s simple or complex).

The doctor gave me no treatment, but to see him for a follow up ultrasound after 6 months. I am really stressed about this result. Is this diagnosis something to worry about? I have no symptoms, no abnormal bleeding, and my periods are about 5-6 days long.
Last year I had 3 transvaginal sonograms (one at the same time with the first abnormal pap test, another one before the D&C and the last was a month after the D&C), which revealed that my endometrium was 5.7mm (on day 11 of my cycle), 10.3mm (on day 14) and 7.4mm (on day 23 of my cycle).
My question is: are there any chances that I’ve been overdiagnosed, that the 2 conventional pap smears could just be false positives and the hyperplasia in the pathology report a normal secretory endometrium, as the D&C was performed on the 25th day of the menstrual cycle?
I’ve lost confidence in my dr. and I’m very confused and scared. Any advise you may have will be greatly appreciated!
Sincerely,
Emma

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Roger Reichert, MD PhD March 17, 2015 at 8:51 pm

Hi Emma,

The interpretation of potentially atypical glandular cells in a Pap smear is difficult and subjective. Most of the time, these atypical cells are related to reactive endocervical cells associated with inflammation or to a benign process known as tubal metaplasia. However, they could also be due to endocervical adenocarcinoma in situ (AIS) or abnormal glandular cells from the endometrium (or rarely cells that originated in the fallopian tubes or peritoneal cavity). In your particular case, given your young age and lack of significant symptoms, the only lesion that realistically needs to be excluded is endocervical AIS, which is HPV-associated and does occur in your age group. The negative endocervical curettage is comforting in this regard. I think that you are absolutely right that there is a high chance that your endometrial sample is just secretory endometrium rather than simple hyperplasia without atypia — the pathologist’s description that you reproduced conjures up the image of exactly that. If this is the case, then my recommendation would be to skip the ultrasound and talk to your doctor about when to have another follow-up Pap smear. If you would like me to provide you with a second opinion on your endometrial sample, please contact me via reichertpathology.com.

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Emma March 18, 2015 at 9:15 am

Dear Dr. Reichert,
Thank you so much for your quick reply.

While I’d love to have your opinion on my endometrial sample, I’m afraid that’s next to impossible to have it sent to you, as my D&C was performed in a private hospital in Europe.

As for the follow-up Pap smear, I guess a wise thing to do is to wait a few more months and repeat the test in Montreal.

Thank you again for your support!

Sincerely,
Emma

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Linda March 19, 2015 at 5:32 pm

Dear Dr. Reichert:

Thank you for this blog to help a lot of women! I am a 48 year old, 5’5″, 125 lbs. I have had irregular bleeding since 2010. I was diagnosed with complex endometrial hyperplasia with atypia on March 2013 by an endometrial biopsy. Then I was placed on Mirena IUD and oral Provera 10mg/day. Two months later, I did endometrial biopsy and showed complex endometrial hyperplasia without atypia. I continued to repeat endometrial biopsy every 3 months until Dec. 2013 and still showed complex endometrial hyperplasia without atypia. I stopped oral Provera with IUD still inside the uterus, but on June 2014 endometrial biopsy showed low grade endometrial cancer. I repeated endometrial biopsy in another place, and it showed complex endometrial hyperplasia with atypia. On January this year, I did endometrial biopsy and showed low grade endometrial cancer again, and was scheduled total hysterectomy and bilateral salpingooophorectomy. My question is: First, does this mean hormone therapy completely failed on me? and should I try Megace for 3months since I never try Megace before? Second, if I have to do hysterectomy, can I remove uterus only, not removing all ovaries since I am still premenopausal. I really appreciate your help and need your advise!

Sincerely,
Linda

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Magnolia March 19, 2015 at 10:28 pm

Hi Linda,

This is not Dr. Reichert’s blog. It is actually a blog written by me. Dr. Reichert wrote a guest post here which has proven to be an excellent post of high interest to my readers. He has another site of his own which I’m sure he’ll let you know about when he answers your comment.

Please feel free to peruse the other posts here as well and thanks for reading.

Magnolia

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Roger Reichert, MD PhD March 20, 2015 at 9:48 pm

Hi Linda,

Treating complex atypical hyperplasia with progesterone is effective about 40-70% of the time, so your situation is not uncommon. The distinction between complex atypical hyperplasia and low grade endometrial cancer is difficult and subjective, so it is not surprising that your most recent diagnoses have bounced back and forth between these two entities, which are really part of a continuum. Since I am not an expert on the hormonal treatment of endometrial cancer, I cannot answer your question about giving Megace treatment a try. The standard treatment for a patient in your situation would be TAH/BSO, but in recent years there has been more of a trend to spare the ovaries and tubes in selected cases. This would be a decision between you and your doctor.

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Melissa March 25, 2015 at 10:17 am

I was diagnosed with disordered proliferative endometrium at 25 years (5 years ago); three children. I was informed that I was not producing any progesterone. Prior to my diagnosis, I suffered through months (7+) of literal NON stop bleeding, that was not ever painful. This continued for over a year. Prior to having my uterus ablazed and my tubes ligated, I was put onto birth control to manage it, it did not work. A year to the date after this operation, I began to have extreme pain in the uterine area. An ultrasound revealed what was described to me as “a fluid filled sac (blister like) within the scar tissue; contained debris along the bottom”. I was told that these were complications arising from the ablation. My endometrium was thickening in areas that were missed, causing these “blisters”. I had this operation a little over 2 years ago and have had NO bleeding. The development of these sacs seem to happen throughout the month, with no apparent pattern. Every time the pain is incredibly intense and can last from 1-2 weeks. It is assumed that when the pain stops, the sac has ruptured. I have yet to notice any discharge though. My concern is the continuous use of OTC pain medications to cope with this. My new gynecologist wished to do a D&C to correct this issue. I feel that this would be counter productive and create the bleeding issue all over again (2 surgeries and no resolution for the original issue?) . I requested the removal of my uterus, and he denied my request. What am I supposed to do with these hurdles that are in the way of me living a pain free, blood free life? I have presented this new doctor with all of my clinical history and now I feel stuck between a rock and a hard spot. Please, any information would be great.
Melissa
fiztheliz2@yahoo.com

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Roger Reichert, MD PhD March 28, 2015 at 11:39 am

Hi Melissa,

It sounds to me like you have chronic cyclic pelvic pain related to the cyclic accumulation of blood within your endometrial cavity (known as hematometra). Residual endometrium left behind after your ablation is creating menstrual products, but scarring of your endocervical canal from the ablation is preventing this admixture of degenerated tissue and blood from exiting your uterus (since you have also had a bilateral tubal ligation, that escape route is also closed and your menstrual products are being trapped within your uterus). I agree with your gynecologist that a D & C may be beneficial, since it will (a) provide an opportunity to remove residual endometrial tissue and/or have a repeat ablation, and (b) open up your endocervical canal so that any menstrual products that you create can pass. You are young and hysterectomy has its own set of risks and complications, so in your case I would proceed with hysterectomy only as a last resort.

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Katherine March 25, 2015 at 3:10 pm

Thank you so much for such an informative article. I am 46 yo, not on medication, overweight, fibroid uterus. Periods lately are becoming further and further apart. I have been advised to consider a hysterectomy. I have ongoing 6 monthly endometrial biopsies that vary in results between normal endometrium and simple hyperplasia. My latest histology report states: “sections reveal fragments of endometrium with somewhat crowded glands showing proliferative activity and separated by a fair amount of the stroma. The microscopic features are consistent with simple hyperplasia.”

What does this mean? Do these results warrant a hysterectomy? I am very tired of the ongoing biopsies and the subsequent wait for the results but this option is preferable to major surgery. On the other hand I do not wish to be one day told the hyperplasia has progressed to cancer because I ignored the advice for hysterectomy. I am very anxious about this. I would be so grateful for your opinion.

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Roger Reichert, MD PhD March 28, 2015 at 11:48 am

Hi Katherine,

I think that your endometrium is doing what is expected in the perimenopausal period. I reinterpret many cases of simple hyperplasia without atypia as disordered proliferative endometrium, which is discussed in my guest post on this blog. Neither of these diagnoses is much cause for concern. In my opinion, you are being followed with endometrial biopsies too frequently. Ask your doctor if you can be biopsied only if warranted by symptoms of abnormal uterine bleeding outside of what would be expected for a perimenopausal woman. If your doctor responds that your close follow-up is based on your history of “hyperplasia,” then it may be worth it for you to have me provide you with a second opinion to see if I can downgrade your diagnosis to disordered proliferative endometrium. If you want to go this route, contact me through my website at reichertpathology.com.

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Katherine March 25, 2015 at 3:19 pm

I should also mention that on transvaginal ultrasound the thickness of my endometrium was 5 mm.

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