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.
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.