Endometrial Hyperplasia

Intro
• Endometrial Hyperplasia
• Pathogenesis
• Risk Factors
• Classification
• Investigations
• Case 1
• Case 2
 Endometrial Hyperplasia
• Endometrial hyperplasia is defined as irregular proliferation of the
endometrial glands with an increase in the gland to stroma ratio
when compared with proliferative endometrium.
• May be a precursor for Endometrial Cancer.
• Incidence: estimated to be at least three times higher than
endometrial cancer. (8617 new cases of Endometrial Ca in 2012)
• Symptoms: Abnormal uterine bleeding – HMB, IMB, PMB, Irregular
bleeding, unscheduled bleeding on HRT.
 Pathogenesis

• Hyperplasia usually develops in the presence of continuous estrogen

stimulation unopposed by progesterone.
• Estrogen and progesterone—control the changes in the uterine lining.
• Estrogen builds up the uterine lining.
• Progesterone maintains and controls this growth.
• Estrogen without enough progesterone may cause the lining of the
uterus to thicken.
 Risk Factors for Endometrial Hyperplasia
Endometrial hyperplasia is associated with prolonged estrogen
stimulation of the endometrium, which may be due to:
• Anovulation eg PCOS
• Obesity
• Oestrogen secreting tumours- granulosa cell tumours
• Drug induced e.g. unopposed estrogen replacement therapy or long-term
tamoxifen
Classification of endometrial hyperplasia

1. Hyperplasia without Atypia (EHWA)

2. Atypical Hyperplasia (AEH)

 Investigations

• TV ultrasound- a cut-off of 4-5 mm

• Endometrial biopsy
• Hysteroscopy & D&C
• CT/MRI- not routinely recommended
Case 1
A 54 year old lady, Para 1, BMI 35, presents with PMB. She was found
to have an ET of 7 mm of TV USS. A pipelle biopsy was done which
came back showing endometrial hyperplasia without atypia.

What would you like to do?

Algorithm for management of EHWA
Case 2
A 44 year old lady, nulliparous, BMI 40, presents with irregular
bleeding. She was found to have an ET of 15 mm of TV USS. A pipelle
biopsy was done which came back showing atypical hyperplasia.

What would you like to do?

 Atypical Hyperplasia
• AEH carries a much greater risk of progression to endometrial cancer
• 8% in 4 years
• 12.4% in 9 years
• 27.5% after 19 years
• Rates of concurrent endometrial cancer may be as high as 43% in
patients diagnosed with AEH.
Algorithm for management of AH
Conclusion