Endometrial

Hyperplasia
Zakaria Sanad,MD

Definition

Abnormal endometrial glandular

proliferation
Spectrum of morphologic and biologic
alteration of end glands and stroma
(exaggerated physiologic state to CIS)

Etiology

Usually a result of chronic unopposed

estrogen stimulation in absence of
progesterone influence

Risk Factors

Obesity
Age above 40 y
Nulliparity
Early menarche , late menopause
Chronic anovulation , PCOS
Estrogen-producing ovarian tumors
Menopausal use of ERT without proges
Tamoxifen used for tt of cancer breast

DM , Hypertension
Family history
Alcohol intake
High animal fat
Chronic liver disease

Decreased Risk

Combined pills
Pregnancy
Smoking

Clinical Importance

May be associated w estrogen-producing

ovarian tumors
May result from exog unopposed E therapy
May cause abnormal uterine bleedig
May precede or occur simultaneously with
endometrial cancer

Classification (ISGP)

Based on architectural and cytologic

features as well as long-term prognosis
Simple (cystic without atypia)
1%
Complex (adenomatous without atypia) 3 %
Atypical : Simple (cystic w atypia)
8%.............Complex (adenomatous w
atypia) 29 %

Simple : dilated,cystic glands w round shapes

increased G/S ratio , no crowding , no atypia
Complex : budding and infolding , crowded
glands w less stroma , no atypia
Atypical : large nuclei of variable size and
shape , loss of polarity , increased N/C ratio ,
prominent nucleoli , irreg clumped chromatin
w parachromatin clearing

Diagnosis

Endometrial tissue sampling : Pipelle ,

Novak , Vabra
D & C biopsy

Treatment

Depends on age , desire for future fertility

, surgical risk , presence of atypia
H without atypia : Some recommend D&C
+ Cyclic progestin ( MPA 10 mg / day for
14 days per cycle for 3-6 m) or Mirena or
combined pills + re-biopsy
H w atypia : Hystrectomy is recommended,
continuous progestin ( Megestrol A 40 mg
2-4 times daily for 3-6 m )+maint if d F

Asherman Syndrome

Destruction of the endometrium and

intra-uterine synechia resulting in 2ry
amenorrhea
5-7 % of women w 2ry amenorrhea
1-2 % of infertile women

Risk Factors

Overzealous postpartum or post-abortive

curettage IU scarification (bleeding after
delivery ,placental remnants,septic
abortion,repeat D&C for retained POC)
Uterine surgery :CS , myomectomy ,
metroplasty
Endometritis,TB,B,severe pelvic infection
Postpartum hypogonadism (Sheehan synd)
UAE (endom damage from ischemia)

Presenting Complaints

Menstrual disorders ( 60 % ) : 2ry

amenorrhea,hypomenorrhea,dysmenorrhea
Infertility after possible ut insult ( 40 % )
Repeated miscarriage

Diagnosis

HSG
Sonohysterograpgy (SIS)
Diagnostic office hysteroscopy
MRI

Treatment

Hysteroscopy with direct lysis of adhesions

by cutting , cautery or laser
Prevention of reformation of adhesions : a
pediatric Foley catheter (3 ml,7 d), broadsp antibiotic for 10 d , high dose estrogen
for 2 m
Repeat attempts are worthwile

Prognosis

Restoration of menses : more than 90%

Successful pregnancy : 70-80%
Live-birth : 30-70%
Pregnancy complicated by preterm labor,
p accreta, p previa, postpartum hem

Uterine Polyps-Corporeal

Adenomatous (mucous)
Fibroid
Placental
Malignant

Uterine Polyps - Cervical

Adenomatous ( mucous )
Fibroid
Malignant
Bilharzial
Tuberculous