{"id":201,"date":"2020-08-13T16:16:14","date_gmt":"2020-08-13T16:16:14","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=201"},"modified":"2021-05-09T20:53:47","modified_gmt":"2021-05-09T20:53:47","slug":"54-endometrial-hyperplasia-and-carcinoma","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/54-endometrial-hyperplasia-and-carcinoma\/","title":{"rendered":"54. Endometrial Hyperplasia and Carcinoma"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/Q87BvZmUmPk\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration = 8:01<\/p>\n<input type='hidden' bg_collapse_expand='69e9c8ed5b5ff6094508844' value='69e9c8ed5b5ff6094508844'><input type='hidden' id='bg-show-more-text-69e9c8ed5b5ff6094508844' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c8ed5b5ff6094508844' value='Hide Transcript'><button id='bg-showmore-action-69e9c8ed5b5ff6094508844' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c8ed5b5ff6094508844' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number 54 for<br \/>\n00:02<br \/>\nendometrial hyperplasia and carcinoma<br \/>\n00:04<br \/>\nuterine carcinoma is the most common<br \/>\n00:07<br \/>\ngynecologic malignancy and approximately<br \/>\n00:09<br \/>\n2 to 3 percent of women will develop<br \/>\n00:10<br \/>\nuterine cancer during their lifetime if<br \/>\n00:12<br \/>\nthe cancer arises from the glands of the<br \/>\n00:15<br \/>\nendometrium it is an endometrial<br \/>\n00:17<br \/>\ncarcinoma if the cancer arises from the<br \/>\n00:19<br \/>\nmesenchymal uterine components than it<br \/>\n00:21<br \/>\nis a sarcoma 97 percent of uterine<br \/>\n00:23<br \/>\ncancers are endometrial cancers and 3%<br \/>\n00:26<br \/>\nare sarcomas fortunately most patients<br \/>\n00:28<br \/>\nwith endometrial cancer will have early<br \/>\n00:30<br \/>\npresentation and 90 percent of women<br \/>\n00:32<br \/>\nwith endometrial cancer will develop<br \/>\n00:34<br \/>\nsymptomatic bleeding or discharge this<br \/>\n00:36<br \/>\ncan facilitate early diagnosis and most<br \/>\n00:38<br \/>\nendometrial cancers are diagnosed in<br \/>\n00:40<br \/>\nstage 1 the 5-year survival for women<br \/>\n00:42<br \/>\nolder than 65 is 81 percent for white<br \/>\n00:45<br \/>\nwomen and 53% for black women the<br \/>\n00:47<br \/>\netiology for this disparity of outcomes<br \/>\n00:49<br \/>\nis unclear and needs to be further<br \/>\n00:51<br \/>\ninvestigated the objectives of this<br \/>\n00:54<br \/>\nvideo are to identify risk factors for<br \/>\n00:56<br \/>\nendometrial hyperplasia and cancer to<br \/>\n00:58<br \/>\ndescribe the symptoms and physical exam<br \/>\n01:00<br \/>\nfindings with endometrial hyperplasia<br \/>\n01:02<br \/>\nand cancer and to outline the causes<br \/>\n01:04<br \/>\ndiagnosis and management of<br \/>\n01:06<br \/>\npostmenopausal bleeding endometrial<br \/>\n01:08<br \/>\nhyperplasia is the most common precursor<br \/>\n01:10<br \/>\nto endometrial carcinoma endometrial<br \/>\n01:12<br \/>\nhyperplasia is organized into 4<br \/>\n01:14<br \/>\ndifferent World Health Organization<br \/>\n01:16<br \/>\nclassifications in simple hyperplasia<br \/>\n01:19<br \/>\nboth the glands and stromal cell<br \/>\n01:21<br \/>\nelements proliferate excessively here<br \/>\n01:24<br \/>\nare the glands G and the stroma s<br \/>\n01:27<br \/>\nhistologically the glands vary markedly<br \/>\n01:29<br \/>\nin size from small to systole enlarged<br \/>\n01:32<br \/>\ncomplex hyperplasia represents an<br \/>\n01:34<br \/>\nabnormal proliferation of primarily the<br \/>\n01:37<br \/>\nglandular elements without proliferation<br \/>\n01:39<br \/>\nof the stromal elements thus will be an<br \/>\n01:41<br \/>\nincreased gland to stromal ratio the<br \/>\n01:44<br \/>\nglands appear to be almost back-to-back<br \/>\n01:46<br \/>\nthe hyperplasia are then further<br \/>\n01:48<br \/>\nclassified depending on the presence or<br \/>\n01:50<br \/>\nabsence of nuclear a tibia we can thus<br \/>\n01:52<br \/>\nhave simple hyperplasia without a tibia<br \/>\n01:54<br \/>\nand complex hyperplasia without a tibia<br \/>\n01:57<br \/>\nsimple hyperplasia with a tibia and Here<br \/>\n02:00<br \/>\nI am drawing the simple glands again and<br \/>\n02:06<br \/>\ncomplex hyperplasia with a tibia the<br \/>\n02:09<br \/>\ndifference is that atypical cells have<br \/>\n02:12<br \/>\ndisordered mature<br \/>\n02:13<br \/>\nwith nuclear enlargement thus have<br \/>\n02:15<br \/>\nincreased nuclear &#8211; cytoplasmic ratios<br \/>\n02:17<br \/>\nwhich I am drawing here each of these<br \/>\n02:20<br \/>\nfour classifications has a defined risk<br \/>\n02:23<br \/>\nof progression to cancer simple<br \/>\n02:25<br \/>\nhyperplasia without atypia has a 1% risk<br \/>\n02:27<br \/>\ncomplex hyperplasia without atypia has a<br \/>\n02:30<br \/>\n3% risk simple hyperplasia with atypia<br \/>\n02:32<br \/>\nhas an 8% risk and complex hyperplasia<br \/>\n02:35<br \/>\nwith atypia has a 29% risk of<br \/>\n02:37<br \/>\nprogression of cancer as a fun aside<br \/>\n02:39<br \/>\nnotice how easy these numbers can be<br \/>\n02:41<br \/>\nremembered if you think of multiples of<br \/>\n02:43<br \/>\n3 1 3 9 27 or you could think of penny<br \/>\n02:47<br \/>\nnickel dime quarter it&#8217;s close enough<br \/>\n02:49<br \/>\nhere is a histological slide of simple<br \/>\n02:52<br \/>\nhyperplasia without atypia courtesy of<br \/>\n02:54<br \/>\ndr. rich lieberman here is a gland G and<br \/>\n02:57<br \/>\nstroma S this next histological slide is<br \/>\n03:00<br \/>\ncomplex hyperplasia with atypia note the<br \/>\n03:03<br \/>\nincreased gland to stroma ratio and the<br \/>\n03:05<br \/>\nincreased nuclear to cytoplasmic ratio<br \/>\n03:07<br \/>\nof these cells here the most significant<br \/>\n03:10<br \/>\nrisk factor for endometrial hyperplasia<br \/>\n03:12<br \/>\nis exposure to unopposed estrogen which<br \/>\n03:14<br \/>\ncauses overgrowth of the endometrium<br \/>\n03:16<br \/>\nthis unopposed estrogen can come from<br \/>\n03:19<br \/>\nexogenous or endogenous sources we will<br \/>\n03:23<br \/>\nnow move on to risk factors using our<br \/>\n03:24<br \/>\npatient miss Edna metrium miss Edna is<br \/>\n03:27<br \/>\ngetting on in years and older age is our<br \/>\n03:30<br \/>\nfirst risk factor the next risk factor<br \/>\n03:33<br \/>\nis obesity for adipose tissue contains<br \/>\n03:35<br \/>\naroma taste which converts androstenone<br \/>\n03:37<br \/>\nto ester own now miss Edna is receiving<br \/>\n03:41<br \/>\npills if these are high dose<br \/>\n03:43<br \/>\npostmenopausal estrogen pills and this<br \/>\n03:45<br \/>\nwill significantly increase your risk of<br \/>\n03:47<br \/>\nendometrial hyperplasia and cancer<br \/>\n03:49<br \/>\nremember that estrogen must be given<br \/>\n03:51<br \/>\nwith progesterone for any patient with a<br \/>\n03:53<br \/>\nuterus if she has a history of breast<br \/>\n03:55<br \/>\ncancer and is taking tamoxifen then this<br \/>\n03:58<br \/>\nwould also be a risk factor tamoxifen is<br \/>\n04:00<br \/>\na selective estrogen receptor modulator<br \/>\n04:02<br \/>\nand acts as an estrogen agonist on the<br \/>\n04:05<br \/>\nendometrium poor miss Edna also has an<br \/>\n04:07<br \/>\novarian mass and one specific type of<br \/>\n04:09<br \/>\novarian cancer the granulosa cells to<br \/>\n04:11<br \/>\nmyrrh produces estrogen thus will be a<br \/>\n04:14<br \/>\nrisk factor other risk factors would<br \/>\n04:16<br \/>\ninclude characteristics that increase<br \/>\n04:17<br \/>\nthe duration that the endometrium was<br \/>\n04:19<br \/>\nexposed to estrogen stimulation so<br \/>\n04:21<br \/>\nNullah parity early menarchy and late<br \/>\n04:24<br \/>\nmenopause are all risk factors last<br \/>\n04:26<br \/>\nLeith living in North America or<br \/>\n04:27<br \/>\nnorthern Europe are risk factors as well<br \/>\n04:29<br \/>\nhere is a table that summarizes the risk<br \/>\n04:32<br \/>\nfactor and the estimated relative risk<br \/>\n04:34<br \/>\nof developing endometrial hyperplasia or<br \/>\n04:35<br \/>\ncancer older age two to threefold<br \/>\n04:38<br \/>\nobesity two to fivefold high-dose<br \/>\n04:40<br \/>\nestrogen ten to twenty fold tamoxifen<br \/>\n04:42<br \/>\nthree to seven fold infertility and<br \/>\n04:45<br \/>\nnella parity threefold estrogen<br \/>\n04:47<br \/>\nproducing tumor greater than fivefold<br \/>\n04:49<br \/>\nand residency in North America or<br \/>\n04:51<br \/>\nNorthern Europe three to eighteen fold<br \/>\n04:52<br \/>\nnotice that these three risk factors the<br \/>\n04:55<br \/>\nhigh dose estrogens tamoxifen and<br \/>\n04:57<br \/>\nresidency in North America and Europe<br \/>\n04:59<br \/>\nhave the highest relative risks let&#8217;s<br \/>\n05:01<br \/>\nmove on to symptoms and physical exam<br \/>\n05:03<br \/>\nfindings we discussed earlier in this<br \/>\n05:05<br \/>\nvideo that patients usually present<br \/>\n05:07<br \/>\nearly for the symptoms are often obvious<br \/>\n05:09<br \/>\nto the patient I am having abnormal<br \/>\n05:10<br \/>\nuterine bleeding having a high index of<br \/>\n05:14<br \/>\nsuspicion is important and an<br \/>\n05:15<br \/>\nendometrial biopsy should be performed<br \/>\n05:17<br \/>\non any patient with abnormal uterine<br \/>\n05:18<br \/>\nbleeding over 35 and a younger woman<br \/>\n05:21<br \/>\nwith additional risk factors that we<br \/>\n05:22<br \/>\nhave previously discussed transvaginal<br \/>\n05:25<br \/>\nultrasound may be used as an adjunct<br \/>\n05:27<br \/>\nevaluation for postmenopausal women for<br \/>\n05:29<br \/>\nan endometrial stripe of less than four<br \/>\n05:31<br \/>\nmillimeters indicates a low probability<br \/>\n05:32<br \/>\nfor endometrial cancer this point let&#8217;s<br \/>\n05:35<br \/>\nstart thinking about management to<br \/>\n05:36<br \/>\nreview we had early presentation with<br \/>\n05:38<br \/>\nabnormal uterine bleeding we performed<br \/>\n05:40<br \/>\nan endometrial biopsy which demonstrated<br \/>\n05:42<br \/>\nendometrial hyperplasia what do we do<br \/>\n05:44<br \/>\nnow it will depend on what type of<br \/>\n05:46<br \/>\nhyperplasia she has for simple and<br \/>\n05:49<br \/>\ncomplex hyperplasia without atypia<br \/>\n05:51<br \/>\nmedical therapy with progesterone is the<br \/>\n05:53<br \/>\nfirst-line therapy the risk of<br \/>\n05:55<br \/>\nprogression of cancer is very low and<br \/>\n05:57<br \/>\nthe progesterone therapy will decrease<br \/>\n05:59<br \/>\nthe glandular proliferation the most<br \/>\n06:01<br \/>\ncommon progesterone therapy is oral<br \/>\n06:03<br \/>\nMadrasi progesterone acetate when atypia<br \/>\n06:06<br \/>\nis present there is more concern for<br \/>\n06:07<br \/>\nprogression at endometrial cancer of<br \/>\n06:09<br \/>\nnote simple hyperplasia with atypia is a<br \/>\n06:11<br \/>\nrelatively rare finding and we will<br \/>\n06:13<br \/>\nfocus on complex hyperplasia with atypia<br \/>\n06:15<br \/>\ndefinitive therapy with hysterectomy is<br \/>\n06:18<br \/>\nrecommended once childbearing is<br \/>\n06:19<br \/>\ncomplete for women with complex atypical<br \/>\n06:21<br \/>\nhyperplasia for women who desire future<br \/>\n06:23<br \/>\nfertility long term high-dose<br \/>\n06:25<br \/>\nprogesterone therapy may be attempted to<br \/>\n06:27<br \/>\navoid hysterectomy however this does<br \/>\n06:29<br \/>\nrequire frequent endometrial sampling to<br \/>\n06:31<br \/>\nensure that disease progression has not<br \/>\n06:33<br \/>\noccurred as we have discussed the<br \/>\n06:34<br \/>\netiology for most endometrial cancers is<br \/>\n06:37<br \/>\nsecondary to excess estrogen exposure<br \/>\n06:38<br \/>\nand Dmitry all cancers<br \/>\n06:40<br \/>\nestrogen dependent are classified as<br \/>\n06:42<br \/>\ntype one 90% of endometrial cancers are<br \/>\n06:45<br \/>\ntype one the more aggressive variety of<br \/>\n06:48<br \/>\nendometrial cancer type two accounts for<br \/>\n06:50<br \/>\n10% of cases there is no clear<br \/>\n06:52<br \/>\nepidemiological profile for type 2<br \/>\n06:54<br \/>\ncancers type 2 cancers tend to have<br \/>\n06:56<br \/>\naggressive high-grade nuclei or clear<br \/>\n06:58<br \/>\ncell histology let&#8217;s discuss<br \/>\n07:00<br \/>\npostmenopausal bleeding for a moment<br \/>\n07:02<br \/>\nthis is bleeding that occurs after 12<br \/>\n07:04<br \/>\nmonths of amenorrhea the risk of<br \/>\n07:06<br \/>\nendometrial cancer is 10 to 15 percent<br \/>\n07:08<br \/>\nfor these patients so endometrial<br \/>\n07:09<br \/>\nsampling must occur other causes include<br \/>\n07:12<br \/>\nendometrial atrophy which accounts for<br \/>\n07:14<br \/>\n60 to 80 percent of postmenopausal<br \/>\n07:15<br \/>\nbleeding hormone therapy 15 to 25<br \/>\n07:18<br \/>\npercent endometrial polyps 2 to 12% and<br \/>\n07:21<br \/>\nendometrial hyperplasia 5 to 10%<br \/>\n07:23<br \/>\ntherefore when a patient presents with<br \/>\n07:25<br \/>\npostmenopausal bleeding the evaluation<br \/>\n07:27<br \/>\nshould include an endometrial biopsy<br \/>\n07:29<br \/>\ncareful physical and pelvic examination<br \/>\n07:31<br \/>\npelvic ultrasound and don&#8217;t forget to<br \/>\n07:33<br \/>\nscreen for cervical cancer with a pap<br \/>\n07:35<br \/>\nsmear this concludes the aapko<br \/>\n07:36<br \/>\neducational video on endometrial<br \/>\n07:38<br \/>\nhyperplasia and cancer we have reviewed<br \/>\n07:40<br \/>\nrisk factors symptoms physical exam<br \/>\n07:42<br \/>\nfindings and management for women with<br \/>\n07:44<br \/>\nendometrial hyperplasia cancer and<br \/>\n07:46<br \/>\npostmenopausal bleeding<br \/>\n07:56<br \/>\nOh<\/p>\n<p><\/div>\n<hr \/>\n","protected":false},"excerpt":{"rendered":"<p>Duration = 8:01<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":54,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-201","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/201","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=201"}],"version-history":[{"count":1,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/201\/revisions"}],"predecessor-version":[{"id":2861,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/201\/revisions\/2861"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=201"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}