ENDOMETRIAL

HYPERPLASIA
JULY , 2021
 General Data
● 44 years old
● Single
● Nulligravid
● Residing at Manila
● Consulted at FEU NRMF Medical
center on July 8, 2021
 Patient’s Profile
● Birthday: January 11,1976
● Birthplace: Quezon City
● Civil Status Single
● Religion: Roman Catholic
● Occupatio: Nurse aide
● Habits: Non-smoker and Non-alcoholic beverage drinker
● Attitude: cooperative
● Availability of Relatives: Near
Chief Complaint
Heavy Vaginal Bleeding
 History of Present Illness
2 months PTC Few days PTC
○ Interval: 2 weeks ○ Duration: 3 days
○ Duration: 3-5 days ○ Amount: 5 fully soaked
○ Amount: 4-5 fully soaked napkins to 3 diapers
napkins per day moderately soaked per day
○ Symptoms: none ○ Symptoms: none

Few hours PTC CONSULT - JULY 8, 2021

○ Heavy bleeding with
passage of blood clots
LMP: JULY 2, 2021
PMP: JUNE 14, 2021
 Past Medical History
● (+) mumps, measles, chickenpox
● Non-asthmatic
● (+) Hypertension
○ 4 years
○ Maintenance medication: Losartan 50mg 1 tab OD
● (+) Diabetes Mellitus Type 2
○ 5 years
○ Maintenance medication: Metformin 500mg 1 tab OD
● No history of allergies, trauma, accidents, previous hospitalizations,
blood transfusion, major illnesses
 Family History
FATHER
● 71 year old 2 SISTERS
● (+) Hypertension ● (+) Diabetes Mellitus

MOTHER BROTHER
● 69 years old ● (+) Hypertension
● (+) Hypertension

No family history of pulmonary, liver, kidney, thyroid diseases nor

malignancies
 Personal and Social History
● 2nd among 6 siblings
● College undergraduate
● Nursing Aide
● Single
● Living with her family
● Non smoker, non alcoholic beverage drinker, no food preferences, no
history of illicit drug use
 Obstetrical Gynecologic History
History ● Menarche
● Nulligravid ○ 13 years old
○ Duration: 4 days
○ Amount: 4 moderately soaked pads per day
○ Symptoms: no dysmenorrhea
● Subsequent Menses
○ Intercal: 28-30 days
○ Duration: 3-4 days
○ Amount: 3-4 moderately soaked pads per day
○ Symptoms: no dysmenorrhea
● No history of dyspareunia, post-coital bleeding, or
leucorrhea. No history of undergoing pap smear
 Method of
Sexual History
Contraception
● Coitarche: 31 years ● None
old
● 1 lifetime sexual
partner
 Review of Systems
● Constitutional: no fever, no chills, no malaise, no weight loss
● Hematology: no easy fatigability, no easy bruisability
● CNS: no headache, no seizure, and no loss of consciousness
● HEENT: no blurring of vision, no hearing loss, and no tinnitus
● Respiratory: no dyspnea, no cough, no colds, and no apnea
● CVS: no orthopnea, no palpitations
● GIT: no diarrhea, no constipation
● GUT: no dysuria, no frequency, no urgency
● NMS: no malaise, no arthralgia, no myalgia, no numbness
 Physical Examination
General Survey

BP: 130/90 CR: 87 bpm RR: 20 bpm

Temp: 36.9C O2 sat: 98% BMI: 31 kg/m2

 Physical Examination
HEENT: pinkish palpebral conjunctivae, anicteric sclerae, no nasoaural
discharge, no tonsillopharyngeal congestion.

Neck: Supple, no neck vein engorgement, no palpable lymph nodes

Chest: Symmetrical chest expansion, no retractions, no lagging

Lungs: Vesicular breath sounds, no crackles, no wheezes

Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs.

Breasts: Symmetrical in contour, no dimpling, no palpable mass or

abnormal nipple discharge
Abdomen: flabby, soft, nontender, no palpable masses

Speculum: clean-looking cervix with minimal to moderate vaginal

bleeding per os

Internal Exam: normal looking external genitalia, nulliparous

introitus, vagina admits 2 fingers, cervix is firm and closed, uterus
unenlarged, no adnexal mass nor tenderness

Extremities: No gross deformities, No edema on both upper and lower

extremities, full pulses.

Skin: No Active Dermatoses

 Salient Features
● 44 years old
● Nulligravid
● Heavy vaginal bleeding
○ I: 2 weeks; D: 3-5 days; A: 4-5 fully soaked pads per day
● Hypertension
● Diabetes Mellitus
● BMI of 31 kg/m2
● Speculum: clean-looking cervix with minimal to moderate vaginal
bleeding per os
● Internal Exam: normal looking external genitalia, nulliparous
introitus, vagina admits 2 fingers, cervix is firm and closed, uterus
unenlarged, no adnexal mass nor tenderness
 Admitting Diagnosis

Nulligravid, Acute Abnormal Uterine

Bleeding t/c Endometrial Hyperplasia, to
rule out Malignancy, Hypertension Stage 2,
Diabetes Mellitus Type 2, Obese class 1
 PLAN
● Admit the patient
● Hook to LRS 1L
● Request for
○ RT-PCR, CBC, Blood typing, Urinalysis, Pregnancy Test, RBS, Transvaginal
Ultrasound, Endometrial Biopsy
● Referral to dietary services
● For CP clearance
● For possible Endometrial Curettage
DISCUSSION
ABNORMAL UTERINE
BLEEDING
 ABNORMAL UTERINE BLEEDING

bleeding from the uterine corpus that is abnormal in regularity, volume,

frequency, or duration and occurs in the absence of pregnancy

Acute uterine bleeding

- An episode of heavy bleeding that is of sufficient quantity to require

immediate intervention to prevent further blood loss
 ABNORMAL UTERINE BLEEDING
● Bleeding or spotting between periods
● Bleeding or spotting after sex
● Heavy bleeding during period
● Menstrual cycles that are longer than 38 days or shorter than 24 days
● Irregular period in which cycle length varies more than 7-9 days
● Bleeding after menopause
NORMAL MENSTRUAL FLOW
 NORMAL MENSTRUAL FLOW

Mean interval 28 +/- 7 days

Mean duration 4-8 days

Average menstrual blood loss 35 mL

 ABNORMAL UTERINE BLEEDING

● Heavy menstrual bleeding

- Excessive bleeding of more than 80 ml occuring at regular
intervals
● Intermenstrual bleeding
- Variable amounts that occur between clearly defined cyclic and
predictable menses
● Oligomenorrhea
- Interval vary from 35 days to 6 months
● Amenorrhea
- No menses for at least 6 months
PALM/COEIN
DIFFERENTIAL
DIAGNOSIS
 ENDOMETRIAL HYPERPLASIA
RULE IN
● Reproductive age
● Manifestation- Heavy menstrual bleeding
● Risk factors- Nulliparity, Hypertension, Diabetes, Obesity
● Ultrasound- Thickened endometrium (1.84 cm)

RULE OUT
● Cannot be totally ruled out - histopathology and biopsy
 ENDOMETRIAL CANCER
RULE IN
● Manifestation- abnormal menstrual bleeding
● Risk factors-Increasing age, Diabetes, Nulliparity, Obesity
● Ultrasound- Thickened endometrium

RULE OUT
● Cannot be totally ruled out - histopathology and biopsy
 ENDOMETRIAL POLYP

RULE IN
● Manifestation: Abnormal bleeding
● Age (40-49)

RULE OUT
● Polyps were not detected on transvaginal ultrasound
● Cannot be totally ruled out- Saline Infusion Sonography
 SUBMUCOUS LEIOMYOMA
RULE IN
● Manifestation- Abnormal and Excessive bleeding
● Risk factors- Increasing age, Obesity

RULE OUT
● Pelvic pressure or pelvic pain
● No concentric solid hypoechoic masses at the endometrial
lining
DIAGNOSTIC
WORK-UPS
 Office Endometrial Sampling
➢ Z technique: to increase the yield of endometrial sampling
➢ Often performed with a thin 3 mm plastic pipelle; OPD procedure
➢ Not used for active bleeding

INDICATIONS:

○ > 45 years old presenting with abnormal uterine bleeding

○ < 40 years old with risk factors for endometrial carcinoma

○ Failure of medical treatment

○ Breast cancer patients who complain of abnormal vaginal bleeding

➢ When office endometrial biopsy is not possible or if the tissue sample is insufficient,
dilation and curettage (D&C) should be performed under anesthesia.
➢ 68% sensitivity compared with hysterectomy specimens, 78% compared with D&C.
 Dilatation and Curettage
➢ Procedure in which cervical dilators are used to facilitate the introduction of instruments
into the uterus, and endometrial cavity is either sampled or emptied with a curette
➢ Both diagnostic and therapeutic.
➢ Preferred in moderate to severe bleeding; Patient is admitted
 Transvaginal Ultrasonography

➢ Adjunct for diagnosis of endometrial hyperplasia and Cancer.

➢ Eliminating diagnosis of neoplasia for those with thickness less than 5 mm
➢ Initial appropriate management for postmenopausal woman who presents with vaginal
bleeding
➢ less than 4 mm had 100% negative predictive value (Post menopausal)
THICK ENDOMETRIUM:

➢ Postmenopausal age group - > 5 mm

➢ Pre menopausal women - > 15 mm
 Saline infusion sonography
/Sonohysterography
➢ Valuable to assess uterine cavity and to rule out an intracavitary lesion before ascribing the
diagnosis to endometrial disorders or ovulatory dysfunction.
➢ The primary goal of sonohysterography is to visualize the endometrial cavity in more
detail than is possible with routine transvaginal ultrasonography
➢ 10 to 15 mL of saline or sterile water is usually introduced through the cervix with an
insemination catheter, or with a special catheter that has a balloon for inflation in the
cervical canal, allowing continuous infusion.
➢ If probable anatomic problem may be present (ex: Submucous myoma,polyps)
 Hysteroscopy
➢ Recommended; can directly visualize the uterine cavity;
➢ Most accurate diagnostic tool in the diagnosis of endometrial hyperplasia
➢ Not indicated to patients with active bleeding
➢ Both diagnostic and therapeutic

Hysteroscopically Guided Endometrial Biopsy

- Gold standard in diagnosing endometrial hyperplasia
WORK- UPS
Pregnancy test
Transvaginal Ultrasound
Complete Blood Count
Blood Typing
Urinalysis
Endometrial curettage
Pregnancy Test
Negative
 Transvaginal Ultrasound
Anteverted unenlarged uterus.
The endometrium is thickened (1.84 cm) and
heterogenous with irregular cystic spaces.
Endometrial midline is nonlinear and the
endometrial-myometrial junction is regular.
No color flow noted on initial color mapping.
Nabothian cysts, cervix. Unremarkable bilateral
ovaries.
Complete Blood Count Blood typing
RBC 3.11 x 10^12/L
Hemoglobin 10.8 g/dL
B+
Hematocrit 36. 8%
MCV 89. 8 fL
MCH 29.9 pg
MCHC 33.4 g/L
Platelet Count 299 x10^9/L
WBC 9.53 x 10 ^9/L
Neutrophils 85. 9%
Lymphocytes 10.6 %
Monocytes 3.1 %
Eosinophils 0.1%
Basophils 0.3%
 Urinalysis
Color Yellow
Transparency Hazy
Blood +1
Bilirubin Negative
Urobilinogen Normal
Ketones Negative
Protein Negative
Nitrite Negative
Glucose Negative
pH 7.0
Specific Gravity 1.010

Leukocytes +2

WBC 14-15
RBC 4-5
Epithelial cells Few

Bacteria 401
 Endometrial curettage

Uterine depth of 8 cm
Obtained 1 specimen cup of pink, chunky non-friable tissues
Histopathologic Report: Simple Hyperplasia with Atypia
 ENDOMETRIAL HYPERPLASIA
According to the WHO and ISGP Classification:

➢ SIMPLE HYPERPLASIA
○ WITHOUT ATYPIA - glands cystically dilated with occasional outpouchings
and focal crowding, 1%
○ WITH ATYPIA - With hyperchromatic enlarged epithelial cells with
increased N:C ratio, 8%
➢ COMPLEX HYPERPLASIA
○ WITHOUT ATYPIA - Crowding of glands with disparity in size and irregular
in shape, 3%
○ WITH ATYPIA - glands are highly irregular in shape, hyperchromatic and
increased N:C ratio, 29%
NORMAL ENDOMETRIUM
Simple Hyperplasia
Nuclear Atypia
 Final Diagnosis

Nulligravid
Acute Abnormal Uterine Bleeding secondary to Endometrial
Hyperplasia (AUB - P0A0L0M1 C0O0E0I0N0)
s/p Endometrial curettage (2021) - Simple Hyperplasia with
Atypia
Urinary Tract Infection
Mild anemia
Hypertension Stage II
Diabetes mellitus Type II
Obese Class I
 Incidence/Prevalence

ABNORMAL UTERINE BLEEDING

➢ Abnormal uterine bleeding is a common condition, with a prevalence of 3% - 30% among

women of reproductive age.
➢ Most commonly occurring at menarche and perimenopause.

ENDOMETRIAL HYPERPLASIA

➢ 133 women per 100,000 per year

➢ after menopause, in women from 50 to 54 years of age.
○ Atypical hyperplasia is seen most commonly in 60- to 64-year-olds
ENDOMETRIAL CARCINOMA

➢ Endometrial cancer is the sixth most common cancer in women

➢ 14th most common cancer overall
➢ Incidence peaks between ages 60 and 70 years
➢ 10 - 15% - < 50 years
➢ PHILIPPINE STATISTICS:
○ 3rd most common gynecologic malignancy
○ 11th most common overall ( 2.8%)
○ Incidence starts rising steeply at age 40
○ 4,374 new cases and 1306 deaths (2020)
 RISK FACTORS
● Unopposed estrogen stimulation
● Late menopause
● BMI >30
● Nulliparity
● Diabetes mellitus
● Granulosa cell tumor or Theca lutein cysts
● Polycystic ovarian syndrome
● Tamoxifen use
 PATHOPHYSIOLOGY
RISK FACTORS
PROLONGED ESTROGEN
● Unopposed estrogen STIMULATION OF THE
ENDOMETRIUM
stimulation
● Late menopause
● BMI >30
● Nulliparity
● Diabetes mellitus ENDOMETRIAL HYPERPLASIA
● Granulosa cell tumor or
WHO & ISGP classification:
Theca lutein cysts ❏ Simple hyperplasia
● Polycystic ovarian ❏ Complex hyperplasia
syndrome ❏ Atypical simple hyperplasia
● Tamoxifen use ❏ Atypical complex hyperplasia
MANAGEMENT
 MANAGEMENT
Urinary Tract Infection
Cephalexin 500 mg BID for 7 days
Cefuroxime axetil 500 mg BID for 7 days

Mild Anemia
Supplemental Iron 60-120 mg
 MANAGEMENT: Endometrial Hyperplasia

FACTORS TO CONSIDER:

● Presence of atypia
● Age of the patient
● Desire to get pregnant
● Patient’s surgical risks/ comorbidities
MANAGEMENT
MEDICAL MANAGEMENT
● Simple Hyperplasia with Atypia
○ Use high dose progestins

Medroxyprogesterone acetate 10-20 mg/day for 3-6 months

Megestrol acetate 40-200 mg/day for 3-6 months

Levonorgestrel releasing IUD For 5 years

SURGICAL MANAGEMENT

❏ Below 45 years old EXTRAFASCIAL

❏ Not desirous of HYSTERECTOMY
pregnancy
 FUTURE PLANS
FOLLOW-UP (POST HORMONAL MANAGEMENT SURVEILLANCE)
● Endometrial sampling is repeated every three to six months
○ If the patient has nonatypical EH after 3 months
→ progestin therapy should be continued.
○ If persistent atypical EH is present at 6 to 12 months
→ The total progestin dose may be increased or
hysterectomy may be considered
 FUTURE PLANS
FOLLOW-UP

● Lifestyle intervention
○ Healthy diet
○ Exercise
THANK YOU!