Endometrial hyperplasia

Introduction to endometrial hyperplasia Endometrial hyperplasia has a certain tendency to cancer, so it is classified as precancerous lesions. However, according to long-term observation, the vast majority of endometrial hyperplasia is a reversible disease, or maintain a persistent benign state, and only a few cases may develop into cancer after a longer interval. There are three types of endometrial hyperplasia: simple hyperplasia, complex hyperplasia and dysplasia. The following discussion focuses on atypical hyperplasia. basic knowledge The proportion of the disease: the incidence rate of pregnant women is about 0.04% - 0.07% Susceptible people: women Mode of infection: non-infectious Complications: shock

Endometrial hyperplasia

No ovulation (25%):

In adolescent girls, perimenopausal women, a certain disorder of the hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome, etc., can have no ovulation, so that the endometrium is sustained by estrogen for a long time, no Progesterone confrontation, lack of periodic secretory phase transformation, long-term hyperplasia state, 41 patients under 40 years old with endometrial atypical hyperplasia in Peking Union Medical College Hospital, except for focal dysplasia, other endometrium More than 80% have no secretory phase; 70% of the basal body temperature measurement results are single-phase, so most patients have no ovulation.

Obesity (15%):

In obese women, androstenedione secreted by the adrenal gland is converted to estrone by aromatase in adipose tissue; the more adipose tissue, the stronger the transformation ability, the higher the level of estrone in plasma, thus causing persistent estrogen Impact.

Endocrine functional tumors (10%):

Endocrine functional tumors are rare tumors, but they account for 7.5% of endocrine functional tumors in the research and statistics of Peking Union Medical College Hospital. The gonadotropin function of the pituitary gland is abnormal. Ovarian granulosa cell tumor is also a tumor that continuously secretes estrogen.

Exogenous estrogen (20%):

(1) Estrogen replacement therapy (ERT): peri-menopausal or postmenopausal, due to estrogen deficiency and menopausal syndrome, the same fashion may have osteoporosis, abnormal lipid metabolism, cardiovascular changes, and even brain cells Changes in activities, etc., ERT has been widely used, and has achieved good results, but ERT alone has estrogen, will stimulate endometrial hyperplasia, with estrogen alone, you can have 20% of women in the womb Membrane hyperplasia (Woodruff 1994), and the application of ERT, often over the years, even until the end of life, long-term, if not combined with progesterone, there will be severe intimal hyperplasia, or even endometrial cancer.

(2) Application of tamoxifen: Tamoxifen TAM has anti-estrogen effect, so it is used in postmenopausal women with advanced breast cancer. Under low estrogen conditions, TAM has a weak similarity. The role of estrogen, so long-term use of TAM, can also make endometrial hyperplasia, Cohen (1996) reported 164 cases of postmenopausal TAM, there are 20.7% of endometrial lesions, the incidence of endometrial lesions and the duration of taking TAM For those who take >48 months, 30.8% have endometrial lesions, including simple hyperplasia of the endometrium and complex hyperplasia, and there are individual endometrial cancers. Therefore, postmenopausal breast cancer patients should pay more attention to this during TAM. In the Cohen (1996) group, 12 cases of breast cancer were treated with progesterone during the TAM administration. In all cases, the endometrial stroma was decidual.

Pathogenesis

1. Histological classification

In the name terminology, the old classification is not very precise, such as "cystic hyperplasia", its histological changes are not limited to the glandular components of the intima, and the glandular lesions do not always appear to be cystic expansion, thus The expression of this term is not very appropriate. "Adenoma-like hyperplasia" is not only contradictory in concept and meaning. The diagnostic criteria of histology has not been clear, and it is easy to cause tumor and hyperplasia in pathological diagnosis. Confusion, the classification name of "atypical hyperplasia" is the same as the new classification, but there are still differences in the diagnostic criteria of histology. The new classification is further defined as the heterotypic change of the nucleus.

2. Pathological features

(1) endometrial hyperplasia: the lesion of the uterus is slightly larger, the intima is thickened, sometimes diffuse polypoid, the amount of curettage is large, can be mixed with red smooth polypoid tissue, the lesion is diffuse, involving The functional layer and basal layer of the intima do not show glandular crowding due to the simultaneous proliferation of mesenchyme and gland. The size of the gland is different and the contour is smooth. The morphology of glandular epithelial cells is similar to the normal late proliferative phase. Shaped.

(2) complex hyperplasia of the endometrium: the cause of complex hyperplasia is similar to simple hyperplasia, but because the lesion is focal, it may be related to the distribution of hormone receptors in the tissue, and a few complex hyperplasia can develop into dysplasia. Influencing the prognosis, there were 21 cases of endometrial hyperplasia in women under 40 years old, and 4 cases were complicated hyperplasia. After short-term drug treatment, the lesions retracted and were conceived, and full-term delivery, of which 3 cases were postpartum 2~ The recurrence of the 3-year lesion is still complicated hyperplasia, and no cancer has been seen in the follow-up period of 9 to 38 years.

The endometrium of the lesion can be thickened or thin, or it can be polypoid. Unlike simple hyperplasia, the lesion is a focal hyperplasia of glandular components without involving the interstitium. The amount of curettage can be more or less, often mixed. There are normal, atrophic or other types of hyperplasia of the endometrium, the gland of the lesion is crowded, can be "back to back", the interstitial is significantly reduced, the contour of the gland is irregular, or the curve is jagged, or the glandular nipple is formed, but Abnormality of glandular epithelial cells.

(3) Endometrial atypical hyperplasia: The occurrence of dysplasia is similar to that of complex hyperplasia, but some cases can slowly develop into cancer. In severe dysplasia, the cancer rate can reach 30% to 50%.

This type of hyperplasia is limited to endometrial glands. The atypia of glandular epithelial cells is the key to diagnosis. The lesions are focal or multifocal, and normal, atrophic or other types of hyperplasia are also seen. Increased, interstitial reduction, hyperplasia of the gland not only irregular contours, but also the genotype of glandular epithelial cells, that is, the alignment of the cells is extremely disordered or disappeared, the nucleus increases and becomes round, irregular, nucleoli is obvious, cytoplasm is rich Eosinophilic, according to the extent of the lesion, dysplasia can be divided into light, medium, and heavy three degrees, mild: gland outline is slightly irregular, glandular epithelial cells are mildly shaped, severe: gland outlines are obviously irregular branches, There are budding and papillary structures in the glandular cavity, and the genotype of glandular epithelial cells is evident in Figure 3, moderate: the lesion is between the two.

Severe dysplasia needs to be differentiated from well-differentiated endometrial cancer. The presence or absence of interstitial infiltration is an extremely important basis for identification. The morphological features are: gland "fusion", "back to back", "complex branch nipple" "Sieving" or "bridge" in the gland, and interstitial disappearance; interstitial fibrosis, and interstitial necrosis, in addition, the response to progesterone therapy and the age of the patient also contribute to the identification of the two.

Atypical hyperplasia with interstitial muscle fiber metaplasia, can be polypoid into the uterine cavity, known as atypical endometrial adenoma-like polyps or polypoid adenoma, it is easy to be misdiagnosed as cancer when the diagnosis of curettage Muscle infiltration, the main point of identification is that the myogenic fibroblasts are more disordered than the smooth muscles of the uterine wall, the nuclei are large and the cytoplasm is rich. The young women's curettage materials should be carefully diagnosed with adenocarcinoma, and there must be a clear interstitial under the microscope. Invasive and poorly differentiated, it is best not to use a curettage material for the diagnosis of myometrial invasion.

Endometrial hyperplasia prevention

Because of the tendency to become cancerous, it should be followed up after treatment to find early treatment in time.

Endometrial hyperplasia complications Complications

Infection, shock occurs due to bleeding.

Endometrial hyperplasia symptoms Common symptoms Vaginal irregular bleeding Menstrual rare endometrial proliferative lesions Atypical hyperplasia Postmenopausal endometrial thickening Menstrual cycle changes Anti-intimal antibody positive Decidual reaction Amenorrhea

Menstrual disorders are one of the prominent symptoms of this disease, often manifested as irregular vaginal bleeding, menstrual thin hair, amenorrhea after a period of amenorrhea or amenorrhea. Generally called anovulatory dysfunctional uterine bleeding. In addition to vaginal bleeding in patients with anovulatory dysfunctional uterine bleeding, infertility is also the main symptom.

Endometrial hyperplasia has a certain tendency to cancer, so it is classified as precancerous lesions. However, according to long-term observation, the vast majority of endometrial hyperplasia is a reversible lesion, or maintain a persistent benign state. Only a few cases may develop cancer after a longer interval. There are three types of endometrial hyperplasia: simple hyperplasia, complex hyperplasia and dysplasia.

Endometrial hyperplasia

Hysteroscopic examination, using hysteroscopy can not only see the endometrial condition from the appearance of the endometrium, but also can be used for curettage or negative pressure suction under direct vision, and the examination diagnosis is more detailed and comprehensive.

1. X-ray or CT examination: examination of the pituitary sella and fundus visual field, in order to exclude pituitary tumors.

2. Serum hormone determination: B-ultrasound or laparoscopy to understand the presence or absence of polycystic ovary.

3. Determination of basal body temperature: It can be understood whether there is ovulation, that is, the body temperature is biphasic type, and the function of the corpus luteum can be understood according to the curvature of the body temperature rise and the length of the maintenance time after the rise.

Diagnosis and differentiation of endometrial hyperplasia

Diagnostic criteria

According to the clinical manifestations, combined with histological examination, diagnosis can be made. The methods of histological diagnosis include endometrial tissue scraping biopsy, uterine curettage and negative pressure aspiration, due to endometrial dysplasia sometimes manifested as Scattered and single focal lesions, sometimes coexist with endometrial adenocarcinoma, curettage or endometrial diagnosis of endometrial atypical hyperplasia and hysterectomy, found that 35% to 50% of patients, there are endometrium in the uterus Adenocarcinoma (Hunter, 1994; Widra, 1995; Lu Weiguo, 2001), so the endometrial tissue of the entire uterine surface must be obtained for diagnosis.

Compared with endometrial biopsy, the curettage is more comprehensive. However, some parts may be missed when the teeth are not scratched, especially at the double uterine horn and the bottom of the palace. Negative pressure attracting has negative pressure attraction. The endometrial detachment is more complete, and the diagnosis will be more comprehensive and reliable. Therefore, the accuracy of the negative pressure suction is the highest among the three diagnostic methods, and it can also be combined with the specific conditions of the patient.

Differential diagnosis

Endometrial atypical hyperplasia and other two types of simple hyperplasia, complex hyperplasia must be identified, the same fashion should pay attention to early endometrial adenocarcinoma.

1. Identification of pathological morphology

Since ISGP (International Gynecological Pathology Association) has widely adopted the classification criteria for intimal hyperplasia, the confusion in the diagnosis of intimal hyperplasia and cancer has improved a lot. However, intimal hyperplasia and its canceration are over-diagnosed. The situation is still reported, although it is diagnosed by pathologists, the original diagnosis of cancer, after review, some of the cases are not cancer, but various types of proliferative lesions, the rate of non-conformity is 8.8%, more 50% of them are mostly over-diagnosed. Different experts read the film, the diagnosis results are different from each other, the repeatability is poor, and even the same person can read the film at different times. The result may also be different, and the non-conformity rate is 10% to 50%.

According to the endometrium taken by the curettage, there is a certain difficulty in the diagnosis of endometrial hyperplasia or carcinogenesis. Therefore, gynecological pathologist Silverberg (2000) pointed out that proliferative lesions of endometrial specimens are the most frequently diagnosed lesions in the pathological diagnosis of external examination. The following are some of the following: 1 For the diagnosis of cell atypia, the authors have different standards. 2 The interstitial infiltration for identifying dysplasia and well-differentiated adenocarcinoma is difficult to determine. 3 Endometrial mesenchymal fibers Metaplasia of mother cells or smooth muscle is easily misdiagnosed as myometrial invasion of the tumor, and 4 polypoid adenomyoma (Polypoid adenomyoma) is also easily misdiagnosed as interstitial infiltration.

The difficulty of diagnosis can be continuously explored, the continuous improvement of diagnostic criteria, and the development of molecular biology genes, so that the diagnostic accuracy is improved, as the clinician's difficulties in the diagnosis and differential diagnosis of intimal hyperplasia To have sufficient understanding and attention, in case of diagnosis, close cooperation with pathologists, provide detailed clinical information, as a reference for diagnosis, and if necessary, cooperate with pathologists to discuss diagnosis problems. Now, many hospitals have In the routine, that is, patients who receive any referral treatment, the diagnosis of the endometrium must be reviewed to avoid misdiagnosis, especially to prevent over-diagnosis and excessive treatment.

2. Identification of clinical features

When the differential diagnosis of histology is difficult, it can be combined with clinical characteristics. According to the analysis of the clinical data and pathological materials of Peking Union Medical College Hospital, the identification of endometrial atypical hyperplasia and endometrial adenocarcinoma, the following two points Have reference value.

(1) Age: Age has important differential significance. Those with endometrial adenocarcinoma who are younger than 40 years old are very rare. Among the 1566 cases of endometrioid carcinoma collected by the Norwegian Cancer Center, the average age is 62 years old (36-91). Years old, 0.6% <40 years old, 8.4% <50 years old, so for young women, especially those who are looking forward to giving birth, if the curettage material can not definitely see the characteristics of interstitial infiltration, although there is obvious glandular hyperplasia And cell atypia, should still be inclined to the diagnosis of dysplasia, but this age is the rule of endometrial cancer, those less common types of endometrial cancer, that is, non-estrogen Dependent type II endometrial cancer, including serous papillary carcinoma and clear cell carcinoma, does not have the characteristics of young age. Some scholars have reported 5 younger patients with non-estrogen-dependent endometrial cancer. The ages are 28, 34, 37, 41, and 43 years old. Therefore, in the differential diagnosis, the histological type of histopathological suggestion should be used first, only when the differentiated endometrial cancer and dysplasia cannot be identified. Age can be used as an identification Factor.

(2) Reaction of drug treatment: The response to drug treatment also contributes to the differential diagnosis of endometrial atypical hyperplasia and endometrial adenocarcinoma. The former is more sensitive to drug treatment, and the endometrium is shortly after administration. There is a significant reversal, and the dosage can be small. In the case of Peking Union Medical College Hospital, mild dysplasia, if treated with small doses of progesterone (8 to 10 days per cycle), generally 3 The effect is shown in the month, moderate or severe dysplasia, the dose of progesterone used needs to be increased and must be continuously applied for 3 to 6 months. After stopping the drug, although it may recur, most of them have been relieved after a considerable period of time. It will recur, and patients with endometrial adenocarcinoma generally respond slowly to drug treatment, and need a larger dose to make the endometrium have a transformation reaction. Once the drug is discontinued, it will quickly recur. Therefore, the drug treatment response can be used for differential diagnosis. Reference.

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