Endometrial intraepithelial neoplasia (hyperplasia) and carcinoma: Clinical sciences

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Introduction 0:00–1:01

Endometrial intraepithelial neoplasia or simply Ein, also known as complex atypical endometrial hyperplasia is a precursor lesion to type one, endometrial carcinoma.
Endometrial carcinoma, or uterine cancer is the most common genital tract malignancy with a lifetime prevalence of 2 to 3% in biological females.
It is classified into two categories based on histology. Type one represents endometrial adenocarcinoma.
While type two encompasses non endometrioid carcinoma, including clear cell and papillary serous histologies. In general.
Type one accounts for the vast majority of all endometrial carcinoma cases with most being low grade and confined to the uterus at the time of diagnosis.
Type two, carcinomas are considered high grade with an increased risk of extrauterine diseases and have a poorer prognosis compared to type one disease when evaluating a patient with a chief concern suggesting ein or endometrial carcinoma.

History and Physical 1:01–3:31

Your first step is to obtain a focused history and physical exam as well as a pregnancy test with HCG. If your patient is premenopausal.
The hallmark symptom of a patient with ein or endometrial carcinoma is abnormal uterine bleeding or aub or postmenopausal bleeding.
Your patient might also report less specific symptoms such as abdominal or pelvic pain, and bloating. Risk factors include a history of unopposed estrogen exposure.
This can be endogenous such as from chronic anovulation in conditions like Polycystic Ovarian syndrome or from conversion of androgens to estrone in adipose tissue.
As seen in obesity, unopposed, estrogen exposure can also be exogenous such as in patients using estrogen therapy without progesterone, which is not recommended in those with a uterus.
Other risk factors include type two diabetes, age of 45 or greater nulliparity, early age of menarche, late age of menopause and a personal or family history of Lynch Syndrome.
On physical exam, you may find uterine bleeding and palpate an enlarged globular uterus but most often the exam is benign.
Finally, HCG is negative based on these findings. You should suspect ein or endometrial carcinoma and obtain a transvaginal ultrasound or TVU S which assesses the uterus cervix and ovaries on ultrasound.
There will be no structural causes of aub but you might see abnormally thickened endometrium in a postmenopausal patient, an endometrial lining of more than four millimeters is abnormal.
On the other hand, in a premenopausal patient, there is no standardized normal endometrial thickness as the endometrium is constantly changing with the menstrual cycle.
As such, it is generally considered an incidental finding. Here is a clinical pearl.
If you discover endometrial thickening in post menopausal patients, incidentally, you don't need to start the evaluation for E or endometrial carcinoma right away.
Be sure to individually assess the need for further tests based on the patients, characteristics and risk factors. Ok.

Age less than 45 3:31–4:15

The next step is to assess your patients age and menopausal status. If your patient is less than 45 years old, premenopausal and has no risk factors for ein or endometrial carcinoma management involves monitoring and assessing for other causes of aub, these include nonstructural causes like coagulopathy or ovulatory dysfunction.
If they continue to have aub without an identifiable cause, consider an endometrial biopsy On the flip side, if your patient is less than 45 years old and premenopausal, but has risk factors or if they have failed medical management or if they have persistent aub.

Age greater than 45 4:15–5:10

Your next step is to obtain an endometrial biopsy. Similarly, if your patient is 45 years or older, premenopausal and reports, aub you should obtain an endometrial biopsy.
Finally, keep in mind that in all postmenopausal individuals with ultrasound findings of endometrial thickness greater than four millimeters or inadequate endometrial visualization, you should proceed with endometrial biopsy.
Endometrial biopsy is used to assess the endometrial tissue for benign glandular cells e or endometrial carcinoma. While there are different ways to obtain a sample of the endometrial tissue.
The most common is by using an endometrial pipelle which can be performed in the office. Occasionally the results may be unsatisfactory for diagnosis.
If this is the case and your suspicion is high for ein or endometrial carcinoma. Then hysteroscopy with direct endometrial sampling is typically indicated.

Benign endometrium 5:10–5:58

Alternatively, hysteroscopy with direct biopsy may be performed instead of a blind endometrial biopsy. Ok.
If the pathology report shows regular spacing of endometrial glands within the stroma, your diagnosis is a benign endometrium management includes monitoring.
However, if your patient continues to have aub consider further diagnostic intervention. Here's another clinical pearl.
The finding of a benign endometrium on pathology includes simple hyperplasia with and without atypia as well as complex hyperplasia with and without atypia.
The risk of progression to cancer is much smaller. When no atypia is visualized.

EIN (complex atypical hyperplasia) 5:58–8:41

The risk of progression for those with simple hyperplasia without atypia is 1% simple hyperplasia with atypia is 8% complex hyperplasia.
Without atypia is 3% and complex hyperplasia with atypia is 24%. All right.
If the pathology report shows crowding of endometrial glands within the stroma and nuclear atypia, you can diagnose ein.
Remember that ein also called complex atypical hyperplasia is technically a benign finding. However, it has a 24% risk of progression to cancer because it is a precursor to endometrial carcinoma.
It is managed differently than simple hyperplasia or complex hyperplasia without atypia management of ein revolves around your patients desire for future fertility.
If your patient is postmenopausal or has completed childbearing, proceed with total hysterectomy with or without bilateral salpingo oophorectomy or BSO.
The decision to perform a BSO depends on your patients age as well as a discussion on the risks and benefits of removal versus retention of the ovaries.
If the ovaries are retained. It is still recommended to offer a bilateral salpingectomy for risk reduction of fallopian tube carcinoma.
If your patient does desire future fertility or they are not a surgical candidate for hysterectomy. Consider hysteroscopic guided endometrial sampling to rule out endometrial carcinoma.
Next, counsel your patient on the increased risk of progression from ein to endometrial carcinoma. You may offer progestin therapy for the management of ein progesterone works to counteract the effects of unopposed estrogen on the endometrium and regression rates.
For those on progestin therapy are high. Options include oral progestin, the levonorgestrel releasing intrauterine system or a combination.
If using oral progestin, continuous use is more effective than cyclic use. Vomiting is most common with oral progestins and vaginal bleeding with the intrauterine system.
After initiation of progestin therapy. Be sure to repeat endometrial sampling within 3 to 6 months.
If there is no response or only mild regression of ein, then repeat sampling after another 3 to 6 months. If there is no response after a total of 9 to 12 months.
Discuss other options with your patient including definitive surgical management with hysterectomy. If there is a resolution of ein on endometrial sampling, then progestin therapy is generally continued for two years as recurrence can occur.

Endometrial carcinoma 8:41–9:12

However, if symptoms return after cessation of progestin therapy repeat the endometrial biopsy. Here's a clinical pearl endometrial carcinoma is found in 30 to 50% of hysterectomy specimens in patients who had a hysterectomy for Ein.
Finally, if the pathology report shows crowded endometrial glands with little intervening stroma, nuclear atypia and significant glandular irregularity.

Age greater than 45, no endometrial thickening 9:12–9:27

You can diagnose endometrial carcinoma. Management involves a total hysterectomy.
Typically with a BSO and surgical staging which should be completed by a gynecologist, oncologist after surgery, chemotherapy and or radiation may be needed based on the surgical staging and pathologic grade of the cancer.

Review 9:27–10:37

Lets take a step back for one more finding if your patient is postmenopausal with aub and the ultrasound reveals endometrial thickness of four or less, monitor them if the postmenopausal bleeding is persistent or recurrent.
An endometrial biopsy is the next step in management. Rare cases of endometrial carcinoma, particularly type two can present with an endometrial thickness of less than three.
All right. As a quick recap, the work up for ei and endometrial carcinoma includes a TVU S and often endometrial biopsy.
A pathologically benign endometrium is managed with monitoring while ein management includes hysterectomy or progestin therapy.
Lastly, endometrial carcinoma is treated with hysterectomy and based on surgical staging, possible chemotherapy and or radiation.
Endometrial intraepithelial neoplasia (hyperplasia) and carcinoma | Osmosis