Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Dear Dr. Pat,

I am 46 and have had infrequent periods my whole life.  I was diagnosed with polycystic ovarian disease when I was in my late teens. Like most people with this condition, I had only a few, often heavy, periods a year, as well as acne and facial hair. I have also been quite overweight my whole adult life.  I tried to take birth control pills to regulate my cycle but took them only briefly due to side effects. I developed diet-controlled diabetes in my early 40s. Recently, I had no period for 10 months, then I had a heavy period that lasted 10 days.  I had hoped that I was in menopause before I had this most recent period. After this period, I started staining every two to three weeks for a few days.  I knew that this kind of bleeding could happen in the time around menopause so I wasn’t worried until it continued for another three months. 

My last visit to my gynecologist for an annual physical and Pap smear was less than a year ago. When I saw the gynecologist recently about my current bleeding, she did a pelvic sonogram and found that the lining of the uterus was thick.  She tried to do an office biopsy of the uterine lining but, since I had never had children, she could not get the biopsy instrument into the cervical opening. So, I had to undergo a D&C in an operating room the next week. 

The pathology report after the D&C revealed complex endometrial hyperplasia with atypical cells but no cancer. Despite these results, the gynecologist told me that the D&C removes only a sample of the endometrial tissue. Even though no cancer was found, she recommended I have a hysterectomy for this kind of hyperplasia because endometrial cancer could be present as well.  I don’t understand how this hyperplasia developed and I don’t know why I should have a hysterectomy.  I read all the time that too many hysterectomies are being done.  Everyone talks about breast and ovarian cancer, but I don’t hear much about endometrial cancer.  Is it common?

Deb

Dear Deb,

You and your doctor have done the right things at the right time. The history of infrequent periods throughout your life made this harder for you to sort out, but you knew that something other than menopause could be causing this abnormal bleeding. Your doctor wasted no time and efficiently did the right tests.

Endometrial cancer is the most common invasive gynecologic cancer in U.S. women, with an estimated 52,630 new cases expected to occur in 2014 and an estimated 8,590 women expected to die of the disease.1  

First, let me share a bit about the uterus, its lining (the endometrium), and ovarian hormones.  The uterus has two main parts: the upper part (body of the uterus) and lower part (the cervix). The body of the uterus has both an outer layer, which is a thick muscle called the myometrium, and a lining of the uterine cavity, the endometrium. Ovarian hormones affect the lining of the uterus in specific ways during normal menstrual cycles. During the early part of each menstrual cycle, estrogen is produced and causes the lining of the uterus to become thicker. After ovulation, progesterone is the predominant ovarian hormone that affects the endometrium, causing it to become more compact and to shed each month as a normal period. A shift in the balance of these two hormones toward more estrogen increases a woman’s risk for developing endometrial cancer.

Endometrial hyperplasia is defined as a proliferation of glands of irregular size and shape, with more glands crowded together.  This proliferation of endometrial glands may progress to or coexist with endometrial cancer. Endometrial hyperplasia virtually always results from chronic estrogen stimulation unopposed by the counterbalancing effects of progesterone.  

Your endometrial tissue has been exposed to a lifetime of constant estrogen stimulation and infrequent progesterone, allowing this hyperplasia to develop. Your primary risks for this condition are due to the polycystic ovarian syndrome and obesity. Polycystic ovarian syndrome is a condition where there is an abundance of estrogen and infrequent progesterone produced by the ovaries.  Some doctors prescribe oral contraceptive pills for patients with this condition so that the endometrium will be exposed to both estrogen and progestin, which produces regular menstrual cycles and may decrease the risk of endometrial hyperplasia.  Since you never used the birth control pill, your endometrium was exposed to almost constant estrogen. Unopposed estrogen is a recognized risk factor for both endometrial hyperplasia and endometrial cancer.

Obesity is a risk factor for endometrial cancer as well. Most of a woman’s estrogen is produced by her ovaries, but fat tissue can change some hormonal precursors into estrogens. Having more fat tissue can increase a woman’s estrogen levels, which increases her endometrial cancer risk.  In comparison with women who maintain a healthy weight, endometrial cancer is twice as common in overweight women and more than three times as common in obese women.  

Deb, you have had years of increased risk for developing endometrial cancer and now a diagnosis of complex endometrial hyperplasia with atypia increases this risk even more.  Long-term follow-up of women with atypical endometrial hyperplasia diagnosed with endometrial sampling show an increase in risk of endometrial cancer of greater than 20% in many studies.2  I always suggest that, when possible, patients should have a second opinion before major surgery.  I think you would find this reassuring but I do feel that the care and advice you have been given is in keeping with current guidelines.

1. American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014.

2. Trimble CL, Kauderer J, Zaino R, et al. Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: A Gynecologic Oncology Group study. Cancer. 2006; 106: 812–819.