How endometrial biopsy helps us in prognostication of endometrial cancer?? How to counsel a woman who had an endo biopsy has been done in reference to possibility of endometrial cancer in near future??

Endometrial Hyperplasia- Introduction: In fact there are three kinds of   epithelial cells in  endometrium:--a) Surface epithelium, b) glandular Epithelal  and c) Stromal Cells.

Types of hyperplasia -As all of us aware that there are basically four types of Endo Hyperplasia. 1)–Simple cystic  hyperplasia but  no cellular  atypia, 2) Complex hyperplasia  but -no cellular atypia,3) Simple cystic hyperplasia  with cellular atypia and 4) fourthly complex adenomatous hyperplasia  with  cellular atypia---. The last one has a predilection for developing Ca of about 30% by 15 yrs time.

What about complex hyperplasia?? How to treat (deal ) with such cases??  Almost all complex hyperplasia are an effect of long term exposure of unopposed high endogenous estrogen. Having accepted that philosophy, we have to initially  exclude 1) excessive body weight, 2) Hyperinsulinemic state and 3) Hypertension & 4) hyperthyroidism in all case of endometrial  hyperplasia as a preventive measure of developing to (progression)  to  cancer . Admittedly, two last mentioned associations like( 1) excessive body weight, 2) Hyperinsulinemic state)  rarely produce clinically demonstrable  hyper estrogenic state but researchers have affirmed such association, time and again. Understandably, HTN & Hyperthyroidism are minor causes (etiology) of long standing hyperestrinism induced  à  hyperplasia.

Prognostication of Cancer?? Point 1:-The probability of developing Endometrial Cancer in complex adenomatous hyperplasia without atypia is about 3% only but Point 2 in cases with complex adenomatous hyperplasia with atypia is as high as 30%. As such in such cases, we will have to consider whether it will be prudent to preserve the uterus if she is > 42 yrs of age. She may be advised to lose wt and control hyperinsulinemic status thereby an attempt to decrease the E2 level.  Till LH is finalized meanwhile LNG-IUS may be put in. if she likes to purchase time for final decision.

. COC::-- when in endometrial hyperplasia if there is cavitary alterations in womb or woman declies fro Mirena:-COC when in endometrial hyperplasia if there is cavitary alterations in womb or woman declies fro Mirena:-Another temporary alternative is COC :- COC can be used for raised ET . But caveat is if the woman who is having hyperplasia without atypia & she is  aged > 40yrs.-then she must be a nonsmoker, lady of average Wt, Normotensive, normolipidaemic,   no Breast Lump, no Cx diseases or P/H/O thromboembolic diseases’. But I  am not aware of any specific pharmacotherapy agent which will selectively exhibit antagonist activity( drugs which cause inhibition of growth-mitosis of a  particular group of cells on endometrial glands / stroma except possibly (?)  COC.  But if  (COC) is used in this cases of Endo hyperplasia  for >  6 months how  the detailed histological changes will follow is still not clear

.. Prognostication of endometrial cancer after endometrial biopsy:-But the fact remains that (COC) does cause thinning of endometrium in spite of presence of synthetic .Estrogen-which is most potent estrogen. Possibly progesterone overrides the oestrogenic effects at cellular level. I am not sure. Some women are in a habit of taking/ using oestrogen congaing tablets/creams for various reasons. That has to be enquired. Does  she took Tamoxifen earlier or still taking with wrong belief that will promote her fertility?  Is there any family /O of Lynch II Syndrome-which is a diseases of mutations in MISMATCH REPAIR   GENES in germline cells?  Such type of hyperplasia / Cancers is usually termed as Familial Cancer susceptibility Syndrome- . This  syndrome was previously used to be labeled as HNPCC. Such women with mutation have a life time risk of developing 60% risk of hyperplasia irrespective of medications and life time risk of having Endo ca & Colon Ca of as high as 40%. Unbelievable!

·         In conclusion, I would have insisting on weight control, exercise, metabolic correction to check hyperinsulinaemia, CT Pelvis to detect oestrogen producing tumours, if any and enquire about any topical; /oral use of oestrogen containg drugs. Family h/O of Lynch Syndrome II have to be enquired. Treatement options mild atypia are  1) LNG-IUS 2) only follow up 3) oral pills 4) LH if associated with  cervical diseases  or endometriosis (associated pelvic pathology).

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·         Lap hysterectomy with conservation of uterus in cases of simple hyperplasia with some atypia and  woman has crossed 42 yrs: A hard decision for lap hysterectomy!!  –But when had to opt for Lap Hysterctomy?? When ?? Ans; If concomitant epithelial diseases of cervix of sever degree. By and large, if there is association of CIN III (which is not uncommon in our country due to poor hygienic settings , repeated difficult child birth--- child birth related cervical trauma)-) , & , use of household unclean sanitary Napkins etc. etc. then the edge will be in favour of TAH if cytological atypia is evident in endo biopsy. I, as a senior doctor will be hesitant to preserve such a uterus with CIN III , more so if HPV DNA-HR(high Risk) strain is +ve.. To summarize the issue of Hysterectomy or no Hysterectomy, I personally take into account of degree of existing prevailing cervical pathology-I am talking benign epithelial diseases of cervix also as an one of the determinant factor.