Hyperplasia of the endometrium—A clinical and pathological study

Abstract Hyperplasia of the endometrium, a condition first described by Cullen as far back as 1900, is one of the most important of all endometrial lesions. Clinically its characteristic symptom is bleeding, while pathologically it is characterized by hyperplasia of both epithelial and stromal elements in varying degree and in varying proportion. The glands are of the “swiss cheese” pattern, large dilated glands being found side by side with glands which are small and narrow. The epithelium is at times considerably thickened, while the stroma is often over-abundant and may give evidence of proliferative activity by mitoses. Grossly the endometrium may be enormously increased in amount, and may present the polypoid picture which has so often been incorrectly described as “chronic polypoid endometritis.” In almost half of our cases, however, it was of normal thickness, and in over one-half it was smooth rather than polypoid. The hyperplasia may be localized in uterine polypi, in which case, unless associated with other lesions or with strangulation of the polyp, bleeding has not been a symptom. The hyperplasia pattern is not uncommon with adenomyoma, in either the endometrium of the surface or that of the islets in the musculature. This study comprises 66 cases of hyperplasia of the uterine endometrium. In 32 cases hysterectomy was performed and in the other 34 our only pathological material consists of uterine curettings. The cases studied were taken in chronological order and selected because of a definite endometrial hyperplasia and not on the basis of the clinical symptoms or signs of abnormal uterine bleeding. About one-half of our patients with hyperplasia were above 40 years of age while the remainder were in women under the age of forty. The occurrence of hyperplasia in girls near the age of puberty is, in our experience, not common (less than 5 per cent). Our study shows no definite abnormality in the menstrual history of these patients prior to the onset of the symptoms of hyperplasia. With the onset of the symptoms of hyperplasia there was, however, in almost every case excessive menstruation, manifested usually by an increase in both the amount and duration of the menstrual discharge. Menorrhagia or metrorrhagia may occur as symptoms of hyperplasia, the former being the more common of the two. The passage of blood clots is not unusual. Amenorrhea, as part of the symptom complex of hyperplasia, was noted in about one-sixth of our cases. Pregnancy occurring after the onset of hyperplasia is uncommon in our study, but did occur in two patients. About one-half of our patients had had one or more full term pregnancies prior to the onset of the symptoms which are associated with hyperplasia. Schroder believes that an absence of corpora lutea in the ovaries is a characteristic finding with hyperplasia. We have found some exceptions to this rule, so that the matter needs further investigation. The characteristic gland pattern is attributed by some merely to epithelial hyperplasia, and by some to simple cystic distention, while to us the evidence suggests that an enormous overgrowth of the basal layer of the endometrium and an absence of the superficial functioning layers is sufficient to explain the characteristic picture. The therapeutic measures to be considered for the relief of the uterine bleeding associated with hyperplasia are curettage, organotherapy, radiotherapy and hysterectomy. There are probably a certain number of mild cases which get well spontaneously. Curettage is necessary to make a diagnosis, and may bring about relief of symptoms. Recurrence of the bleeding within a comparatively short time is more common, and repeated curettage may be necessary in the case of young patients where both radiotherapy and hysterectomy are undesirable. At the menopausal age the bleeding can be checked by sufficient dosage of either x-ray or radium. Hysterectomy is reserved for intractable cases where radium is unavailable, or where associated lesions make laparotomy preferable to simple abolition of the menstrual function. The most important clinical group of hyperplasia cases—and the largest one—is that occurring at or near the menopausal age. The importance of the condition at this age lies in the fact that it is brought into diagnostic conflict with cancer. While it is still true that climacteric bleeding should be looked upon as of cancerous causation until this assumption is disproved, the fact remains that in many cases the cause will be revealed as hyperplasia, a benign condition with no tendency toward malignancy. This is an important point to impress upon those interested in educating the laity on the early recognition of cancer, for there can be no doubt that not a few women with climacteric bleeding delay seeking medical advice through dread of being told that cancer is the cause of their symptoms. Any elecment of justifiable hopefulness that can be injected into the situation will be of material aid in the cancer education of the public. In conclusion, the authors wish to express to Dr. Thomas S. Cullen, the head of the department, their appreciation of the privilege of making this study. To Mr. Herman Schapiro they are indebted for the excellent photomicrographs.