Endometrial Hyperplasia The terminology used to describe endometrial hyperplasia is confusing, and the clinician must consult with the pathologist to ensure an understanding of the diagnosis. The World Health Organization (WHO) system classifies endometrial hyperplasia as simple hyperplasia, complex hyperplasia, simple atypical hyperplasia, and complex atypical hyperplasia (259). Approximately 40% to 50% of women with atypical hyperplasia have concurrent carcinoma. The management of endometrial hyperplasia is based on an understanding of the natural history of the lesion involved. The risk of progression of hyperplasia without atypia is low but is approximately 30% among those with atypical hyperplasia (259). Hysterectomy is recommended for treatment of atypical endometrial hyperplasia in postmenopausal women. Management of endometrial cancer with surgical staging and multidisciplinary review of pathology and treatment planning is addressed in Chapter 35.
Progestin therapy (oral, parenteral, or intrauterine device delivery) may be used in women with atypical endometrial hyperplasia who are poor operative candidates. These women should have an endometrial biopsy every 3 months to check for recurrence, with recurrence risks approaching 50% (185). A suggested scheme of management is outlined in Figure 14.34. This treatment is discussed in more detail in Chapter 35.
Differential Diagnosis Ovarian Masses During the postmenopausal years, the ovaries become smaller. Ovarian volume is related to age, menopausal status, weight, height, and use of exogenous hormones (260). A large body habitus and uterine size make it more difficult to palpate and assess ovarian size, particularly among postmenopausal women, and transvaginal ultrasonography is significantly more accurate than clinical examination. Transvaginal ultrasonography is suggested in addition to annual pelvic examination among overweight postmenopausal women (261). Although ovarian cancer is notoriously difficult to diagnose at any early stage, the concept that it is frequently asymptomatic is challenged. Symptoms may include back pain, fatigue, bloating, constipation, abdominal pain, and urinary symptoms; these symptoms are of greater severity and more recent onset in women with ovarian malignancy (262). Thus it is argued that among primary clinicians, the possibility of an ovarian mass (either benign or malignant) in women with these symptoms warrants further diagnostic investigation. However, the positive predictive value of these symptoms is not high for the prediction of early-stage disease, and the use of symptoms to trigger an evaluation for ovarian cancer is noted to result in diagnosis of the disease in only 1 in 100 women in the general population with such symptoms (263). Ovarian cancer is predominantly a disease of postmenopausal women; the incidence increases with age, and the average patient age is about 56 to 60 years (see Chapter 37).
With increased use of pelvic ultrasonographic evaluation, a new problem arose in post-menopausal women: the discovery of a small ovarian cyst. This is particularly troublesome in
CHAPTER 14 Benign Diseases of the Female Reproductive Tract
Perform D&C to rule out endometrial carcinoma in symptomatic patients Desire to retain uterus Persistent atypical hyperplasia Normal or atrophic endometrium  Continue Provera 5 mg/day 10 days/month for 12 months  Consider annual endometrial biopsy  Ovulation induction if childbearing desired Provera 10–20 mg/day for 11 to 14 days per month Repeat endometrial biopsy in 3 to 6 months Trial of high dose progestins (e.g., Provera 40–100 mg/day for 3 months) No desire to retain uterus Hysterectomy