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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 171-175

Endometrial hyperplasia: A-2 decade retrospective analysis of histopathological pattern at a university teaching hospital in Northern Nigeria


1 Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
2 Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
3 Department of Histopathology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
4 Department of Obstetrics and Gynaecology, Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria

Date of Web Publication11-Jul-2017

Correspondence Address:
Idris U Takai
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano PMB 3452, Kano State
Nigeria
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DOI: 10.4103/ssajm.ssajm_31_16

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  Abstract 

Background: Endometrial hyperplasia (EH) produces a continuum of lesions that may be a precursor to the development of endometrial cancer, but the risk of which depends on the type of hyperplasia.
Objective: To determine the prevalence and histopathological pattern of EH at the University of Maiduguri Teaching Hospital (UMTH), Maiduguri.
Materials and Methods: This was a 20-year retrospective review of all endometrial biopsies of patients diagnosed with EH in the histopathology department of the UMTH, Maiduguri, from January 1989 to December 2008 inclusive.
Results: A total of 862 endometrial biopsies were reviewed during the study period. Out of this, 541 biopsies were EH, giving a proportion of 62.3%. The age ranged from 10 to 79 years with a mean of 32.5 ± SD 10.4 years. Most of the patients (79.7%) were in their 3rd decade. The results showed that simple EH was the leading histopathological type accounting for 83.2% (450/541) of the cases. Complex EH was responsible for 14.8% (80/541) of cases, while atypical EH was found in only 11/541 (2.0%).
Conclusion: This study has shown that EH is very common among reproductive age women exposing them to high risk of endometrial cancers; therefore, close follow-up and definitive management are highly recommended.

Keywords: Endometrial hyperplasia, histological pattern, UMTH


How to cite this article:
Takai IU, Bukar M, Mayun AA, Ugwa EA, Audu BM, Abdurrahman A. Endometrial hyperplasia: A-2 decade retrospective analysis of histopathological pattern at a university teaching hospital in Northern Nigeria. Sub-Saharan Afr J Med 2016;3:171-5

How to cite this URL:
Takai IU, Bukar M, Mayun AA, Ugwa EA, Audu BM, Abdurrahman A. Endometrial hyperplasia: A-2 decade retrospective analysis of histopathological pattern at a university teaching hospital in Northern Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2017 Sep 19];3:171-5. Available from: http://www.ssajm.org/text.asp?2016/3/4/171/210201


  Introduction Top


Endometrial hyperplasia (EH) is defined as a proliferation of glands of irregular size and shape with an increase in the gland-to-stroma ratio.[1] This results in varying degrees of architectural complexity and cytologic atypia. The classification of EH has had numerous terminologies. The World Health Organization[2],[3] and the International Society of Gynecologic Pathologists[4] classify EH based on the glandular architectural pattern as simple or complex and describes the presence or absence of nuclear atypia. In general, there are four types of hyperplasia: simple, complex, simple with atypia, and complex with atypia. The clinical significance of this classification is the risk that each hyperplasia presents for progression to endometrial cancer (a good pneumonic to remember the approximate risks is “penny, nickel, dime, quarter” for 1, 5, 10, and 25%, respectively).[3],[5] Most cases of EH result from high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily counteract estrogen’s proliferative effects on this tissue.[1] This may occur in a number of settings, including polycystic ovary syndrome, estrogen producing tumors (e.g., granulosa cell tumour) and certain formulations of estrogen replacement therapy.[1] EH is most frequently diagnosed in postmenopausal women, but women of any age can be at risk if they are exposed to a source of unopposed estrogen.[1],[3],[5] EH can frequently be seen in young women with chronic anovulation. Other risk factors for EH include obesity, nulliparity, early menarche, and late menopause.[1],[3]

The most common clinical presentation of patients with EH is abnormal uterine bleeding,[1],[3] whether in the form of menorrhagia, metrorrhagia, or postmenopausal bleeding. Others present with abnormal vaginal discharge or  Pap smear More Details results showing glandular abnormalities.[1],[4],[5] Occasionally, uterine hemorrhaging occurs, which may necessitate medical or surgical interventions, loss of fertility, and blood transfusion therapy.[1] Once a tissue diagnosis of EH is made, treatment depends on the patient’s symptoms such as degree of bleeding, presence of cytologic atypia, patient’s surgical risks, and wish for future childbearing.[1],[2],[3],[4],[5] As a rule, medical management with a progesterone agent best manages patients with hyperplasia − simple or complex − who do not have atypia, and they can serve as prevention of recurrence in those with continued risk factors.[1],[4],[6] In the presence of atypia, the ideal management is hysterectomy given the high rate of potential progression to cancer.[1],[2],[3]

The importance of endometrial biopsy or curettage to obtain tissue for histopathological evaluation of patients which aids in the diagnosis and treatment cannot, therefore, be overemphasized considering the varying degrees of clinical presentations and the risks of progression to cancer. The study was, therefore, undertaken to determine the prevalence and histopathological pattern of EH at the University of Maiduguri Teaching Hospital (UMTH), Maiduguri, over a 20-year period. This study will serve as a baseline data in the region for references and further research.


  Materials and Methods Top


This was a 20-year retrospective review of all endometrial biopsies and curettages of patients with abnormal uterine bleeding and only histologically diagnosed with EH in the histopathology department of the UMTH, Maiduguri, from January 1989 to December 2008 inclusive. The patients’ information for the study which included age, clinical presentation and histological diagnosis was retrieved from the UMTH histopathology departmental bench book and patients’ case file which were retrieved from central medical record department and as well as from the Department of Obstetrics and Gynaecology. Patients with diagnoses of pregnancy related complications such as abortions, gestational trophoblastic diseases and cancers were excluded from the analysis. Similarly cases with incomplete information for the study and/or whose slides were not found were excluded from the study. Institutional research and ethics committee approved the study.

Most of the specimens were sent from UMTH obstetrics and gynaecology department, but a few came from private and other public hospitals within Maiduguri and its environs. The endometrial biopsies generally called small biopsies arrived the histopathology department in small containers. After collection from the patients, they were registered in the reception where a histology number was given. They were then fixed in 10% formal saline with a volume 10 times that of the tissue. From the reception, they were taken to the surgical bench where grossing was done to describe the tissues and take representative samples. These were then processed in the automatic tissue processor for a minimum of 12 h. The samples were then embedded in molten wax, allowed to solidify and taken for microtomy. The paraffin embedded tissue sections were then cut using the microtome machine at 3 μm. The tissue sections were placed on a floating bath and captured on slides. These were allowed to dry and stained using hematoxylin and eosin as basic stains. Special stains were used where necessary; for example, Zheil Nielsen stains if tuberculous endometritis was suspected, or Gomori Methamine Silver if fungal infection was contentious. The slides were then covered with cover slips, properly labeled and taken to the Pathologist for reporting and diagnosis. A consultant histopathologist with vast experiences in the field of gynaecologic pathology who worked at the UMTH histopathology department read the slides.

The cases were then appropriately selected and classified into three diagnostic histological groups and included: simple hyperplasia (SH) which shows glands are irregular in size and shape with occasional dilated, cystic glands lined by pseudo-stratified uniform and oval nuclei showing orientation toward the basement membrane and separated by abundant stroma [microphotograph, [Figure 1]], complex hyperplasia (CH) composed of closely spaced glands, highly irregular in size and shape with pseudo-stratified uniform and oval nuclei [microphotograph, [Figure 2]], and atypical hyperplasia (AH), a CH, in which cells show atypia including irregular, stratified, rounded nuclei with nucleoli [microphotograph, [Figure 3]].
Figure 1: Simple hyperplasia, (hematoxylin and eosin) ×40

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Figure 2: Complex hyperplasia, (hematoxylin and eosin) ×40

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Figure 3: Atypical hyperplasia, (hematoxylin and eosin) ×40

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The patients were then divided into the following age groups according to American College of Obstetrics and Gynecology bulletin[7] as follows: adolescents (13–18 years), women of reproductive age (19–39 years), perimenopausal (40–51 years) and postmenopausal (52 years and older). The data collected were analyzed using Minitab (Minitab 1998 Minitab for Windows, Drive State College: Minitab Inc., Pa. (Release 12.21)) (version 12.21). Descriptive analysis was performed, and absolute numbers and simple percentages were used to describe qualitative variables, and finally Chi-square for trend was performed. A P-value of <0.05 was considered statistically significant. Results are presented in tabular forms and graphs.


  Results Top


A total of 862 endometrial biopsies were reviewed during the study period. Out of this, 541 biopsies were histologically confirmed EH, giving a proportion of 62.3%. The age ranged from 10 to 79 years with a mean age of 32.5 ± SD 10.4 years. Most of the patients (79.7%) were in their 3rd decade.

[Table 1] shows the age distribution of patients with histological diagnosis of EH. Both simple and complex EH are found among all age groups but simple EH predominates. In the same vain, both simple and complex EH were most common in the reproductive age group (63.6 and 9.8%) respectively, while atypical EH was more common in the perimenopausal and postmenopausal age groups (1.1 and 0.6%) respectively. There was no AH in the adolescent age group.
Table 1: Age distribution of patients with histological diagnosis of endometrial hyperplasia (EH)

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The pattern of EH is represented in [Table 2]. The results showed that simple EH was the leading histopathological type accounting for 83.2% (450/541) of the cases. Complex EH was responsible for 14.8% (80/541) of cases, while atypical EH was found in only 11/541 (2.0%).
Table 2: Pattern of endometrial hyperplasia in UMTH Maiduguri

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The yearly prevalence of EH over the 2-decades is shown in [Table 3]. It has shown a decreasing trend in the prevalence of EH over the period of review which is statistically significant x2 for trend = 3.0754; df = 1; P-value = 0.0054 [Table 4]. The trend is further graphically represented as in [Figure 4].
Table 3: Trends of endometrial hyperplasia at UMTH Maiduguri

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Table 4: Chi-squared for linear trend

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Figure 4: Line graphs of category proportions with linear trend lines. SH = simple hyperplasia; CH = complex hyperplasia; AH = atypical hyperplasia

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[Table 3] and [Figure 4] above shows the trend for EH from 1989 to 2008 with a slope towards the end line. There is, therefore, a significant reduction.


  Discussion Top


The clinical significance of EH is the risk of progression to endometrial cancer.[3],[5] The present study reports that 62.3% of assessed endometrial biopsy specimens showed EH. Other studies reported lower proportions of 18.3,[8] 9.1,[9] and 1.25%.[10] This finding is of public health implication as the risk of progression to cancer has been well documented.[11] These women will, therefore, need very close follow-up and definitive surgical management. Expected normal proportion is 0.5–5%.[12]

In the present study, an age ranged of 10–79 years with a mean age of 32.5 ± SD 10.4 years was reported. A previous study in same hospital and another centre showed an average age of 28 years.[10],[13] Another study reported an age range of 17–86 years and mean of 38.8 ± SD 6.8 years in the South-south Nigeria[14] The results showed that simple EH was the leading histopathological type accounting for 83.2%. This picture is consistent with reports of previous study.[8],[15],[16]

This study has shown that simple and complex EH are found among all age groups but predominantly among those of the reproductive age group while atypical forms were commoner among premenopausal and postmenopausal age groups. There was no AH in the adolescent age group. This is in contrast with findings of other studies which reported that simple and CH were commoner among those 50–54 years and the atypical forms among 60–64 years old women.[8],[12],[17] The explanation may be that our sample was skewed towards the reproductive age-group who presented to the hospital for various reproductive health services, most commonly for infertility, as delay in getting pregnancy after 1 year of marriage is a serious socio-cultural and religious concern in Northern Nigeria. Therefore, endometrial malignancy may be detected at an earlier age among these women.Our study has also shown a decreasing trend in the prevalence of EH over the period of review. This is similar to a previous finding.[12] This finding could possibly be explained by decreasing use of unopposed estrogen therapies in women with a uterus. Theoretically, the greatest impact of changes in practice regarding unopposed estrogen use would have occurred in the 1980s shortly after researches that associated increased endometrial carcinoma risk with unopposed estrogen in the 1970s[18],[19] with a persistent slow decline over the ensuing years. This may, therefore, partly explain lowering hyperplasia incidence observed from 1989 to 2008.

In conclusion, this study has shown that EH is very common among reproductive age women exposing them to high risk of endometrial cancers; therefore, close follow-up and definitive management are highly recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kurman RJ, Kaminski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer 1985;56:403-12.  Back to cited text no. 1
[PUBMED]    
2.
Bergeron C, Nogales FF, Masseroli M, Abeler V, Duvillard P, Müller-Holzner E et al. A multicentric European study testing the reproducibility of the WHO classification of endometrial hyperplasia with a proposal of a simplified working classification for biopsy and curettage specimens. Am J Surg Pathol 1999;23:1102-8.  Back to cited text no. 2
    
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Lacey JV Jr, Chia VM. Endometrial hyperplasia and the risk of progression to carcinoma. Maturitas 2009;63:39-44.  Back to cited text no. 3
    
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Zaino RJ, Kauderer J, Trimble CL, Silverberg SG, Curtin JP, Lim PC et al. Reproducibility of the diagnosis of atypical endometrial hyperplasia: A Gynecologic Oncology Group study. Cancer 2006;106:804-11.  Back to cited text no. 4
    
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Trimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ 2nd et al. Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: A Gynecologic Oncology Group study. Cancer 2006;106:812-9.  Back to cited text no. 5
    
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Gambrell RD Jr. Progestogens in estrogen-replacement therapy. Clin Obstet Gynecol 1995;38:890-901.  Back to cited text no. 6
    
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ACOG. Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013;122:176-85.  Back to cited text no. 7
    
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Baral R, Pudasaini S. Histopathological pattern of endometrial samples in abnormal uterine bleeding. J Pathol Nepal 2011;1:13-6.  Back to cited text no. 8
    
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Abdullah LS, Bondagji NS. Histopathological pattern of endometrial sampling performed for abnormal uterine bleeding. Bahrain Med Bullet 2011;33:1-6.  Back to cited text no. 9
    
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Ojo BA, Aboyeji PA, Buhari MO, Abdulraman MB. Endometrial pathology in a teaching hospital in North Central Nigeria: A histopathological survey. Niger J Health Biomed Sci 2005;4:107-11.  Back to cited text no. 10
    
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Miller C, Bidus MA, Pulcini JP, Maxwell GL, Cosin JA, Rose GS. The ability of endometrial biopsies with atypical complex hyperplasia to guide surgical management. Am J Obstet Gynecol 2008;199:69.e1-4.  Back to cited text no. 11
    
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Reed SD, Newton KM, Clinton WL, Epplein M, Garcia R, Allison K et al. Incidence of endometrial hyperplasia. Am J Obstet Gynecol 2009;200:678.e1-e6. doi: 10.1016/j.ajog.2009.02.032  Back to cited text no. 12
    
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Idrisa A, Emeka O, Abimiku BM. Endometrial sampling at a teaching hospital in northern Nigeria. West Afr J Med 2000;19:212-5.  Back to cited text no. 13
    
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Forae GD, Aligbe JU. Histopathological patterns of endometrial lesions in patients with abnormal uterine bleeding in a cosmopolitan population. J Basic Clin Reprod Sci 2013;2:101-4.  Back to cited text no. 14
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Jairajpuri ZS, Rana S, Jetley S. Atypical uterine bleeding − A histopathological audit of endometrium. A study of 638 cases. Al Ameen J Med Sci 2013;6:21-8.  Back to cited text no. 15
    
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Takreem A, Danish N, Razaq S. Incidence of endometrial hyperplasia in 100 cases presenting with polymenorrhagia/menorrhagia in perimenupausal women. J Ayub Med Coll Abbottabad 2009;21:60-3.  Back to cited text no. 16
    
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Dhakal HP, Pradhan M. Histological pattern of gynecological cancers. J Nepal Med Assoc 2009;48:301-5.  Back to cited text no. 17
    
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United States National Institute on Aging. Estrogen use and postmenopausal women. NIH Consens Dev Conf Summ 1979;2:1-5.  Back to cited text no. 18
    
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Berger GS, Fowler WC Jr. Exogenous estrogens and endometrial carcinoma: Review and comments for the clinician. J Reprod Med 1977;18:177-80.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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