Endometrial hyperplasia screening
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Badria Munir M.B.B.S.[2] , Soujanya Thummathati, MBBS [3]
Oveview
Routine screening for endometrial hyperplasia or endometrial carcinoma is not recommended.
Screening
Routine screening for endometrial hyperplasia or endometrial carcinoma is not recommended. In the case of endometrial carcinoma, the current consensus among experts in the field of periodic health examinations is not to recommend screening for endometrial cancer and its precursors because there is no scientific evidence to support such examinations in menopausal and postmenopausal women.35 The arguments against screening for endometrial carcinoma are as follows:
Although endometrial carcinoma is common, morbidity rates are low, comparatively less important in number than breast carcinoma, colon carcinoma, lung carcinoma, leukemia, lymphoma, brain carcinoma, pancreas carcinoma, and ovary carcinoma. Based on the incidence of endometrial carcinoma in asymptomatic women, it would take about 1000 procedures to detect a single case of either a carcinoma or its precursor, atypical hyperplasia (AH).36, 37 The techniques available for diagnosing endometrial disease in asymptomatic women suffer from pitfalls in interpretation or instrumentation. One is the difficulty in interpreting relatively inexpensive cytologic material;38 the other is that office biopsy aspiration techniques are relatively expensive and uncomfortable to painful, and tissue insufficient for diagnosis rates may be 25%. No controlled randomized trials have been done to evaluate the effectiveness of screening in endometrial carcinoma. Even in high-risk menopausal women, screening would detect only 50% of all cases of endometrial carcinoma.39 Most patients with disease eventually become symptomatic (i.e., presenting with abnormal uterine bleeding, yet have early clinical stage disease at the time of surgical diagnosis and treatment). This contention is supported by the excellent 5-year survival rates of patients with stage I endometrial carcinoma (i.e., 80–91%).40 The clinicopathologic and epidemiologic data suggest that about 80% of endometrial carcinomas are slow growing with a favorable course,34 and earlier treatment of asymptomatic carcinomas would be no more effective than treatment given when symptoms appear. Elderly people are difficult to enroll into screening programs, and the dropout rate is relatively high. This is particularly true if painful techniques are used for endometrial evaluation. The incidence of endometrial carcinoma and its precursors is low in women aged younger than 50 years and in women receiving combination-type HRT (estrogen/progestins).32
Screening for endometrial carcinoma or its precursor, EIN, in asymptomatic, postmenopausal women is presently not recommended because of the low incidence of endometrial carcinoma in this group of women, estimated to be 1.7 cases per 1000 women per year, and the low prevalence, in the order of 1 per 1000 women.36 In the Postmenopausal Estrogen/Progestin Intervention (PEPI) trial, no patients developed endometrial carcinoma while on daily estrogen-only replacement therapy, 0.625 mg, during a follow-up of 36 months versus 1% of women who developed endometrial carcinoma on placebo.41 The average age of women with EIN is 52 years, which is about 8 years earlier than the average age of 60 for endometrioid endometrial adenocarcinoma in the same patient population.42 The interval for progression from EIN to adenocarcinoma can be more directly estimated in individual patients who undergo protracted surveillance following an EIN diagnosis. Once patients with concurrent adenocarcinoma are excluded (defined as cancer found within the first year of follow-up), the average interval to diagnosis of adenocarcinoma is 4 years.11
Who should be screened?
Women receiving unopposed estrogens need endometrial sampling once every 2 years (relative risk increases only after 2 years of estrogen use), particularly if endometrial hyperstimulation has been documented previously and has not been treated by short-term administration of progestins. Also, if the informed, high-risk individual requests an endometrial evaluation before or during HRT or at any time during her periodic health examinations, she should not be deprived of an office-based investigative procedure to rule out endometrial pathology. An endometrial evaluation also should be performed in women at high risk for endometrial carcinoma, such as women with history of Lynch II syndrome.43